1
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Heching M, Slomianksy L, Mussaffi H, Prais D, Weinberg J, Kramer MR. Dual inhaled antibiotics for treatment of pulmonary exacerbations in cystic fibrosis - A real life pilot study. Respir Med Res 2024; 86:101128. [PMID: 39053340 DOI: 10.1016/j.resmer.2024.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 07/03/2024] [Accepted: 07/04/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Moshe Heching
- Pulmonary Department, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel; School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Liora Slomianksy
- Pulmonary Department, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Huda Mussaffi
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Dario Prais
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Joel Weinberg
- Pulmonary Department, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Mordechai R Kramer
- Pulmonary Department, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel; School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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2
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Nickerson R, Thornton CS, Johnston B, Lee AHY, Cheng Z. Pseudomonas aeruginosa in chronic lung disease: untangling the dysregulated host immune response. Front Immunol 2024; 15:1405376. [PMID: 39015565 PMCID: PMC11250099 DOI: 10.3389/fimmu.2024.1405376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024] Open
Abstract
Pseudomonas aeruginosa is a highly adaptable opportunistic pathogen capable of exploiting barriers and immune defects to cause chronic lung infections in conditions such as cystic fibrosis. In these contexts, host immune responses are ineffective at clearing persistent bacterial infection, instead driving a cycle of inflammatory lung damage. This review outlines key components of the host immune response to chronic P. aeruginosa infection within the lung, beginning with initial pathogen recognition, followed by a robust yet maladaptive innate immune response, and an ineffective adaptive immune response that propagates lung damage while permitting bacterial persistence. Untangling the interplay between host immunity and chronic P. aeruginosa infection will allow for the development and refinement of strategies to modulate immune-associated lung damage and potentiate the immune system to combat chronic infection more effectively.
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Affiliation(s)
- Rhea Nickerson
- Department of Microbiology and Immunology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Christina S. Thornton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Brent Johnston
- Department of Microbiology and Immunology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Amy H. Y. Lee
- Department of Molecular Biology and Biochemistry, Faculty of Science, Simon Fraser University, Burnaby, BC, Canada
| | - Zhenyu Cheng
- Department of Microbiology and Immunology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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3
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Bernabéu-Gimeno M, Pardo-Freire M, Chan BK, Turner PE, Gil-Brusola A, Pérez-Tarazona S, Carrasco-Hernández L, Quintana-Gallego E, Domingo-Calap P. Neutralizing antibodies after nebulized phage therapy in cystic fibrosis patients. MED 2024:S2666-6340(24)00221-6. [PMID: 38917792 DOI: 10.1016/j.medj.2024.05.017] [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: 02/28/2024] [Revised: 04/02/2024] [Accepted: 05/30/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Cystic fibrosis (CF) patients are prone to recurrent multi-drug-resistant (MDR) bacterial lung infections. Under this scenario, phage therapy has been proposed as a promising tool. However, the limited number of reported cases hampers the understanding of clinical outcomes. Anti-phage immune responses have often been overlooked and only described following invasive routes of administration. METHODS Three monophage treatments against Staphylococcus aureus and/or Pseudomonas aeruginosa lung infections were conducted in cystic fibrosis patients. In-house phage preparations were nebulized over 10 days with standard-of-care antibiotics. Clinical indicators, bacterial counts, phage and antibiotic susceptibility, phage detection, and immune responses were monitored. FINDINGS Bacterial load was reduced by 3-6 log in two of the treatments. No adverse events were described. Phages remained in sputum up to 33 days after completion of the treatment. In all cases, phage-neutralizing antibodies were detected in serum from 10 to 42 days post treatment, with this being the first report of anti-phage antibodies after nebulized therapy. CONCLUSIONS Nebulized phage therapy reduced bacterial load, improving quality of life even without bacterial eradication. The emergence of antibodies emphasizes the importance of long-term monitoring to better understand clinical outcomes. These findings encourage the use of personalized monophage therapies in contrast to ready-to-use cocktails, which might induce undesirable antibody generation. FUNDING This study was supported by the Spanish Ministry of Science, Innovation and Universities; Generalitat Valenciana; and a crowdfunding in collaboration with the Spanish Cystic Fibrosis Foundation.
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Affiliation(s)
- Mireia Bernabéu-Gimeno
- Institute for Integrative Systems Biology, University of Valencia-CSIC, 46980 Paterna, Spain
| | - Marco Pardo-Freire
- Institute for Integrative Systems Biology, University of Valencia-CSIC, 46980 Paterna, Spain
| | - Benjamin K Chan
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT 06520, USA; Center for Phage Biology and Therapy, Yale University, New Haven, CT 06520, USA
| | - Paul E Turner
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT 06520, USA; Center for Phage Biology and Therapy, Yale University, New Haven, CT 06520, USA; Program in Microbiology, Yale School of Medicine, New Haven, CT 06520, USA
| | - Ana Gil-Brusola
- Microbiology Department, La Fe University and Polytechnic Hospital, 46026 Valencia, Spain; Severe Infection Research Group, Health Research Institute La Fe, 46026 Valencia, Spain
| | - Santiago Pérez-Tarazona
- Pediatric Pulmonology Unit, La Fe University and Polytechnic Hospital, 46026 Valencia, Spain
| | - Laura Carrasco-Hernández
- Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocío University Hospital, 41013 Sevilla, Spain; CIBER Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Esther Quintana-Gallego
- Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocío University Hospital, 41013 Sevilla, Spain; CIBER Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Pilar Domingo-Calap
- Institute for Integrative Systems Biology, University of Valencia-CSIC, 46980 Paterna, Spain.
