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Haworth CS, Shteinberg M, Winthrop K, Barker A, Blasi F, Dimakou K, Morgan LC, O'Donnell AE, Ringshausen FC, Sibila O, Thomson RM, Carroll KJ, Pontenani F, Castellani P, Chalmers JD. Inhaled colistimethate sodium in patients with bronchiectasis and Pseudomonas aeruginosa infection: results of PROMIS-I and PROMIS-II, two randomised, double-blind, placebo-controlled phase 3 trials assessing safety and efficacy over 12 months. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00225-X. [PMID: 39270696 DOI: 10.1016/s2213-2600(24)00225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/13/2024] [Accepted: 07/15/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Chronic lung infection with Pseudomonas aeruginosa is associated with increased exacerbations and mortality in people with bronchiectasis. The PROMIS-I and PROMIS-II trials investigated the efficacy and safety of 12-months of inhaled colistimethate sodium delivered via the I-neb. METHODS Two randomised, double-blind, placebo-controlled trials of twice per day colistimethate sodium versus placebo were conducted in patients with bronchiectasis with P aeruginosa and a history of at least two exacerbations requiring oral antibiotics or one requiring intravenous antibiotics in the previous year in hospitals in Argentina, Australia, Belgium, Canada, France, Germany, Greece, Israel, Italy, Netherlands, New Zealand, Poland, Portugal, Spain, Switzerland, the UK, and the USA. Randomisation was conducted through an interactive web response system and stratified by site and long term use of macrolides. Masking was achieved by providing colistimethate sodium and placebo in identical vials. After random assignment, study visits were scheduled for 1, 3, 6, 9, and 12 months (the end of the treatment period); and telephone calls were scheduled for 7 days after random assignment and 2 weeks after the end of treatment. The primary endpoint was the mean annual exacerbation rate. These trials are registered with EudraCT: number 2015-002743-33 (for PROMIS-I) and 2016-004558-13 (for PROMIS-II), and are now completed. FINDINGS 377 patients were randomly assigned in PROMIS-I (177 to colistimethate sodium and 200 to placebo; in the modified intention-to-treat population, 176 were in the colistimethate sodium group and 197 were in the placebo group) between June 6, 2017, and April 8, 2020. The annual exacerbation rate was 0·58 in the colistimethate sodium group versus 0·95 in the placebo group (rate ratio 0·61; 95% CI 0·46-0·82; p=0·0010). 287 patients were randomly assigned in PROMIS-II (152 were assigned to colistimethate sodium and 135 were assigned to placebo, in the modified intention-to-treat population), between Feb 12, 2018, and Oct 22, 2021. PROMIS-II was then prematurely terminated due to the effect of the COVID-19 pandemic. No significant difference was observed in the annual exacerbation rate between the colistimethate sodium and placebo groups (0·89 vs 0·89; rate ratio 1·00; 95% CI 0·75-1·35; p=0·98). No major safety issues were identified. The overall frequency of adverse events was 142 (81%) patients in the colistimethate sodium group versus 159 (81%) patients in the placebo group in PROMIS-I, and 123 (81%) patients versus 104 (77%) patients in PROMIS-II. There were no deaths related to study treatment. INTERPRETATION The data from PROMIS-I suggest a clinically important benefit of colistimethate sodium delivered via the I-neb adaptive aerosol delivery system in patients with bronchiectasis and P aeruginosa infection. These results were not replicated in PROMIS-II, which was affected by the COVID-19 pandemic and prematurely terminated. FUNDING Zambon.
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Affiliation(s)
- Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital and University of Cambridge, Cambridge, UK
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel; Technion Israel Institute of Technology, the B Rappaport Faculty of Medicine, Haifa, Israel
| | - Kevin Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA
| | - Alan Barker
- Department of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Respiratory Unit and Cystic Fibrosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Katerina Dimakou
- 5th Respiratory Medicine Department, General Hospital for Chest Diseases of Athens Sotiria, Athens, Greece
| | - Lucy C Morgan
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | - Anne E O'Donnell
- Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Felix C Ringshausen
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover, German Center of Lung Research, Hannover, Germany; European Reference Network on Rare and Complex Respiratory Diseases, Frankfurt, Germany
| | - Oriol Sibila
- Department of Respiratory Medicine, Hospital Clinic of Barcelona, University of Barcelona, Centro de Investigacion Biomedica En Red Enfermedades Respiratorias, Institut d Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Rachel M Thomson
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, QLD, Australia; University of Queensland, Brisbane, QLD, Australia
| | | | | | - Paola Castellani
- Research and Development Department. Zambon SpA, Bresso, Milan, Italy
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK.
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2
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Röver C, Friede T. Investigating the Heterogeneity of "Study Twins". Biom J 2024; 66:e202300387. [PMID: 39223907 DOI: 10.1002/bimj.202300387] [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: 12/15/2023] [Revised: 05/06/2024] [Accepted: 07/03/2024] [Indexed: 09/04/2024]
Abstract
Meta-analyses are commonly performed based on random-effects models, while in certain cases one might also argue in favor of a common-effect model. One such case may be given by the example of two "study twins" that are performed according to a common (or at least very similar) protocol. Here we investigate the particular case of meta-analysis of a pair of studies, for example, summarizing the results of two confirmatory clinical trials in phase III of a clinical development program. Thereby, we focus on the question of to what extent homogeneity or heterogeneity may be discernible and include an empirical investigation of published ("twin") pairs of studies. A pair of estimates from two studies only provide very little evidence of homogeneity or heterogeneity of effects, and ad hoc decision criteria may often be misleading.
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Affiliation(s)
- Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
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3
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Long MB, Chotirmall SH, Shteinberg M, Chalmers JD. Rethinking bronchiectasis as an inflammatory disease. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00176-0. [PMID: 38971168 DOI: 10.1016/s2213-2600(24)00176-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 07/08/2024]
Abstract
Bronchiectasis is understood to be the result of a complex interaction between infection, impaired mucociliary clearance, inflammation, and lung damage. Current therapeutic approaches to bronchiectasis are heavily focused on management of infection along with enhancing mucus clearance. Long-term antibiotics have had limited success in clinical trials, suggesting a need to re-evaluate the concept of bronchiectasis as an infective disorder. We invoke the example of asthma, for which treatment paradigms shifted away from targeting smooth muscle constriction, towards permanently suppressing airway inflammation, reducing risk and ultimately inducing remission with precision anti-inflammatory treatments. In this Review, we argue that bronchiectasis is primarily a chronic inflammatory disease, requiring early identification of at-risk individuals, and we introduce a novel concept of disease activity with important implications for clinical practice and future research. A new generation of novel anti-inflammatory treatments are under development and repurposing of anti-inflammatory agents from other diseases could revolutionise patient care.
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Affiliation(s)
- Merete B Long
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel; The Technion, Israel Institute of Technology, The B Rappaport Faculty of Medicine, Haifa, Israel
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK.
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4
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Gao Y, Richardson H, Dicker AJ, Barton A, Kuzmanova E, Shteinberg M, Perea L, Goeminne PC, Cant E, Hennayake C, Pollock J, Abo Leyah H, Choi H, Polverino E, Blasi F, Welte T, Aliberti S, Long M, Shoemark A, Sibila O, Huang JTJ, Chalmers JD. Endotypes of Exacerbation in Bronchiectasis: An Observational Cohort Study. Am J Respir Crit Care Med 2024; 210:77-86. [PMID: 38717347 DOI: 10.1164/rccm.202310-1729oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 05/07/2024] [Indexed: 07/02/2024] Open
Abstract
Rationale: Bronchiectasis is characterized by acute exacerbations, but the biological mechanisms underlying these events are poorly characterized. Objectives: To investigate the inflammatory and microbial characteristics of exacerbations of bronchiectasis. Methods: A total of 120 patients with bronchiectasis were enrolled and presented with acute exacerbations within 12 months. Spontaneous sputum samples were obtained during a period of clinical stability and again at exacerbation before receipt of antibiotic treatment. A validated rapid PCR assay for bacteria and viruses was used to classify exacerbations as bacterial, viral, or both. Sputum inflammatory assessments included label-free liquid chromatography-tandem mass spectrometry and measurement of sputum cytokines and neutrophil elastase activity. 16 s rRNA sequencing was used to characterize the microbiome. Measurements and Main Results: Bronchiectasis exacerbations showed profound molecular heterogeneity. At least one bacterium was identified in 103 samples (86%), and a high bacterial load (total bacterial load > 107 copies/g) was observed in 81 patients (68%). Respiratory viruses were identified in 55 (46%) patients, with rhinovirus being the most common virus (31%). PCR testing was more sensitive than culture. No consistent change in the microbiome was observed at exacerbation. Exacerbations were associated with increased neutrophil elastase, proteinase-3, IL-1β, and CXCL8. These markers were particularly associated with bacterial and bacterial plus viral exacerbations. Distinct inflammatory and microbiome profiles were seen between different exacerbation subtypes, including bacterial, viral, and eosinophilic events in both hypothesis-led and hypothesis-free analysis using integrated microbiome and proteomics, demonstrating four subtypes of exacerbation. Conclusions: Bronchiectasis exacerbations are heterogeneous events with contributions from bacteria, viruses, and inflammatory dysregulation.
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Affiliation(s)
- Yonghua Gao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hollian Richardson
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Alison J Dicker
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Alun Barton
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Elena Kuzmanova
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Michal Shteinberg
- Pulmonology Institute and Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel
| | - Lidia Perea
- Respiratory Institute, Hospital Clínic, Institute of Biomedical Research August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Pieter C Goeminne
- Department of Respiratory Disease, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Erin Cant
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Chandani Hennayake
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Jennifer Pollock
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Hani Abo Leyah
- Department of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Hayoung Choi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBERES, Barcelona, Spain
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; and
| | - Stefano Aliberti
- Istituto di Ricovero e Cura a Carattere Scientifico di natura pubblica Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Merete Long
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Amelia Shoemark
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Oriol Sibila
- Respiratory Institute, Hospital Clínic, Institute of Biomedical Research August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Jeffrey T J Huang
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
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Mac Aogáin M, Dicker AJ, Mertsch P, Chotirmall SH. Infection and the microbiome in bronchiectasis. Eur Respir Rev 2024; 33:240038. [PMID: 38960615 PMCID: PMC11220623 DOI: 10.1183/16000617.0038-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/02/2024] [Indexed: 07/05/2024] Open
Abstract
Bronchiectasis is marked by bronchial dilatation, recurrent infections and significant morbidity, underpinned by a complex interplay between microbial dysbiosis and immune dysregulation. The identification of distinct endophenotypes have refined our understanding of its pathogenesis, including its heterogeneous disease mechanisms that influence treatment and prognosis responses. Next-generation sequencing (NGS) has revolutionised the way we view airway microbiology, allowing insights into the "unculturable". Understanding the bronchiectasis microbiome through targeted amplicon sequencing and/or shotgun metagenomics has provided key information on the interplay of the microbiome and host immunity, a central feature of disease progression. The rapid increase in translational and clinical studies in bronchiectasis now provides scope for the application of precision medicine and a better understanding of the efficacy of interventions aimed at restoring microbial balance and/or modulating immune responses. Holistic integration of these insights is driving an evolving paradigm shift in our understanding of bronchiectasis, which includes the critical role of the microbiome and its unique interplay with clinical, inflammatory, immunological and metabolic factors. Here, we review the current state of infection and the microbiome in bronchiectasis and provide views on the future directions in this field.
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Affiliation(s)
- Micheál Mac Aogáin
- Biochemical Genetics Laboratory, Department of Biochemistry, St. James's Hospital, Dublin, Ireland
- Clinical Biochemistry Unit, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Alison J Dicker
- Respiratory Research Group, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Pontus Mertsch
- Department of Medicine V, LMU University Hospital, LMU Munich, Comprehensive Pneumology Center (CPC), Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
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6
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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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Wang J, Guo Y, Lu W, Liu X, Zhang J, Sun J, Chai G. Dry powder inhalation containing muco-inert ciprofloxacin and colistin co-loaded liposomes for pulmonary P. Aeruginosa biofilm eradication. Int J Pharm 2024; 658:124208. [PMID: 38723731 DOI: 10.1016/j.ijpharm.2024.124208] [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: 01/23/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
Pseudomonas aeruginosa (PA), a predominant pathogen in lung infections, poses significant challenges due to its biofilm formation, which is the primary cause of chronic and recalcitrant pulmonary infections. Bacteria within these biofilms exhibit heightened resistance to antibiotics compared to their planktonic counterparts, and their secreted toxins exacerbate lung infections. Diverging from traditional antibacterial therapy for biofilm eradication, this study introduces a novel dry powder inhalation containing muco-inert ciprofloxacin and colistin co-encapsulated liposomes (Cipro-Col-Lips) prepared using ultrasonic spray freeze drying (USFD) technique. This USFD dry powder is designed to efficiently deliver muco-inert Cipro-Col-Lips to the lungs. Once deposited, the liposomes rapidly diffuse into the airway mucus, reaching the biofilm sites. The muco-inert Cipro-Col-Lips neutralize the biofilm-secreted toxins and simultaneously trigger the release of their therapeutic payload, exerting a synergistic antibiofilm effect. Our results demonstrated that the optimal USFD liposomal dry powder formulation exhibited satisfactory in vitro aerosol performance in terms of fine particle fraction (FPF) of 44.44 ± 0.78 %, mass median aerodynamic diameter (MMAD) of 4.27 ± 0.21 μm, and emitted dose (ED) of 99.31 ± 3.31 %. The muco-inert Cipro-Col-Lips effectively penetrate the airway mucus and accumulate at the biofilm site, neutralizing toxins and safeguarding lung cells. The triggered release of ciprofloxacin and colistin works synergistically to reduce the biofilm's antibiotic resistance, impede the development of antibiotic resistance, and eliminate 99.99 % of biofilm-embedded bacteria, including persister bacteria. Using a PA-beads induced biofilm-associated lung infection mouse model, the in vivo efficacy of this liposomal dry powder aerosol was tested, and the results demonstrated that this liposomal dry powder aerosol achieved a 99.7 % reduction in bacterial colonization, and significantly mitigated inflammation and pulmonary fibrosis. The USFD dry powder inhalation containing muco-inert Cipro-Col-Lips emerges as a promising therapeutic strategy for treating PA biofilm-associated lung infections.
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Affiliation(s)
- Jian Wang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease Guangzhou Institute of Respiratory Health The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou 510120, Guangdong, China
| | - Yutong Guo
- State Key Laboratory of Anti-Infective Drug Discovery and Development, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, China
| | - Wenju Lu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease Guangzhou Institute of Respiratory Health The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou 510120, Guangdong, China
| | - Xinyue Liu
- State Key Laboratory of Anti-Infective Drug Discovery and Development, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, China
| | - Jingfeng Zhang
- The Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo 315000, China
| | - Jihong Sun
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Guihong Chai
- State Key Laboratory of Anti-Infective Drug Discovery and Development, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, China.
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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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9
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Islam N, Reid D. Inhaled antibiotics: A promising drug delivery strategies for efficient treatment of lower respiratory tract infections (LRTIs) associated with antibiotic resistant biofilm-dwelling and intracellular bacterial pathogens. Respir Med 2024; 227:107661. [PMID: 38729529 DOI: 10.1016/j.rmed.2024.107661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/12/2024]
Abstract
Antibiotic-resistant bacteria associated with LRTIs are frequently associated with inefficient treatment outcomes. Antibiotic-resistant Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Staphylococcus aureus, infections are strongly associated with pulmonary exacerbations and require frequent hospital admissions, usually following failed management in the community. These bacteria are difficult to treat as they demonstrate multiple adaptational mechanisms including biofilm formation to resist antibiotic threats. Currently, many patients with the genetic disease cystic fibrosis (CF), non-CF bronchiectasis (NCFB) and chronic obstructive pulmonary disease (COPD) experience exacerbations of their lung disease and require high doses of systemically administered antibiotics to achieve meaningful clinical effects, but even with high systemic doses penetration of antibiotic into the site of infection within the lung is suboptimal. Pulmonary drug delivery technology that reliably deliver antibacterials directly into the infected cells of the lungs and penetrate bacterial biofilms to provide therapeutic doses with a greatly reduced risk of systemic adverse effects. Inhaled liposomal-packaged antibiotic with biofilm-dissolving drugs offer the opportunity for targeted, and highly effective antibacterial therapeutics in the lungs. Although the challenges with development of some inhaled antibiotics and their clinicals trials have been studied; however, only few inhaled products are available on market. This review addresses the current treatment challenges of antibiotic-resistant bacteria in the lung with some clinical outcomes and provides future directions with innovative ideas on new inhaled formulations and delivery technology that promise enhanced killing of antibiotic-resistant biofilm-dwelling bacteria.
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Affiliation(s)
- Nazrul Islam
- Pharmacy Discipline, School of Clinical Sciences, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Centre for Immunology and Infection Control (CIIC), Queensland University of Technology, Brisbane, Queensland, Australia; Centre for Materials Science, Queensland University of Technology, Brisbane, Queensland, Australia.
| | - David Reid
- Lung Inflammation and Infection, QIMR Berghofer Medical Research Institute, Australia
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10
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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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11
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Gao YH, Zheng HZ, Lu HW, Li YY, Feng Y, Gu SY, Sun XL, Mao B, Bai JW, Liang S, Cheng KB, Li JX, Ge A, Li MH, Yang JW, Bai L, Yu HY, Qu JM, Xu JF. Quality-of-Life Bronchiectasis Respiratory Symptom Scale Predicts the Risk of Exacerbations in Adults with Bronchiectasis: A Prospective Observational Study. Ann Am Thorac Soc 2024; 21:393-401. [PMID: 37962906 DOI: 10.1513/annalsats.202302-133oc] [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: 02/12/2023] [Accepted: 11/13/2023] [Indexed: 11/15/2023] Open
Abstract
Rationale: The relationship between symptoms, measured using a validated disease-specific questionnaire, and longitudinal exacerbation risk has not been demonstrated in bronchiectasis. Objectives: The aim of this study is to investigate whether baseline symptoms, assessed using the Quality-of-Life Bronchiectasis Respiratory Symptom Scale (QoL-B-RSS) and its individual component scores, could predict future exacerbation risk in patients with bronchiectasis. Methods: The study included 436 adults with bronchiectasis from three tertiary hospitals. Symptoms were measured using the QoL-B-RSS, with scores ranging from 0 to 100, where lower scores indicated more severe symptoms. We examined whether symptoms as continuous measures were associated with the risk of exacerbation over 12 months. The analysis was also repeated for individual components of the QoL-B-RSS score. Results: The baseline QoL-B-RSS score was associated with an increased risk of exacerbations (rate ratio, 1.25 for each 10-point decrease; 95% confidence interval [CI], 1.15-1.35; P < 0.001), hospitalizations (rate ratio, 1.24; 95% CI, 1.05-1.43; P = 0.02), and reduced time to the first exacerbation (hazard ratio, 1.12; 95% CI, 1.03-1.21; P = 0.01) over 12 months, even after adjusting for relevant confounders, including exacerbation history. The QoL-B-RSS score was comparable to exacerbation history in its association with future frequent exacerbations (defined as three or more exacerbations per year) and hospitalization (area under the curve, 0.86 vs. 0.84; P = 0.46; and area under the curve, 0.81 vs. 0.83; P = 0.41, respectively). Moreover, patients with more severe symptoms in the majority of individual components of the QoL-B-RSS were more likely to experience exacerbations. Conclusions: Symptoms can serve as useful indicators for identifying patients at increased risk of exacerbation in bronchiectasis. Beyond relying solely on exacerbation history, a comprehensive assessment of symptoms could facilitate timely and cost-effective implementation of interventions for exacerbation prevention.
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Affiliation(s)
- Yong-Hua Gao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Hui-Zhen Zheng
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Hai-Wen Lu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Yuan-Yuan Li
- Department of Respiratory Medicine, Branch of National Clinical Research Center for Respiratory Disease, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China; and
| | - Yun Feng
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital and
- Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shu-Yi Gu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Xiao-Li Sun
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Bei Mao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Jiu-Wu Bai
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Shuo Liang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Ke-Bin Cheng
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Jian-Xiong Li
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Ai Ge
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Man-Hui Li
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Jia-Wei Yang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Lu Bai
- Department of Respiratory Medicine, Branch of National Clinical Research Center for Respiratory Disease, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China; and
| | - Han-Yu Yu
- Department of Respiratory Medicine, Branch of National Clinical Research Center for Respiratory Disease, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China; and
| | - Jie-Ming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital and
- Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, and
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
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12
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Heyard R, Held L, Schneeweiss S, Wang SV. Design differences and variation in results between randomised trials and non-randomised emulations: meta-analysis of RCT-DUPLICATE data. BMJ MEDICINE 2024; 3:e000709. [PMID: 38348308 PMCID: PMC10860009 DOI: 10.1136/bmjmed-2023-000709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 12/27/2023] [Indexed: 02/15/2024]
Abstract
Objective To explore how design emulation and population differences relate to variation in results between randomised controlled trials (RCT) and non-randomised real world evidence (RWE) studies, based on the RCT-DUPLICATE initiative (Randomised, Controlled Trials Duplicated Using Prospective Longitudinal Insurance Claims: Applying Techniques of Epidemiology). Design Meta-analysis of RCT-DUPLICATE data. Data sources Trials included in RCT-DUPLICATE, a demonstration project that emulated 32 randomised controlled trials using three real world data sources: Optum Clinformatics Data Mart, 2004-19; IBM MarketScan, 2003-17; and subsets of Medicare parts A, B, and D, 2009-17. Eligibility criteria for selecting studies Trials where the primary analysis resulted in a hazard ratio; 29 RCT-RWE study pairs from RCT-DUPLICATE. Results Differences and variation in effect sizes between the results from randomised controlled trials and real world evidence studies were investigated. Most of the heterogeneity in effect estimates between the RCT-RWE study pairs in this sample could be explained by three emulation differences in the meta-regression model: treatment started in hospital (which does not appear in health insurance claims data), discontinuation of some baseline treatments at randomisation (which would have been an unusual care decision in clinical practice), and delayed onset of drug effects (which would be under-reported in real world clinical practice because of the relatively short persistence of the treatment). Adding the three emulation differences to the meta-regression reduced heterogeneity from 1.9 to almost 1 (absence of heterogeneity). Conclusions This analysis suggests that a substantial proportion of the observed variation between results from randomised controlled trials and real world evidence studies can be attributed to differences in design emulation.
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Affiliation(s)
- Rachel Heyard
- Center for Reproducible Science, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Leonhard Held
- Center for Reproducible Science, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology, Brigham and Womems Hospital Harvard Medical School, Boston, Massachusetts, USA
| | - Shirley V Wang
- Division of Pharmacoepidemiology, Brigham and Womems Hospital Harvard Medical School, Boston, Massachusetts, USA
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13
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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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14
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Barbosa M, Chalmers JD. Bronchiectasis. Presse Med 2023; 52:104174. [PMID: 37778637 DOI: 10.1016/j.lpm.2023.104174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023] Open
Abstract
Bronchiectasis is a final common pathway of a wide variety of underlying conditions including infectious, autoimmune, allergic, genetic and inflammatory conditions. Patients experience a chronic disease with variable clinical symptoms and course, but most experience cough, sputum production and recurrent exacerbations. Symptoms of bronchiectasis lead to poor quality of life and exacerbations are the major driver of morbidity and mortality. Patients are often chronically infected with bacteria with the most common being Pseudomonas aeruginosa and Haemophilus influenzae. Treatment of bronchiectasis includes standardised testing to identify the underlying cause with targeted treatment if immune deficiency, allergic bronchopulmonary aspergillosis or non-tuberculous mycobacterial infection, for example, are identified. Airway clearance is the mainstay of therapy for patients with symptoms of cough and sputum production. Frequently exacerbating patients may benefit from long term antibiotic or mucoactive therapies. Bronchiectasis is a heterogeneous disease and increasingly precision medicine approaches are advocated to target treatments most appropriately and to limit the emergence of antimicrobial resistance.