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4
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Crabbé A. Intracellular Pseudomonas aeruginosa: An Overlooked Reservoir in the Lungs of People with Cystic Fibrosis? Am J Respir Crit Care Med 2024; 209:1421-1423. [PMID: 38498854 PMCID: PMC11208970 DOI: 10.1164/rccm.202402-0388ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/18/2024] [Indexed: 03/20/2024] Open
Affiliation(s)
- Aurélie Crabbé
- Laboratory of Pharmaceutical Microbiology Ghent University Ghent, Belgium
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5
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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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6
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Grassi L, Asfahl KL, Van den Bossche S, Maenhout I, Sass A, Vande Weygaerde Y, Van Braeckel E, Verhasselt B, Boelens J, Tunney MM, Dandekar AA, Coenye T, Crabbé A. Antibiofilm activity of Prevotella species from the cystic fibrosis lung microbiota against Pseudomonas aeruginosa. Biofilm 2024; 7:100206. [PMID: 38975276 PMCID: PMC11225020 DOI: 10.1016/j.bioflm.2024.100206] [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: 01/24/2024] [Revised: 05/06/2024] [Accepted: 06/06/2024] [Indexed: 07/09/2024] Open
Abstract
It is increasingly recognized that interspecies interactions may modulate the pathogenicity of Pseudomonas aeruginosa during chronic lung infections. Nevertheless, while the interaction between P. aeruginosa and pathogenic microorganisms co-infecting the lungs has been widely investigated, little is known about the influence of other members of the lung microbiota on the infection process. In this study, we focused on investigating the impact of Prevotella species isolated from the sputum of people with cystic fibrosis (pwCF) on biofilm formation and virulence factor production by P. aeruginosa. Screening of a representative collection of Prevotella species recovered from clinical samples showed that several members of this genus (8 out 10 isolates) were able to significantly reduce biofilm formation of P. aeruginosa PAO1, without impact on growth. Among the tested isolates, the strongest biofilm-inhibitory activity was observed for Prevotella intermedia and Prevotella nigrescens, which caused a reduction of up to 90% in the total biofilm biomass of several P. aeruginosa isolates from pwCF. In addition, a strain-specific effect of P. nigrescens on the ability of P. aeruginosa to produce proteases and pyocyanin was observed, with significant alterations in the levels of these virulence factors detected in LasR mutant strains. Overall, these results suggest that non-pathogenic bacteria from the lung microbiota may regulate pathogenicity traits of P. aeruginosa, and possibly affect the outcome of chronic lung infections.
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Affiliation(s)
- Lucia Grassi
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium
| | - Kyle L. Asfahl
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | | | - Ine Maenhout
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium
| | - Andrea Sass
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium
| | - Yannick Vande Weygaerde
- Cystic Fibrosis Reference Centre, Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Eva Van Braeckel
- Cystic Fibrosis Reference Centre, Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Bruno Verhasselt
- Laboratory of Medical Microbiology, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Jerina Boelens
- Laboratory of Medical Microbiology, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Michael M. Tunney
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Ajai A. Dandekar
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Tom Coenye
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium
| | - Aurélie Crabbé
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium
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7
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Burgel PR, Ballmann M, Drevinek P, Heijerman H, Jung A, Mainz JG, Peckham D, Plant BJ, Schwarz C, Taccetti G, Smyth A. Considerations for the use of inhaled antibiotics for Pseudomonas aeruginosa in people with cystic fibrosis receiving CFTR modulator therapy. BMJ Open Respir Res 2024; 11:e002049. [PMID: 38702073 PMCID: PMC11086488 DOI: 10.1136/bmjresp-2023-002049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 04/11/2024] [Indexed: 05/06/2024] Open
Abstract
The major cause of mortality in people with cystic fibrosis (pwCF) is progressive lung disease characterised by acute and chronic infections, the accumulation of mucus, airway inflammation, structural damage and pulmonary exacerbations. The prevalence of Pseudomonas aeruginosa rises rapidly in the teenage years, and this organism is the most common cause of chronic lung infection in adults with cystic fibrosis (CF). It is associated with an accelerated decline in lung function and premature death. New P. aeruginosa infections are treated with antibiotics to eradicate the organism, while chronic infections require long-term inhaled antibiotic therapy. The prevalence of P. aeruginosa infections has decreased in CF registries since the introduction of CF transmembrane conductance regulator modulators (CFTRm), but clinical observations suggest that chronic P. aeruginosa infections usually persist in patients receiving CFTRm. This indicates that pwCF may still need inhaled antibiotics in the CFTRm era to maintain long-term control of P. aeruginosa infections. Here, we provide an overview of the changing perceptions of P. aeruginosa infection management, including considerations on detection and treatment, the therapy burden associated with inhaled antibiotics and the potential effects of CFTRm on the lung microbiome. We conclude that updated guidance is required on the diagnosis and management of P. aeruginosa infection. In particular, we highlight a need for prospective studies to evaluate the consequences of stopping inhaled antibiotic therapy in pwCF who have chronic P. aeruginosa infection and are receiving CFTRm. This will help inform new guidelines on the use of antibiotics alongside CFTRm.