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Affiliation(s)
- Miguel Barbosa
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.
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15
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Lenders V, Koutsoumpou X, Phan P, Soenen SJ, Allegaert K, de Vleeschouwer S, Toelen J, Zhao Z, Manshian BB. Modulation of engineered nanomaterial interactions with organ barriers for enhanced drug transport. Chem Soc Rev 2023; 52:4672-4724. [PMID: 37338993 DOI: 10.1039/d1cs00574j] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
The biomedical use of nanoparticles (NPs) has been the focus of intense research for over a decade. As most NPs are explored as carriers to alter the biodistribution, pharmacokinetics and bioavailability of associated drugs, the delivery of these NPs to the tissues of interest remains an important topic. To date, the majority of NP delivery studies have used tumor models as their tool of interest, and the limitations concerning tumor targeting of systemically administered NPs have been well studied. In recent years, the focus has also shifted to other organs, each presenting their own unique delivery challenges to overcome. In this review, we discuss the recent advances in leveraging NPs to overcome four major biological barriers including the lung mucus, the gastrointestinal mucus, the placental barrier, and the blood-brain barrier. We define the specific properties of these biological barriers, discuss the challenges related to NP transport across them, and provide an overview of recent advances in the field. We discuss the strengths and shortcomings of different strategies to facilitate NP transport across the barriers and highlight some key findings that can stimulate further advances in this field.
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Affiliation(s)
- Vincent Lenders
- Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium.
| | - Xanthippi Koutsoumpou
- Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium.
| | - Philana Phan
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Stefaan J Soenen
- Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium.
- NanoHealth and Optical Imaging Group, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, CN Rotterdam, 3015, The Netherlands
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B3000 Leuven, Belgium
- Leuven Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
- Woman and Child, Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Steven de Vleeschouwer
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Leuven, Belgium
- Leuven Brain Institute (LBI), KU Leuven, Leuven, Belgium
| | - Jaan Toelen
- Leuven Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
- Woman and Child, Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Zongmin Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Bella B Manshian
- Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium.
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16
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Heyard R, Held L, Schneeweiss S, Wang SV. DESIGN DIFFERENCES EXPLAIN VARIATION IN RESULTS BETWEEN RANDOMIZED TRIALS AND THEIR NON-RANDOMIZED EMULATIONS. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.13.23292601. [PMID: 37502999 PMCID: PMC10370236 DOI: 10.1101/2023.07.13.23292601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Objectives While randomized controlled trials (RCTs) are considered a standard for evidence on the efficacy of medical treatments, non-randomized real-world evidence (RWE) studies using data from health insurance claims or electronic health records can provide important complementary evidence. The use of RWE to inform decision-making has been questioned because of concerns regarding confounding in non-randomized studies and the use of secondary data. RCT-DUPLICATE was a demonstration project that emulated the design of 32 RCTs with non-randomized RWE studies. We sought to explore how emulation differences relate to variation in results between the RCT-RWE study pairs. Methods We include all RCT-RWE study pairs from RCT-DUPLICATE where the measure of effect was a hazard ratio and use exploratory meta-regression methods to explain differences and variation in the effect sizes between the results from the RCT and the RWE study. The considered explanatory variables are related to design and population differences. Results Most of the observed variation in effect estimates between RCT-RWE study pairs in this sample could be explained by three emulation differences in the meta-regression model: (i) in-hospital start of treatment (not observed in claims data), (ii) discontinuation of certain baseline therapies at randomization (not part of clinical practice), (iii) delayed onset of drug effects (missed by short medication persistence in clinical practice). Conclusions This analysis suggests that a substantial proportion of the observed variation between results from RCTs and RWE studies can be attributed to design emulation differences. (238 words).
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Affiliation(s)
- Rachel Heyard
- Center for Reproducible Science, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland
| | - Leonhard Held
- Center for Reproducible Science, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremon St, Boston MA 02120
| | - Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremon St, Boston MA 02120
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17
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Chalmers JD, Polverino E, Crichton ML, Ringshausen FC, De Soyza A, Vendrell M, Burgel PR, Haworth CS, Loebinger MR, Dimakou K, Murris M, Wilson R, Hill AT, Menendez R, Torres A, Welte T, Blasi F, Altenburg J, Shteinberg M, Boersma W, Elborn JS, Goeminne PC, Aliberti S. Bronchiectasis in Europe: data on disease characteristics from the European Bronchiectasis registry (EMBARC). THE LANCET. RESPIRATORY MEDICINE 2023; 11:637-649. [PMID: 37105206 DOI: 10.1016/s2213-2600(23)00093-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Bronchiectasis is a heterogeneous, neglected disease with few multicentre studies exploring the causes, severity, microbiology, and treatment of the disease across Europe. This aim of this study was to describe the clinical characteristics of bronchiectasis and compare between different European countries. METHODS EMBARC is an international clinical research network for bronchiectasis. We report on a multicentre, prospective, observational, non-interventional, cohort study (the EMBARC registry) conducted across 27 European countries and Israel. Comprehensive clinical data were collected from adult patients (aged ≥18 years) at baseline and annual follow-up visits using electronic case report form. Data from individual countries were grouped into four regions (the UK, northern and western Europe, southern Europe, and central and eastern Europe according to modified EU EuroVoc classification). Follow-up data were used to explore differences in exacerbation frequency between regions using a negative binomial regression model. FINDINGS Between Jan 12, 2015, and April 12, 2022, 16 963 individuals were enrolled. Median age was 67 years (IQR 57-74), 10 335 (60·9%) participants were female and 6628 (39·1%) were male. The most common cause of bronchiectasis in all 16 963 participants was post-infective disease in 3600 (21·2%); 6466 individuals (38·1%) were classified as idiopathic. Individuals with bronchiectasis experienced a median of two exacerbations (IQR 1-4) per year and 4483 (26·4%) patients had a hospitalisation for exacerbation in the previous year. When examining the percentage of all isolated bacteria, marked differences in microbiology were seen between countries, with a higher frequency of Pseudomonas aeruginosa and lower Haemophilus influenzae frequency in southern Europe, compared with higher H influenzae in the UK and northern and western Europe. Compared with other regions, patients in central and eastern Europe had more severe bronchiectasis measured by the Bronchiectasis Severity Index (51·3% vs 35·1% in the overall cohort) and more exacerbations leading to hospitalisations (57·9% vs 26·4% in the overall cohort). Overall, patients in central and eastern Europe had an increased frequency of exacerbations (adjusted rate ratio [RR] 1·12, 95% CI 1·01-1·25) and a higher frequency of exacerbations leading to hospitalisations (adjusted RR 1·71, 1·44-2·02) compared with patients in other regions. Treatment of bronchiectasis was highly heterogeneous between regions. INTERPRETATION Bronchiectasis shows important geographical variation in causes, microbiology, severity, and outcomes across Europe. FUNDING European Union-European Federation of Pharmaceutical Industries and Associations Innovative Medicines Initiative. TRANSLATIONS For the Arabic, French, German, Greek, Hebrew, Irish, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Thorax Institute, Institute of Biomedical Research August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Megan L Crichton
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Felix C Ringshausen
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, German Center for Lung Research, Hannover, Germany; European Reference Network on Rare and Complex Respiratory Diseases, Frankfurt, Germany
| | - Anthony De Soyza
- Population and Health Science Institute, Newcastle University and NIHR Biomedical Research Centre for Ageing, Freeman Hospital, Newcastle, UK
| | - Montserrat Vendrell
- Department of Pulmonology, Dr Trueta University Hospital, IDIBGL UdG, Girona, Spain
| | - Pierre Régis Burgel
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, AP-HP and Université Paris Cité, Inserm U1016, Institut Cochin, Paris, France
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital and University of Cambridge, Cambridge, UK
| | - Michael R Loebinger
- Royal Brompton and Harefield Hospitals and National Heart and Lung Institute, Imperial College London, London, UK
| | - Katerina Dimakou
- 5th Respiratory Medicine Department, General Hospital for Chest Diseases of Athens SOTIRIA, Athens, Greece
| | - Marlene Murris
- Department of Respiratory Diseases, CHU Toulouse, Toulouse, France
| | - Robert Wilson
- Royal Brompton and Harefield Hospitals and National Heart and Lung Institute, Imperial College London, London, UK
| | - Adam T Hill
- Royal Infirmary of Edinburgh, Department of Respiratory Medicine, Edinburgh, Edinburgh, UK
| | - Rosario Menendez
- Pneumology Department, Hospital Universitario y Politécnico La Fe-Instituto de Investigación Sanitaria La Fe, Valencia, Spain; Pneumology Department, Hospital Universitario y Politécnico La Fe, Avda, Valencia, Spain
| | - Antoni Torres
- Hospital Clinic of Barcelona, Spain University of Barcelona, CIBERES, IDIBAPS, Barcelona, Spain
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, German Center for Lung Research, Hannover, Germany; European Reference Network on Rare and Complex Respiratory Diseases, Frankfurt, Germany
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Josje Altenburg
- Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel
| | - Wim Boersma
- Department of Pulmonary Diseases, Northwest Clinics, Alkmaar, Netherlands
| | - J Stuart Elborn
- Faculty of Medicine, Health and Life Sciences, Queen's University, Belfast, UK
| | | | - Stefano Aliberti
- IRCCS Humanitas Research Hospital, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
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18
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Gao YH, Guan WJ. The BED-Pro Tool: facilitating the detection of bronchiectasis exacerbations. ERJ Open Res 2023; 9:00087-2023. [PMID: 37143843 PMCID: PMC10152263 DOI: 10.1183/23120541.00087-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 05/06/2023] Open
Abstract
The Bronchiectasis Exacerbation Diary is an eight-item patient-reported outcome instrument for detecting exacerbations in bronchiectasis https://bit.ly/3k2IH4p.
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Affiliation(s)
- Yong-hua Gao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
- Corresponding author: Yong-hua Gao ()
| | - Wei-jie Guan
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, 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
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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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20
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Wang SV, Schneeweiss S, Franklin JM, Desai RJ, Feldman W, Garry EM, Glynn RJ, Lin KJ, Paik J, Patorno E, Suissa S, D'Andrea E, Jawaid D, Lee H, Pawar A, Sreedhara SK, Tesfaye H, Bessette LG, Zabotka L, Lee SB, Gautam N, York C, Zakoul H, Concato J, Martin D, Paraoan D, Quinto K. Emulation of Randomized Clinical Trials With Nonrandomized Database Analyses: Results of 32 Clinical Trials. JAMA 2023; 329:1376-1385. [PMID: 37097356 PMCID: PMC10130954 DOI: 10.1001/jama.2023.4221] [Citation(s) in RCA: 102] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/04/2023] [Indexed: 04/26/2023]
Abstract
Importance Nonrandomized studies using insurance claims databases can be analyzed to produce real-world evidence on the effectiveness of medical products. Given the lack of baseline randomization and measurement issues, concerns exist about whether such studies produce unbiased treatment effect estimates. Objective To emulate the design of 30 completed and 2 ongoing randomized clinical trials (RCTs) of medications with database studies using observational analogues of the RCT design parameters (population, intervention, comparator, outcome, time [PICOT]) and to quantify agreement in RCT-database study pairs. Design, Setting, and Participants New-user cohort studies with propensity score matching using 3 US claims databases (Optum Clinformatics, MarketScan, and Medicare). Inclusion-exclusion criteria for each database study were prespecified to emulate the corresponding RCT. RCTs were explicitly selected based on feasibility, including power, key confounders, and end points more likely to be emulated with real-world data. All 32 protocols were registered on ClinicalTrials.gov before conducting analyses. Emulations were conducted from 2017 through 2022. Exposures Therapies for multiple clinical conditions were included. Main Outcomes and Measures Database study emulations focused on the primary outcome of the corresponding RCT. Findings of database studies were compared with RCTs using predefined metrics, including Pearson correlation coefficients and binary metrics based on statistical significance agreement, estimate agreement, and standardized difference. Results In these highly selected RCTs, the overall observed agreement between the RCT and the database emulation results was a Pearson correlation of 0.82 (95% CI, 0.64-0.91), with 75% meeting statistical significance, 66% estimate agreement, and 75% standardized difference agreement. In a post hoc analysis limited to 16 RCTs with closer emulation of trial design and measurements, concordance was higher (Pearson r, 0.93; 95% CI, 0.79-0.97; 94% meeting statistical significance, 88% estimate agreement, 88% standardized difference agreement). Weaker concordance occurred among 16 RCTs for which close emulation of certain design elements that define the research question (PICOT) with data from insurance claims was not possible (Pearson r, 0.53; 95% CI, 0.00-0.83; 56% meeting statistical significance, 50% estimate agreement, 69% standardized difference agreement). Conclusions and Relevance Real-world evidence studies can reach similar conclusions as RCTs when design and measurements can be closely emulated, but this may be difficult to achieve. Concordance in results varied depending on the agreement metric. Emulation differences, chance, and residual confounding can contribute to divergence in results and are difficult to disentangle.
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Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Now with Optum, Boston, Massachusetts
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William Feldman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julie Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Elvira D'Andrea
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Now with AbbVie Inc, Washington, DC
| | - Dureshahwar Jawaid
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sushama Kattinakere Sreedhara
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Helen Tesfaye
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luke Zabotka
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nileesa Gautam
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cassie York
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heidi Zakoul
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John Concato
- Office of Medical Policy, US Food and Drug Administration, Silver Springs, Maryland
| | - David Martin
- Office of Medical Policy, US Food and Drug Administration, Silver Springs, Maryland
- Now with Moderna, Cambridge, Massachusetts
| | - Dianne Paraoan
- Office of Medical Policy, US Food and Drug Administration, Silver Springs, Maryland
| | - Kenneth Quinto
- Office of Medical Policy, US Food and Drug Administration, Silver Springs, Maryland
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21
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Flume PA, Basavaraj A, Garcia B, Winthrop K, Di Mango E, Daley CL, Philley JV, Henkle E, O'Donnell AE, Metersky M. Towards development of evidence to inform recommendations for the evaluation and management of bronchiectasis. Respir Med 2023; 211:107217. [PMID: 36931575 DOI: 10.1016/j.rmed.2023.107217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/17/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023]
Abstract
Bronchiectasis (BE) is a chronic condition characterized by airway dilation as a consequence of a variety of pathogenic processes. It is often associated with persistent airway infection and an inflammatory response resulting in cough productive of purulent sputum, which has an adverse impact on quality of life. The prevalence of BE is increasing worldwide. Treatment guidelines exist for managing BE, but they are generally informed by a paucity of high-quality evidence. This review presents the findings of a scientific advisory board of experts held in the United States in November 2020. The main focus of the meeting was to identify unmet needs in BE and propose ways to identify research priorities for the management of BE, with a view to developing evidence-based treatment recommendations. Key issues identified include diagnosis, patient evaluation, promoting airway clearance and appropriate use of antimicrobials. Unmet needs include effective pharmacological agents to promote airway clearance and reduce inflammation, control of chronic infection, clinical endpoints to be used in the design of BE clinical trials, and more accurate classification of patients using phenotypes and endotypes to better guide treatment decisions and improve outcomes.
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Affiliation(s)
- Patrick A Flume
- Department of Medicine and Pediatrics, Medical University of South Carolina, 96 Jonathan Lucas Street, Room 816-CSB, Charleston, SC, USA.
| | - Ashwin Basavaraj
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine, 462 First Avenue, Administration Building OBV, A601, New York, NY, 10016, USA.
| | - Bryan Garcia
- University of Alabama at Birmingham, 1900 University Blvd, THT Suite 541A, Birmingham, AL, 35233, USA.
| | - Kevin Winthrop
- Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, 97239, Portland, OR, USA.
| | - Emily Di Mango
- Department of Medicine, Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA.
| | - Charles L Daley
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO, 80206, USA.
| | - Julie V Philley
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at Tyler, 11937 US Hwy 271, 75708, Tyler, USA.
| | - Emily Henkle
- Oregon Health and Science University, OHSU-PSU School of Public Health, 3181 SW Sam Jackson Park Rd, Mailcode VPT, Portland, OR, 97239, USA.
| | - Anne E O'Donnell
- Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Medical Center, Washington, DC, USA.
| | - Mark Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030-1321, USA.
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22
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Abstract
PURPOSE OF REVIEW The incidence of bacterial respiratory tract infections is growing. In a context of increasing antibiotic resistance and lack of new classes of antibiotics, inhaled antibiotics emerge as a promising therapeutic strategy. Although they are generally used for cystic fibrosis, their use in other conditions is becoming more frequent, including no-cystic fibrosis bronchiectasis, pneumonia and mycobacterial infections. RECENT FINDINGS Inhaled antibiotics exert beneficial microbiological effects in bronchiectasis and chronic bronchial infection. In nosocomial and ventilator-associated pneumonia, aerosolized antibiotics improve cure rates and bacterial eradication. In refractory Mycobacterium avium complex infections, amikacin liposome inhalation suspension is more effective in achieving long-lasting sputum conversion. In relation to biological inhaled antibiotics (antimicrobial peptides, interfering RNA and bacteriophages), currently in development, there is no still enough evidence that support their use in clinical practice. SUMMARY The effective antimicrobiological activity of inhaled antibiotics, added to their potential to overcoming resistances to systemic antibiotics, make inhaled antibiotics a plausible alternative.
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23
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Guan WJ, Xu JF, Luo H, Xu XX, Song YL, Ma WL, Liang ZA, Liu XD, Zhang GJ, Zhang XJ, Li RK, Zhu SY, Zhang YJ, Cai XJ, Wei LP, Tian DB, Zhao H, Chen PY, Qu JM, Zhong NS. A Double-Blind Randomized Placebo-Controlled Phase 3 Trial of Tobramycin Inhalation Solution in Adults With Bronchiectasis With Pseudomonas aeruginosa Infection. Chest 2023; 163:64-76. [PMID: 35863486 DOI: 10.1016/j.chest.2022.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/26/2022] [Accepted: 07/09/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Few large-scale studies have demonstrated the efficacy of tobramycin nebulization in bronchiectasis. We evaluated the efficacy and safety of nebulized tobramycin inhalation solution (TIS) in adults with bronchiectasis with Pseudomonas aeruginosa infection. RESEARCH QUESTION Can TIS effectively reduce sputum P aeruginosa density and improve the bronchiectasis-specific quality of life in patients with bronchiectasis with P aeruginosa infection? STUDY DESIGN AND METHODS This was a phase 3, 16-week, multicenter, randomized, double-blind, placebo-controlled trial. Eligible adults with bronchiectasis were recruited from October 2018 to July 2021. On the basis of usual care, patients nebulized TIS (300 mg/5 mL twice daily) or normal saline (5 mL twice daily) via vibrating-mesh nebulizer. Treatment consisted of two cycles, each consisting of 28 days on-treatment and 28 days off-treatment. The coprimary end points included changes from baseline in P aeruginosa density and Quality-of-Life Bronchiectasis Respiratory Symptoms score on day 29. RESULTS The modified intention-to-treat population consisted of 167 patients in the tobramycin group and 172 patients in the placebo group. Compared with placebo, TIS resulted in a significantly greater reduction in P aeruginosa density (adjusted mean difference, 1.74 log10 colony-forming units/g; 95% CI, 1.12-2.35; P < .001) and greater improvement in Quality-of-Life Bronchiectasis Respiratory Symptoms score (adjusted mean difference, 7.91; 95% CI, 5.72-10.11; P < .001) on day 29. Similar findings were observed on day 85. TIS resulted in a significant reduction in 24-h sputum volume and sputum purulence score on days 29, 57, and 85. More patients became culture negative for P aeruginosa in the tobramycin group than in the placebo group on day 29 (29.3% vs 10.6%). The incidence of adverse events and serious adverse events were comparable between the two groups. INTERPRETATION TIS is an effective treatment option and has an acceptable safety profile in patients with bronchiectasis with P aeruginosa infection. TRIAL REGISTRATION ClinicalTrials.gov; No. NCT03715322; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Wei-Jie Guan
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Thoracic Surgery, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Institute of Respiratory Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hong Luo
- Department of Pulmonary and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | | | - Yuan-Lin Song
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wan-Li Ma
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zong-An Liang
- Affiliated West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xue-Dong Liu
- Tsingtao Municipal Hospital, Qingdao, Shandong, China
| | - Guo-Jun Zhang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xiao-Ju Zhang
- Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Rong-Kai Li
- Xinxiang First People's Hospital, Xinxiang, Henan, China
| | - Shu-Yang Zhu
- Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yi-Jie Zhang
- Affiliated Huaihe Hospital of Henan University, Huaihe, Henan, China
| | | | - Li-Ping Wei
- Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Dong-Bo Tian
- Qingyuan People's Hospital, Qingyuan, Guangdong, China
| | - Hui Zhao
- Second Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Ping-Yan Chen
- State Key Laboratory of Organ Failure Research, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University
| | - Jie-Ming Qu
- Affiliated Ruijin Hospital, School of Medicine, Shanghai Jiaotong University
| | - Nan-Shan Zhong
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
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24
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Xu K, Diaz AA, Duan F, Lee M, Xiao X, Liu H, Liu G, Cho MH, Gower AC, Alekseyev YO, Spira A, Aberle DR, Washko GR, Billatos E, Lenburg ME. Bronchial gene expression alterations associated with radiological bronchiectasis. Eur Respir J 2023; 61:2200120. [PMID: 36229050 PMCID: PMC9881226 DOI: 10.1183/13993003.00120-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Discovering airway gene expression alterations associated with radiological bronchiectasis may improve the understanding of the pathobiology of early-stage bronchiectasis. METHODS Presence of radiological bronchiectasis in 173 individuals without a clinical diagnosis of bronchiectasis was evaluated. Bronchial brushings from these individuals were transcriptomically profiled and analysed. Single-cell deconvolution was performed to estimate changes in cellular landscape that may be associated with early disease progression. RESULTS 20 participants have widespread radiological bronchiectasis (three or more lobes). Transcriptomic analysis reflects biological processes associated with bronchiectasis including decreased expression of genes involved in cell adhesion and increased expression of genes involved in inflammatory pathways (655 genes, false discovery rate <0.1, log2 fold-change >0.25). Deconvolution analysis suggests that radiological bronchiectasis is associated with an increased proportion of ciliated and deuterosomal cells, and a decreased proportion of basal cells. Gene expression patterns separated participants into three clusters: normal, intermediate and bronchiectatic. The bronchiectatic cluster was enriched by participants with more lobes of radiological bronchiectasis (p<0.0001), more symptoms (p=0.002), higher SERPINA1 mutation rates (p=0.03) and higher computed tomography derived bronchiectasis scores (p<0.0001). CONCLUSIONS Genes involved in cell adhesion, Wnt signalling, ciliogenesis and interferon-γ pathways had altered expression in the bronchus of participants with widespread radiological bronchiectasis, possibly associated with decreased basal and increased ciliated cells. This gene expression pattern is not only highly enriched among individuals with radiological bronchiectasis, but also associated with airway-related symptoms in those without discernible radiological bronchiectasis, suggesting that it reflects a bronchiectasis-associated, but non-bronchiectasis-specific lung pathophysiological process.
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Affiliation(s)
- Ke Xu
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- K. Xu and A.A. Diaz contributed equally to this work
| | - Alejandro A Diaz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- K. Xu and A.A. Diaz contributed equally to this work
| | - Fenghai Duan
- Department of Biostatistics and Center for Statistical Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Minyi Lee
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Xiaohui Xiao
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Hanqiao Liu
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Gang Liu
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Michael H Cho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Adam C Gower
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Yuriy O Alekseyev
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Avrum Spira
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Denise R Aberle
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - George R Washko
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ehab Billatos
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- E. Billatos and M.E. Lenburg contributed equally to this article as lead authors and supervised the work
| | - Marc E Lenburg
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- E. Billatos and M.E. Lenburg contributed equally to this article as lead authors and supervised the work
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25
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Wong C, Martinez-Garcia MA. Randomized Clinical Trials of Inhaled Antibiotics in Bronchiectasis: Cause for Optimism? Chest 2023; 163:3-5. [PMID: 36628672 DOI: 10.1016/j.chest.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 01/10/2023] Open
Affiliation(s)
- Conroy Wong
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, NZ; Department of Medicine, University of Auckland, Auckland, NZ
| | - Miguel Angel Martinez-Garcia
- Respiratory Department, La Fe University and Politechnic Hospital, Valencia, Spain; CIBERES de enfermedades respiratorias, Instituto de salud Carlos III, Madrid, Spain.
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26
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de la Rosa-Carrillo D, Suárez-Cuartín G, Golpe R, Máiz Carro L, Martinez-Garcia MA. Inhaled Colistimethate Sodium in the Management of Patients with Bronchiectasis Infected by Pseudomonas aeruginosa: A Narrative Review of Current Evidence. Infect Drug Resist 2022; 15:7271-7292. [PMID: 36540105 PMCID: PMC9759979 DOI: 10.2147/idr.s318173] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022] Open
Abstract
International guidelines on the treatment of bronchiectasis indicate that the use of inhaled antibiotics is effective, especially in symptomatic chronic bronchial infection (CBI) due to Pseudomonas aeruginosa (PA). To date, however, no such treatment has been approved by regulatory agencies. Of the inhaled antibiotics on the market, colistimethate sodium (colistin) is one of the most used in many countries, either in its nebulized presentation or as dry powder. Among the characteristics of this antibiotic, it is worth noting that its main target is the lipopolysaccharide in the outer membrane of the cell wall of gram-negative bacteria and that it has a low rate of resistance to PA (<1%). Most observational studies have shown that the use of colistin in patients with bronchiectasis and CBI due to PA results in a decrease in both the number and severity of exacerbations, an improvement in quality of life, a decrease in sputum volume and purulence, and a high rate of PA eradication, although there are no clear differences with respect to other inhaled antibiotics. However, the lack of randomized clinical trials (RCT) with positive results for its main variable (exacerbations) in an intention-to-treat analysis has prevented its approval by regulatory agencies as a formal indication for use in bronchiectasis. The PROMIS program, made up of two RCT with identical methodology, is currently underway. The first of these RCT (already concluded) has demonstrated a clearly positive effect on the group randomized to colistin in its main variable (number of annual exacerbations), while the results of the second are still pending. This review presents exhaustive information on the pharmacological and microbiological characteristics of colistin, the results of the studies carried out to date, and the future challenges associated with this treatment.
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Affiliation(s)
| | - Guillermo Suárez-Cuartín
- Respiratory Department, Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Rafael Golpe
- Respiratory Department, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - Luis Máiz Carro
- Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Miguel Angel Martinez-Garcia
- CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
- Respiratory Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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27
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The BATTLE study: Effects of long-term tobramycin inhalation solution (TIS) once daily on exacerbation rate in patients with non-cystic fibrosis bronchiectasis. Study protocol of a double blind, randomized, placebo-controlled trial: study protocol. Contemp Clin Trials Commun 2022; 30:101045. [DOI: 10.1016/j.conctc.2022.101045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 11/16/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
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28
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Amjad Z, Abaza A, Vasavada AM, Sadhu A, Valencia C, Fatima H, Nwankwo I, Anam M, Maharjan S, Penumetcha SS. 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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Affiliation(s)
- Zainab Amjad
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, King Faisal University, Al Ahsa, SAU
| | - Abdelrahman Abaza
- Pathology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Advait M Vasavada
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Akhil Sadhu
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Carla Valencia
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hameeda Fatima
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ijeoma Nwankwo
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mahvish Anam
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shrinkhala Maharjan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sai Sri Penumetcha
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, IND
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Li L, Mac Aogáin M, Xu T, Jaggi TK, Chan LLY, Qu J, Wei L, Liao S, Cheng HS, Keir HR, Dicker AJ, Tan KS, De Yun W, Koh MS, Ong TH, Lim AYH, Abisheganaden JA, Low TB, Hassan TM, Long X, Wark PAB, Oliver B, Drautz-Moses DI, Schuster SC, Tan NS, Fang M, Chalmers JD, Chotirmall SH. Neisseria species as pathobionts in bronchiectasis. Cell Host Microbe 2022; 30:1311-1327.e8. [PMID: 36108613 DOI: 10.1016/j.chom.2022.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/30/2022] [Accepted: 07/18/2022] [Indexed: 02/07/2023]
Abstract
Neisseria species are frequently identified in the bronchiectasis microbiome, but they are regarded as respiratory commensals. Using a combination of human cohorts, next-generation sequencing, systems biology, and animal models, we show that bronchiectasis bacteriomes defined by the presence of Neisseria spp. associate with poor clinical outcomes, including exacerbations. Neisseria subflava cultivated from bronchiectasis patients promotes the loss of epithelial integrity and inflammation in primary epithelial cells. In vivo animal models of Neisseria subflava infection and metabolipidome analysis highlight immunoinflammatory functional gene clusters and provide evidence for pulmonary inflammation. The murine metabolipidomic data were validated with human Neisseria-dominant bronchiectasis samples and compared with disease in which Pseudomonas-, an established bronchiectasis pathogen, is dominant. Metagenomic surveillance of Neisseria across various respiratory disorders reveals broader importance, and the assessment of the home environment in bronchiectasis implies potential environmental sources of exposure. Thus, we identify Neisseria species as pathobionts in bronchiectasis, allowing for improved risk stratification in this high-risk group.
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Affiliation(s)
- Liang Li
- Department of Pharmacology, School of Medicine, Southern University of Science and Technology, Shenzhen, China; Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Micheál Mac Aogáin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Biochemical Genetics Laboratory, Department of Biochemistry, St. James's Hospital, Dublin, Ireland; Clinical Biochemistry Unit, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Tengfei Xu
- School of Civil and Environmental Engineering, Nanyang Technological University, Singapore, Singapore; College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, PRC
| | - Tavleen Kaur Jaggi
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Louisa L Y Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jing Qu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lan Wei
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Shumin Liao
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hong Sheng Cheng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Holly R Keir
- University of Dundee, Ninewells Hospital, Medical School, Dundee, Scotland
| | - Alison J Dicker
- University of Dundee, Ninewells Hospital, Medical School, Dundee, Scotland
| | - Kai Sen Tan
- Department of Otolaryngology, Infectious Disease Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wang De Yun
- Department of Otolaryngology, Infectious Disease Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Thun How Ong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Albert Yick Hou Lim
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - John A Abisheganaden
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Teck Boon Low
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Xiang Long
- Department of Respiratory Medicine and Critical Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Peter A B Wark
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Brian Oliver
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - Daniela I Drautz-Moses
- Singapore Centre for Environmental Life Sciences Engineering (SCELSE), Nanyang Technological University, Singapore, Singapore
| | - Stephan C Schuster
- Singapore Centre for Environmental Life Sciences Engineering (SCELSE), Nanyang Technological University, Singapore, Singapore
| | - Nguan Soon Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Mingliang Fang
- School of Civil and Environmental Engineering, Nanyang Technological University, Singapore, Singapore; Department of Environmental Science and Engineering, Fudan University, Shanghai 200433, China
| | - James D Chalmers
- University of Dundee, Ninewells Hospital, Medical School, Dundee, Scotland
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore.
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Leong EWX, Ge R. Lipid Nanoparticles as Delivery Vehicles for Inhaled Therapeutics. Biomedicines 2022; 10:2179. [PMID: 36140280 PMCID: PMC9496059 DOI: 10.3390/biomedicines10092179] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/30/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Lipid nanoparticles (LNPs) have emerged as a powerful non-viral carrier for drug delivery. With the prevalence of respiratory diseases, particularly highlighted by the current COVID-19 pandemic, investigations into applying LNPs to deliver inhaled therapeutics directly to the lungs are underway. The progress in LNP development as well as the recent pre-clinical studies in three main classes of inhaled encapsulated drugs: small molecules, nucleic acids and proteins/peptides will be discussed. The advantages of the pulmonary drug delivery system such as reducing systemic toxicity and enabling higher local drug concentration in the lungs are evaluated together with the challenges and design considerations for improved formulations. This review provides a perspective on the future prospects of LNP-mediated delivery of inhaled therapeutics for respiratory diseases.
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Affiliation(s)
| | - Ruowen Ge
- Department of Biological Sciences, Faculty of Science, National University of Singapore, Singapore 117558, Singapore
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31
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32
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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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Twiss J, Stewart A, Gilchrist CA, Keelan JA, Metcalfe R, Byrnes CA. Randomised controlled trial of nebulised gentamicin in children with bronchiectasis. J Paediatr Child Health 2022; 58:1039-1045. [PMID: 35170144 PMCID: PMC9307025 DOI: 10.1111/jpc.15899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 12/06/2021] [Accepted: 01/15/2022] [Indexed: 11/12/2022]
Abstract
AIM Following trials of inhaled antibiotics in adults, this study investigates the efficacy of nebulised gentamicin to improve respiratory function in children with bronchiectasis. METHODS This is a randomised, double-blind, placebo-controlled, crossover trial of 12-week nebulised placebo/gentamicin, 6-week washout, 12-week gentamicin/placebo. Participants were children (5-15 years) with bronchiectasis, chronic infection (any pathogen), and able to perform spirometry from a hospital bronchiectasis clinic. Primary outcomes were change in forced expiratory volume in 1 s (FEV1 ) and hospitalisation days. Secondary outcomes included sputum bacterial density, sputum inflammatory markers, additional antibiotics and symptom severity. Analyses were on an intention-to-treat basis. RESULTS Fifteen children (mean 11.7-years-old) completed the study. There was no significant change in mean FEV1 (56%/55%, P = 0.38) or annual rate of hospital admissions (1.1/0, P = 0.12) between gentamicin and placebo, respectively. However, Haemophilus influenzae sputum growth (27% vs. 80%, P = 0.002) and bacterial density (2.4 log10 cfu/mL lower P < 0.001) improved with gentamicin. Sputum inflammatory markers interleukin-1β (P < 0.001), interleukin-8 (P < 0.001) and tumour necrosis factor-α (P = 0.003) were lower with gentamicin. Poor recruitment limited study power and treatment adherence was challenging for this cohort. CONCLUSIONS In this crossover study of nebulised gentamicin in children with bronchiectasis, there was a reduction in sputum bacterial density and inflammation. However, there were no major improvements in clinical outcomes and adherence was a challenge.
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Affiliation(s)
- Jacob Twiss
- Starship Children's HealthAuckland District Health BoardAucklandNew Zealand
| | - Alistair Stewart
- School of Population HealthFaculty of Medical and Health Sciences, The University of AucklandAucklandNew Zealand
| | - Catherine A Gilchrist
- Department of Paediatrics: Child and Youth HealthFaculty of Medical and Health Sciences, The University of AucklandAucklandNew Zealand
| | - Jeffrey A Keelan
- School of Biomedical SciencesFaculty of Health and Medical Sciences, The University of Western AustraliaPerthWestern AustraliaAustralia
| | - Russell Metcalfe
- Starship Children's HealthAuckland District Health BoardAucklandNew Zealand
| | - Catherine A Byrnes
- Starship Children's HealthAuckland District Health BoardAucklandNew Zealand,Department of Paediatrics: Child and Youth HealthFaculty of Medical and Health Sciences, The University of AucklandAucklandNew Zealand
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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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Antibiotic Management in Bronchiectasis. Clin Chest Med 2022; 43:165-177. [DOI: 10.1016/j.ccm.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Aliberti S, Goeminne PC, O'Donnell AE, Aksamit TR, Al-Jahdali H, Barker AF, Blasi F, Boersma WG, Crichton ML, De Soyza A, Dimakou KE, Elborn SJ, Feldman C, Tiddens H, Haworth CS, Hill AT, Loebinger MR, Martinez-Garcia MA, Meerburg JJ, Menendez R, Morgan LC, Murris MS, Polverino E, Ringshausen FC, Shteinberg M, Sverzellati N, Tino G, Torres A, Vandendriessche T, Vendrell M, Welte T, Wilson R, Wong CA, Chalmers JD. Criteria and definitions for the radiological and clinical diagnosis of bronchiectasis in adults for use in clinical trials: international consensus recommendations. THE LANCET. RESPIRATORY MEDICINE 2022; 10:298-306. [PMID: 34570994 DOI: 10.1016/s2213-2600(21)00277-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/27/2021] [Accepted: 06/03/2021] [Indexed: 12/26/2022]
Abstract
Bronchiectasis refers to both a clinical disease and a radiological appearance that has multiple causes and can be associated with a range of conditions. Disease heterogeneity and the absence of standardised definitions have hampered clinical trials of treatments for bronchiectasis and are important challenges in clinical practice. In view of the need for new therapies for non-cystic fibrosis bronchiectasis to reduce the disease burden, we established an international taskforce of experts to develop recommendations and definitions for clinically significant bronchiectasis in adults to facilitate the standardisation of terminology for clinical trials. Systematic reviews were used to inform discussions, and Delphi processes were used to achieve expert consensus. We prioritised criteria for the radiological diagnosis of bronchiectasis and suggest recommendations on the use and central reading of chest CT scans to confirm the presence of bronchiectasis for clinical trials. Furthermore, we developed a set of consensus statements concerning the definitions of clinical bronchiectasis and its specific signs and symptoms, as well as definitions for chronic bacterial infection and sustained culture conversion. The diagnosis of clinically significant bronchiectasis requires both clinical and radiological criteria, and these expert recommendations and proposals should help to optimise patient recruitment into clinical trials and allow reliable comparisons of treatment effects among different interventions for bronchiectasis. Our consensus proposals should also provide a framework for future research to further refine definitions and establish definitive guidance on the diagnosis of bronchiectasis.
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Affiliation(s)
- Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
| | - Pieter C Goeminne
- Department of Respiratory Disease, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Anne E O'Donnell
- Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Timothy R Aksamit
- Mayo Clinic Pulmonary Disease and Critical Care Medicine, Rochester, MN, USA
| | | | - Alan F Barker
- Pulmonary and Critical Care, Oregon Health and Science University, Portland, OR, USA
| | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | | | - Megan L Crichton
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK
| | - Anthony De Soyza
- Population and Health Science Institute, Newcastle University, National Institute for Health Research Biomedical Research Centre for Ageing and Freeman Hospital, Newcastle, UK
| | - Katerina E Dimakou
- Fifth Respiratory Department, Sotiria Hospital for Chest Diseases, Athens, Greece
| | - Stuart J Elborn
- Faculty of Medicine, Health and Life Sciences at Queen's University Belfast, Belfast, UK
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Harm Tiddens
- Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital and University of Cambridge, Cambridge, UK
| | | | - Michael R Loebinger
- Host Defence Unit, Royal Brompton Hospital and Imperial College London, London, UK
| | | | | | - Rosario Menendez
- Pneumology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Lucy C Morgan
- Concord Clinical School, Sydney Medical School, The University of Sydney, NSW, Australia
| | - Marlene S Murris
- Department of Pulmonology, Transplantation, and Cystic Fibrosis Centre, Larrey Hospital, Toulouse, France
| | - Eva Polverino
- Adult Cystic Fibrosis and Bronchiectasis Unit, Respiratory Disease Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Felix C Ringshausen
- Hannover Medical School, Department of Respiratory Medicine, Member of the German Centre for Lung Research, Hannover, Germany
| | - Michal Shteinberg
- Pulmonology Institute and Cystic Fibrosis Centre, Carmel Medical Centre and the Technion-Israel Institute of Technology, Haifa, Israel
| | - Nicola Sverzellati
- Scienze Radiologiche, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Gregory Tino
- Penn Presbyterian Medical Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Antoni Torres
- Pulmonology Department, Hospital Clinic, Universitat of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Ciber de Enfermedades Respiratorias, ICREA Academia, Barcelona, Spain
| | | | - Montserrat Vendrell
- Department of Pneumology Dr Josep Trueta Hospital, Biomedical Research Institute of Girona, Universitat de Girona, Girona, Spain
| | - Tobias Welte
- Hannover Medical School, Department of Respiratory Medicine, Member of the German Centre for Lung Research, Hannover, Germany
| | - Robert Wilson
- Host Defence Unit, Royal Brompton Hospital and Imperial College London, London, UK
| | - Conroy A Wong
- Department of Respiratory Medicine, Middlemore Hospital, Counties Manukau District Health Board and University of Auckland, Auckland, New Zealand
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK
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Tejada S, Ramírez-Estrada S, Forero CG, Gallego M, Soriano JB, Cardinal-Fernández PA, Ehrmann S, Rello J. 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; 11:275. [PMID: 35203878 PMCID: PMC8868526 DOI: 10.3390/antibiotics11020275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [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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Affiliation(s)
- Sofia Tejada
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d’Hebron Institut of Research (VHIR), 08035 Barcelona, Spain;
- Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.G.); (J.B.S.)
| | | | - Carlos G. Forero
- School of Medicine, Universitat Internacional de Catalunya, 08195 Barcelona, Spain;
| | - Miguel Gallego
- Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.G.); (J.B.S.)
- Respiratory Department, Parc Taulí University Hospital, 08208 Barcelona, Spain
| | - Joan B. Soriano
- Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.G.); (J.B.S.)
- Hospital Universitario La Princesa, Universidad Autónoma de Madrid, 28006 Madrid, Spain
| | | | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP F-CRIN Research Network, 37000 Tours, France;
- Centre d’étude des Pathologies Respiratoires, INSERM U1100, Université de Tours, 37032 Tours, France
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d’Hebron Institut of Research (VHIR), 08035 Barcelona, Spain;
- Clinical Research in the ICU, CHU Nimes, Universite de Nimes-Montpellier, 30900 Nimes, France
- Medicine Department, Universitat Internacional de Catalunya (UIC), 08195 Sant Cugat, Spain
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Ekkelenkamp MB, Díez-Aguilar M, Tunney MM, Elborn JS, Fluit AC, Cantón R. Establishing antimicrobial susceptibility testing methods and clinical breakpoints for inhaled antibiotic therapy. Open Forum Infect Dis 2022; 9:ofac082. [PMID: 35265731 PMCID: PMC8900927 DOI: 10.1093/ofid/ofac082] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/10/2022] [Indexed: 12/05/2022] Open
Abstract
Inhaled antibiotics are a common and valuable therapy for patients suffering from chronic lung infection, with this particularly well demonstrated for patients with cystic fibrosis. However, in vitro tests to predict patient response to inhaled antibiotic therapy are currently lacking. There are indications that antimicrobial susceptibility testing (AST) may have a role in guidance of therapy, but which tests would correlate best still needs to be researched in clinical studies or animal models. Applying the principles of European Committee on Antimicrobial Susceptibility Testing methodology, the analysis of relevant and reliable data correlating different AST tests to patients’ outcomes may yield clinical breakpoints for susceptibility, but these data are currently unavailable. At present, we believe that it is unlikely that standard determination of minimum inhibitory concentration will prove the best predictor.
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Affiliation(s)
- Miquel B Ekkelenkamp
- University Medical Center Utrecht, Department of Medical Microbiology, Utrecht, The Netherlands
| | - María Díez-Aguilar
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
- Servicio de Microbiología y Parasitología, Hospital Universitario La Princesa, Madrid, Spain
| | - Michael M Tunney
- Queen’s University Belfast, Department of Pulmonology, Belfast, United Kingdom
| | - J Stuart Elborn
- Queen’s University Belfast, Department of Pulmonology, Belfast, United Kingdom
| | - Ad C Fluit
- University Medical Center Utrecht, Department of Medical Microbiology, Utrecht, The Netherlands
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
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Combination and nanotechnology based pharmaceutical strategies for combating respiratory bacterial biofilm infections. Int J Pharm 2022; 616:121507. [PMID: 35085729 DOI: 10.1016/j.ijpharm.2022.121507] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/31/2021] [Accepted: 01/20/2022] [Indexed: 12/14/2022]
Abstract
Respiratory infections are one of the major global health problems. Among them, chronic respiratory infections caused by biofilm formation are difficult to treat because of both drug tolerance and poor drug penetration into the complex biofilm structure. A major part of the current research on combating respiratory biofilm infections have been focused on destroying the matrix of extracellular polymeric substance and eDNA of the biofilm or promoting the penetration of antibiotics through the extracellular polymeric substance via delivery technologies in order to kill the bacteria inside. There are also experimental data showing that certain inhaled antibiotics with simple formulations can effectively penetrate EPS to kill surficially located bacteria and centrally located dormant bacteria or persisters. This article aims to review recent advances in the pharmaceutical strategies for combating respiratory biofilm infections with a focus on nanotechnology-based drug delivery approaches. The formation and characteristics of bacterial biofilm infections in the airway mucus are presented, which is followed by a brief review on the current clinical approaches to treat respiratory biofilm infections by surgical removal and antimicrobial therapy, and also the emerging clinical treatment approaches. The current combination of antibiotics and non-antibiotic adjuvants to combat respiratory biofilm infections are also discussed.
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Psychometric Validation of the German Translation of the Quality of Life Questionnaire-Bronchiectasis (QOL-B)-Data from the German Bronchiectasis Registry PROGNOSIS. J Clin Med 2022; 11:jcm11020441. [PMID: 35054135 PMCID: PMC8781204 DOI: 10.3390/jcm11020441] [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: 12/05/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/25/2023] Open
Abstract
Patients with bronchiectasis feature considerable symptom burden and reduced health-related quality of life (QOL). We provide the psychometric validation of the German translation of the disease-specific Quality of Life Questionnaire-Bronchiectasis (QOL-B), version 3.1, using baseline data of adults consecutively enrolled into the prospective German bronchiectasis registry PROGNOSIS. Overall, 904 patients with evaluable QOL-B scores were included. We observed no relevant floor or ceiling effects. Internal consistency was good to excellent (Cronbach’s α ≥0.73 for each scale). QOL-B scales discriminated between patients based on prior pulmonary exacerbations and hospitalizations, breathlessness, bronchiectasis severity index, lung function, sputum volume, Pseudomonas aeruginosa status and the need for regular pharmacotherapy, except for Social Functioning, Vitality and Emotional Functioning scales. We observed moderate to strong convergence between several measures of disease severity and QOL-B scales, except for Social and Emotional Functioning. Two-week test-retest reliability was good, with intraclass correlation coefficients ≥0.84 for each scale. Minimal clinical important difference ranged between 8.5 for the Respiratory Symptoms and 14.1 points for the Social Functioning scale. Overall, the German translation of the QOL-B, version 3.1, has good validity and test-retest reliability among a nationally representative adult bronchiectasis cohort. However, responsiveness of QOL-B scales require further investigation during registry follow-up.
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Spencer S, Donovan T, Chalmers JD, Mathioudakis AG, McDonnell MJ, Tsang A, Leadbetter P. Intermittent prophylactic antibiotics for bronchiectasis. Cochrane Database Syst Rev 2022; 1:CD013254. [PMID: 34985761 PMCID: PMC8729825 DOI: 10.1002/14651858.cd013254.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Bronchiectasis is a common but under-diagnosed chronic disorder characterised by permanent dilation of the airways arising from a cycle of recurrent infection and inflammation. Symptoms including chronic, persistent cough and productive phlegm are a significant burden for people with bronchiectasis, and the main aim of treatment is to reduce exacerbation frequency and improve quality of life. Prophylactic antibiotic therapy aims to break this infection cycle and is recommended by clinical guidelines for adults with three or more exacerbations a year, based on limited evidence. It is important to weigh the evidence for bacterial suppression against the prevention of antibiotic resistance and further evidence is required on the safety and efficacy of different regimens of intermittently administered antibiotic treatments for people with bronchiectasis. OBJECTIVES To evaluate the safety and efficacy of intermittent prophylactic antibiotics in the treatment of adults and children with bronchiectasis. SEARCH METHODS We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted searches on 6 September 2021, with no restriction on language of publication. SELECTION CRITERIA We included randomised controlled trials (RCTs) of at least three months' duration comparing an intermittent regime of prophylactic antibiotics with placebo, usual care or an alternate intermittent regimen. Intermittent prophylactic administration was defined as repeated courses of antibiotics with on-treatment and off-treatment intervals of at least 14 days' duration. We included adults and children with a clinical diagnosis of bronchiectasis confirmed by high resolution computed tomography (HRCT), plain film chest radiograph, or bronchography and a documented history of recurrent chest infections. We excluded studies where participants received high dose antibiotics immediately prior to enrolment or those with a diagnosis of cystic fibrosis, allergic bronchopulmonary aspergillosis (ABPA), primary ciliary dyskinesia, hypogammaglobulinaemia, sarcoidosis, or a primary diagnosis of COPD. Our primary outcomes were exacerbation frequency and serious adverse events. We did not exclude studies on the basis of review outcomes. DATA COLLECTION AND ANALYSIS We analysed dichotomous data as odds ratios (ORs) or relative risk (RRs) and continuous data as mean differences (MDs) or standardised mean differences (SMDs). We used standard methodological procedures expected by Cochrane. We conducted GRADE assessments for the following primary outcomes: exacerbation frequency; serious adverse events and secondary outcomes: antibiotic resistance; hospital admissions; health-related quality of life. MAIN RESULTS We included eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2180 adults. All evaluated one of three types of antibiotics over two to six cycles of 28 days on/off treatment: aminoglycosides, ß-lactams or fluoroquinolones. Two studies also included 12 cycles of 14 days on/off treatment with fluoroquinolones. Participants had a mean age of 63.6 years, 65% were women and approximately 85% Caucasian. Baseline FEV1 ranged from 55.5% to 62.6% predicted. None of the studies included children. Generally, there was a low risk of bias in the included studies. Antibiotic versus placebo: cycle of 14 days on/off. Ciprofloxacin reduced the frequency of exacerbations compared to placebo (RR 0.75, 95% CI 0.61 to 0.93; I2 = 65%; 2 studies, 469 participants; moderate-certainty evidence), with eight people (95% CI 6 to 28) needed to treat for an additional beneficial outcome. The intervention increased the risk of antibiotic resistance more than twofold (OR 2.14, 95% CI 1.36 to 3.35; I2 = 0%; 2 studies, 624 participants; high-certainty evidence). Serious adverse events, lung function (FEV1), health-related quality of life, and adverse effects did not differ between groups. Antibiotic versus placebo: cycle of 28 days on/off. Antibiotics did not reduce overall exacerbation frequency (RR 0.92, 95% CI 0.82 to 1.02; I2 = 0%; 8 studies, 1695 participants; high-certainty evidence) but there were fewer severe exacerbations (OR 0.59, 95% CI 0.37 to 0.93; I2 = 54%; 3 studies, 624 participants), though this should be interpreted with caution due to low event rates. The risk of antibiotic resistance was more than twofold higher based on a pooled analysis (OR 2.20, 95% CI 1.42 to 3.42; I2 = 0%; 3 studies, 685 participants; high-certainty evidence) and consistent with unpooled data from four further studies. Serious adverse events, time to first exacerbation, duration of exacerbation, respiratory-related hospital admissions, lung function, health-related quality of life and adverse effects did not differ between study groups. Antibiotic versus usual care. We did not find any studies that compared intermittent antibiotic regimens with usual care. Cycle of 14 days on/off versus cycle of 28 days on/off. Exacerbation frequency did not differ between the two treatment regimens (RR 1.02, 95% CI 0.84 to 1.24; I2 = 71%; 2 studies, 625 participants; moderate-certainty evidence) However, inconsistencies in the results from the two trials in this comparison indicate that the apparent aggregated similarities may not be reliable. There was no evidence of a difference in antibiotic resistance between groups (OR 1.00, 95% CI 0.68 to 1.48; I2 = 60%; 2 studies, 624 participants; moderate-certainty evidence). Serious adverse events, adverse effects, lung function and health-related quality of life did not differ between the two antibiotic regimens. AUTHORS' CONCLUSIONS Overall, in adults who have frequent chest infections, long-term antibiotics given at 14-day on/off intervals slightly reduces the frequency of those infections and increases antibiotic resistance. Intermittent antibiotic regimens result in little to no difference in serious adverse events. The impact of intermittent antibiotic therapy on children with bronchiectasis is unknown due to an absence of evidence, and further research is needed to establish the potential risks and benefits.
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Affiliation(s)
- Sally Spencer
- Health Research Institute, Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, UK
| | - Tim Donovan
- Medical Sciences, Institute of Health, University of Cumbria, Lancaster, UK
| | - James D Chalmers
- University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Melissa J McDonnell
- Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
| | - Anthony Tsang
- Edge Hill University, Ormskirk, UK
- Department of Nursing, Faculty of Health, Social and Psychology, Manchester Metropolitan University, Manchester, UK
| | - Peter Leadbetter
- Medical School, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
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Elborn JS, Blasi F, Haworth CS, Ballmann M, Tiddens HAWM, Murris-Espin M, Chalmers JD, Cantin AM. Bronchiectasis and inhaled tobramycin: A literature review. Respir Med 2022; 192:106728. [PMID: 34998112 DOI: 10.1016/j.rmed.2021.106728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/24/2021] [Accepted: 12/29/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Inhaled antibiotics have been incorporated into contemporary European and British guidelines for bronchiectasis, yet no inhaled antibiotics have been approved in the United States or Europe for the treatment of bronchiectasis not related to cystic fibrosis. Pseudomonas aeruginosa infection is common in patients with bronchiectasis, contributing to a cycle of progressive inflammation, exacerbations, and airway remodelling. OBJECTIVE The aim of the current study was to identify and evaluate published studies of inhaled tobramycin solution or powder in patients with bronchiectasis and P. aeruginosa infection not associated with cystic fibrosis. METHODS A literature review was conducted utilising the PubMed and Cochrane databases. Studies published in the English language that reported safety and/or efficacy outcomes of inhaled tobramycin either alone or in combination with other antibiotics were included. RESULTS Seven clinical trials published between 1999 and 2021 were identified that met inclusion criteria. Inhaled tobramycin therapy was effective in reducing P. aeruginosa microbial density in the sputum of patients with bronchiectasis. Several studies demonstrated favourable impacts on hospitalisations, number and severity of exacerbations, and symptoms. Other studies were underpowered for these clinical outcomes or were exploratory in nature. Although tobramycin was generally well tolerated, some evidence of treatment-associated wheezing was reported. CONCLUSIONS In patients with bronchiectasis and chronic P. aeruginosa infection, inhaled tobramycin was effective in reducing the density of bacteria in sputum, which may be associated with additional clinical benefits. Definitive phase 3 trials of inhaled tobramycin in patients with bronchiectasis are indicated to determine clinical efficacy and long-term safety.
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Affiliation(s)
- J Stuart Elborn
- Medicine, Health and Life Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | - Francesco Blasi
- Department of Internal Medicine, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital and Department of Medicine, University of Cambridge, Cambridge, UK
| | - Manfred Ballmann
- University Medicine Rostock, Rostock, Mecklenburg-Vorpommern, Germany
| | - Harm A W M Tiddens
- Erasmus Medical Center Sophia Children's Hospital, Department of Pediatric Pulmonology and Allergology, Department of Radiology and Nuclear Medicine, Rotterdam, the Netherlands
| | - Marlène Murris-Espin
- Department of Pulmonology, Adult Cystic Fibrosis Center, Larrey Hospital, Toulouse University Hospital, Toulouse, France
| | - James D Chalmers
- Molecular and Clinical Medicine, University of Dundee, Nethergate, Dundee, Scotland, UK
| | - André M Cantin
- Pulmonary Research Unit, Faculty of Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
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Gao YH, Lu HW, Mao B, Guan WJ, Song YL, Li YY, Wang DX, Wang B, Gu HY, Li W, Luo H, Wang LW, Li F, Guo FX, Zhang M, Jie ZJ, Hang JQ, Yang C, Ren T, Yuan Z, Meng QW, Jia Q, Chen Y, Chen RC, Qu JM, Xu JF. The Establishment of China Bronchiectasis Registry and Research Collaboration (BE-China): Protocol of a prospective multicenter observational study. Respir Res 2022; 23:328. [PMID: 36463140 PMCID: PMC9719665 DOI: 10.1186/s12931-022-02254-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Bronchiectasis is a highly heterogeneous chronic airway disease with marked geographic and ethnic variations. Most influential cohort studies to date have been performed in Europe and USA, which serve as the examples for developing a cohort study in China where there is a high burden of bronchiectasis. The Establishment of China Bronchiectasis Registry and Research Collaboration (BE-China) is designed to: (1) describe the clinical characteristics and natural history of bronchiectasis in China and identify the differences of bronchiectasis between the western countries and China; (2) identify the risk factors associated with disease progression in Chinese population; (3) elucidate the phenotype and endotype of bronchiectasis by integrating the genome, microbiome, proteome, and transcriptome with detailed clinical data; (4) facilitate large randomized controlled trials in China. METHODS The BE-China is an ongoing prospective, longitudinal, multi-center, observational cohort study aiming to recruit a minimum of 10,000 patients, which was initiated in January 2020 in China. Comprehensive data, including medical history, aetiological testing, lung function, microbiological profiles, radiological scores, comorbidities, mental status, and quality of life (QoL), will be collected at baseline. Patients will be followed up annually for up to 10 years to record longitudinal data on outcomes, treatment patterns and QoL. Biospecimens, if possible, will be collected and stored at - 80 °C for further research. Up to October 2021, the BE-China has enrolled 3758 patients, and collected 666 blood samples and 196 sputum samples from 91 medical centers. The study protocol has been approved by the Shanghai Pulmonary Hospital ethics committee, and all collaborating centers have received approvals from their local ethics committee. All patients will be required to provide written informed consent to their participation. CONCLUSIONS Findings of the BE-China will be crucial to reveal the clinical characteristics and natural history of bronchiectasis and facilitate evidence-based clinical practice in China. Trial registration Registration Number in ClinicalTrials.gov: NCT03643653.
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Affiliation(s)
- Yong-Hua Gao
- grid.24516.340000000123704535Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200433 China
| | - Hai-Wen Lu
- grid.24516.340000000123704535Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200433 China
| | - Bei Mao
- grid.24516.340000000123704535Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200433 China
| | - Wei-Jie Guan
- grid.470124.4State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuan-Lin Song
- grid.8547.e0000 0001 0125 2443Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan-Yuan Li
- grid.216417.70000 0001 0379 7164Department of Pulmonary and Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan China
| | - Dao-Xin Wang
- grid.412461.40000 0004 9334 6536Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Wang
- grid.413679.e0000 0004 0517 0981Department of Pulmonary and Critical Care Medicine, Huzhou Central Hospital, Huzhou, Zhejiang China
| | - Hong-Yan Gu
- Department of Pulmonary and Critical Care Medicine, The Sixth People’s Hospital of Nantong, Nantong, Jiangsu, China
| | - Wen Li
- grid.412465.0Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang China
| | - Hong Luo
- grid.216417.70000 0001 0379 7164Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan China
| | - Ling-Wei Wang
- grid.440218.b0000 0004 1759 7210Pulmonary and Critical Care Department, Shenzhen People’s Hospital, Shenzhen Institute of Respiratory Diseases, Shenzhen, 518020 Guangdong China
| | - Fan Li
- grid.452742.2Department of Respiratory and Critical Care Medicine, Songjiang District Central Hospital, Shanghai, China
| | - Feng-Xia Guo
- grid.459495.0Department of Respiratory and Critical Care Medicine, The Eighth People’s Hospital of Shanghai, Shanghai, China
| | - Min Zhang
- grid.16821.3c0000 0004 0368 8293Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-Jun Jie
- grid.8547.e0000 0001 0125 2443Department of Respiratory and Critical Care Medicine, Shanghai Fifth People’s Hospital, Fudan University, Shanghai, China
| | - Jing-Qing Hang
- Department of Respiratory and Critical Care Medicine, Shanghai Putuo District People’s Hospital, Shanghai, China
| | - Chao Yang
- Department of Respiratory and Critical Care Medicine, Suzhou Science and Technology Town Hospital, Suzhou, China
| | - Tao Ren
- grid.412528.80000 0004 1798 5117Department of Respiratory and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Zhi Yuan
- Department of Respiratory and Critical Care Medicine, Fenghua District People’s Hospital, Ningbo, Zhejiang China
| | - Qing-Wei Meng
- Department of Respiratory and Critical Care Medicine, Shangrao People’s Hospital, Shangrao, Jiangxi China
| | - Qin Jia
- Department of Respiratory and Critical Care Medicine, Shidong Hospital of Yangpu District, Shanghai, China
| | - Yu Chen
- grid.412449.e0000 0000 9678 1884Department of Respiratory and Critical Care Medicine, Shengjing Hospital, China Medical University, Shenyang, China
| | - Rong-Chang Chen
- grid.440218.b0000 0004 1759 7210Pulmonary and Critical Care Department, Shenzhen People’s Hospital, Shenzhen Institute of Respiratory Diseases, Shenzhen, 518020 Guangdong China
| | - Jie-Ming Qu
- grid.16821.3c0000 0004 0368 8293Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 200025 China
| | - Jin-Fu Xu
- grid.24516.340000000123704535Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200433 China
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45
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Sibila O, Laserna E, Shoemark A, Perea L, Bilton D, Crichton ML, De Soyza A, Boersma WG, Altenburg J, Chalmers JD. Heterogeneity of treatment response in bronchiectasis clinical trials. Eur Respir J 2021; 59:13993003.00777-2021. [PMID: 34675045 DOI: 10.1183/13993003.00777-2021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/15/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Recent randomised clinical trials (RCTs) in Bronchiectasis have failed to reach their primary endpoints, suggesting a need to reassess how we measure treatment response. Exacerbations, quality of life (QOL) and lung function are the most common endpoints evaluated in bronchiectasis clinical trials. We aimed to determine the relationship between responses in terms of reduced exacerbations, improved symptoms and lung function in bronchiectasis. METHODS We evaluated treatment response in 3 RCTs that evaluated mucoactive therapy (inhaled Mannitol), an oral anti-inflammatory/antibiotic (Azithromycin) and an inhaled antibiotic (Aztreonam). Treatment response was defined by absence of exacerbations during follow-up, an improvement of QOL above the minimum clinically important difference (MCID) and an improvement in FEV1 of ≥100 mL from baseline. MEASUREMENTS AND MAIN RESULTS Cumulatively the three trials included 984 patients. Changes in FEV1, QOL and exacerbations were heterogeneous in all trials analysed. Improvements in QOL were not correlated to changes in FEV1 in the azithromycin and aztreonam trials (r=-0.17, p=0.1 and r=0.04, p=0.4) and weakly correlated in the mannitol trial (r=0.22, p<0.0001). An important placebo effect was observed in all trials, especially regarding improvements in QOL. Clinical meaningful lung function improvements were rare across all trials evaluated, suggesting that FEV1 is not a responsive measure in bronchiectasis. CONCLUSIONS Improvements in lung function, symptoms and exacerbation frequency are dissociated in bronchiectasis. FEV1 is poorly responsive and poorly correlated with other key outcome measures. Clinical parameters are poorly predictive of treatment response suggesting the need to develop biomarkers to identify responders.
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Affiliation(s)
- Oriol Sibila
- Respiratory Department, Hospital Clinic, IDIBAPS, CIBERES, Barcelona, Spain
| | - Elena Laserna
- Hospital Comarcal de Mollet, Mollet del Vallés, Spain
| | - Amelia Shoemark
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
| | - Lidia Perea
- Respiratory Department, Hospital Clinic, IDIBAPS, CIBERES, Barcelona, Spain
| | - Diana Bilton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Megan L Crichton
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
| | - Anthony De Soyza
- Freeman Hospital Newcastle and University of Newcastle, Newcastle, UK
| | - Wim G Boersma
- Department of Pulmonary Diseases, Northwest Hospital Group, Alkmaar, Netherlands
| | | | - James D Chalmers
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
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46
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Son YJ, Miller DP, Weers JG. Optimizing Spray-Dried Porous Particles for High Dose Delivery with a Portable Dry Powder Inhaler. Pharmaceutics 2021; 13:pharmaceutics13091528. [PMID: 34575603 PMCID: PMC8470347 DOI: 10.3390/pharmaceutics13091528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022] Open
Abstract
This manuscript critically reviews the design and delivery of spray-dried particles for the achievement of high total lung doses (TLD) with a portable dry powder inhaler. We introduce a new metric termed the product density, which is simply the TLD of a drug divided by the volume of the receptacle it is contained within. The product density is given by the product of three terms: the packing density (the mass of powder divided by the volume of the receptacle), the drug loading (the mass of drug divided by the mass of powder), and the aerosol performance (the TLD divided by the mass of drug). This manuscript discusses strategies for maximizing each of these terms. Spray drying at low drying rates with small amounts of a shell-forming excipient (low Peclet number) leads to the formation of higher density particles with high packing densities. This enables ultrahigh TLD (>100 mg of drug) to be achieved from a single receptacle. The emptying of powder from capsules is directly proportional to the mass of powder in the receptacle, requiring an inhaled volume of about 1 L for fill masses between 40 and 50 mg and up to 3.2 L for a fill mass of 150 mg.
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Affiliation(s)
- Yoen-Ju Son
- Genentech, South San Francisco, CA 94080, USA;
| | | | - Jeffry G. Weers
- Cystetic Medicines, Inc., Burlingame, CA 94010, USA;
- Correspondence: ; Tel.: +1-650-339-3832
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47
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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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48
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Perl S, Shteinberg M. Bronchiectasis Exacerbations: Definitions, Causes, and Acute Management. Semin Respir Crit Care Med 2021; 42:595-605. [PMID: 34261183 DOI: 10.1055/s-0041-1730944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pulmonary exacerbations (PExs) are events in the course of bronchiectasis which are defined as an increase in disease symptoms lasting a period of a few days. It is established that the tendency toward having PEx is stable throughout the course of the disease. Certain conditions were found to be associated with an increased risk of developing a PEx. Among these are chronic airway infection with Pseudomonas aeruginosa or Aspergillus species, concomitant airway diseases (asthma, chronic obstructive pulmonary disease, and chronic rhinosinusitis), genetic factors such as primary ciliary dyskinesia, and nutritional factors. The immediate events underlying the onset of a PEx are less clearly determined. Although acute changes in bacterial airway composition have been the paradigm for decades, recent microbiome-focused research has not uniformly established such acute changes at the onset of PEx. Other acute changes such as air pollution, viral infection, and changes in bacterial metabolic activity have also been implicated as causes of a PEx. Despite these gaps in our knowledge of the biology of PEx, antimicrobial therapy directed against the identified pathogens in sputum is currently the recommended therapeutic strategy. Various long-term therapies, including antimicrobial and anti-inflammatory strategies, have been proven effective in reducing the frequency of PEx, leading to a recommendation for the use of these strategies in people with frequent PEx.
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Affiliation(s)
- Sivan Perl
- Pulmonology Institute, Shamir Medical Center, Tel Aviv, Israel
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Technion-Israel Institute of Technology, Haifa, Israel
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49
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Amati F, Simonetta E, Pilocane T, Gramegna A, Goeminne P, Oriano M, Pascual-Guardia S, Mantero M, Voza A, Santambrogio M, Blasi F, Aliberti S. Diagnosis and Initial Investigation of Bronchiectasis. Semin Respir Crit Care Med 2021; 42:513-524. [PMID: 34261176 DOI: 10.1055/s-0041-1730892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Bronchiectasis refers to both the name of a disease and a single radiological appearance that may, or may not, be associated with disease. As chronic respiratory disease, bronchiectasis is characterized by a variable range of signs and symptoms that may overlap with other chronic respiratory conditions. The proper identification of bronchiectasis as a disease in both primary and secondary care is of paramount importance. However, a standardized definition of radiologically and clinically significant bronchiectasis is still missing. Disease heterogeneity is a hallmark of bronchiectasis and applies not only to radiological features and clinical manifestations but also to other aspects of the disease, including the etiological and microbiological diagnosis as well as the evaluation of pulmonary function. Although the guidelines suggest a "minimum bundle" of tests, the diagnostic approach to bronchiectasis is challenging and may be driven by the "treatable traits" approach based on endotypes and biological characteristics. A broad spectrum of diagnostic tests could be used to investigate the etiology of bronchiectasis as well as other pulmonary, extrapulmonary, and environmental traits. Individualizing bronchiectasis workup according to the site of care (e.g., primary, secondary, and tertiary care) could help optimize patients' management and reduce healthcare costs.
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Affiliation(s)
- Francesco Amati
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Simonetta
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Pilocane
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Andrea Gramegna
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Pieter Goeminne
- Department of Respiratory Medicine, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Martina Oriano
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Sergi Pascual-Guardia
- Department of Respiratory Medicine, Hospital del Mar (PSMAR)-IMIM, Barcelona, Spain.,School of Health and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain.,CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain
| | - Marco Mantero
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Antonio Voza
- Emergency Department, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Martina Santambrogio
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Blasi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefano Aliberti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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50
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Detailleur S, Vos R, Goeminne P. The Deteriorating Patient: Therapies Including Lung Transplantation. Semin Respir Crit Care Med 2021; 42:623-638. [PMID: 34261186 DOI: 10.1055/s-0041-1730946] [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
In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.
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Affiliation(s)
- Stephanie Detailleur
- Department of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Pieter Goeminne
- Department of Respiratory Diseases, AZ Nikolaas, Sint-Niklaas, Belgium
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