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Affiliation(s)
- Pierre-Régis Burgel
- Université Paris Cité, Institut Cochin, Inserm U1016, Paris, France
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- ERN-lung CF Network, Frankfurt, Germany
| | - Manfred Ballmann
- Kinder- und Jugendklinik der Universitätsmedizin Rostock, Rostock, Germany
| | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Harry Heijerman
- Department of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andreas Jung
- Division of Respiratory Medicine, University Children's Hospital, Zurich, Switzerland
| | - Jochen G Mainz
- Medizinische Hochschule Brandenburg (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Daniel Peckham
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Barry J Plant
- Cork Adult Cystic Fibrosis Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Carsten Schwarz
- HMU-Health and Medical University Potsdam, Internal Medicine and Pneumology, Clinic Westbrandenburg, Division of Cystic Fibrosis, CF Center Westbrandenburg, Campus Potsdam, Potsdam, Germany
| | - Giovanni Taccetti
- Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, Department of Paediatric Medicine, Florence, Italy
| | - Alan Smyth
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
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8
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Szabo MM, Foushee SE, McPheeters CM, O'Hagan AR, Ramirez AM, O'Reilly EA. Impact of elexacaftor/tezacaftor/ivacaftor on respiratory colonization in an adult cystic fibrosis clinic. Am J Med Sci 2024; 367:337-342. [PMID: 38336262 DOI: 10.1016/j.amjms.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/16/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Little research has been completed on the correlation between cystic fibrosis (CF) modulator therapy and its effect on respiratory cultures in CF patients. This study evaluated the effect of elexacaftor/tezacaftor/ivacaftor (ETI) on respiratory colonization with Pseudomonas aeruginosa. METHODS This single center, IRB approved, retrospective chart review compared patient data two years immediately prior to ETI initiation with patient data two years post-initiation from January 2017-December 2022. Patients were included in the study if they were at least 18 years old with a diagnosis of CF and had at least one month of ETI dispensed, at least one sputum culture obtained, and were currently on ETI. Those who had not been seen since ETI initiation or received a bilateral lung transplant were excluded. The primary outcome was rate of patients with respiratory colonization post-ETI. Colonization was defined as two or more positive P. aeruginosa cultures in a 12-month period. Decolonization was defined as three consecutive negative P. aeruginosa cultures after previous colonization. Key secondary outcomes included average time to discontinuation of mucolytic therapy and relative risk of pulmonary exacerbation. RESULTS A significant reduction (p<0.001) in colonization with P. aeruginosa was observed with 49 patients in the pre-ETI group compared to 25 in the post-ETI group meeting the definition of colonization (n=79). Average time to discontinuation of mucolytic therapy was 14 months (p=0.002). Relative risk of pulmonary exacerbation was 4.80 (p<0.001). CONCLUSIONS ETI use resulted in reduced colonization with P. aeruginosa, discontinuation of mucolytic therapy, and decreased frequency of pulmonary exacerbation.
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Affiliation(s)
- Michelle M Szabo
- PGY-2 Ambulatory Care Pharmacy Resident, UofL Health-UofL Hospital, Louisville, KY, USA
| | - Sarah E Foushee
- Clinical Pharmacy Specialist, UofL Health-UofL Hospital, Louisville, KY, USA
| | | | - Adrian R O'Hagan
- Adult Cystic Fibrosis, University of Louisville, Louisville, KY, USA
| | - Allan M Ramirez
- Adult Cystic Fibrosis, University of Louisville, Louisville, KY, USA
| | - Emily A O'Reilly
- Clinical Coordinator, Specialty Pharmacy Accreditation and Outcomes, UofL Health-UofL Hospital, Louisville, KY, USA.
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9
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Hong Q, Chang RYK, Assafiri O, Morales S, Chan HK. Optimizing in vitro phage-ciprofloxacin combination formulation for respiratory therapy of multi-drug resistant Pseudomonas aeruginosa infections. Int J Pharm 2024; 652:123853. [PMID: 38280500 DOI: 10.1016/j.ijpharm.2024.123853] [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: 11/26/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 01/29/2024]
Abstract
Respiratory infection caused by multi-drug resistant (MDR) Pseudomonas aeruginosa is challenging to treat. In this study, we investigate the optimal dose of anti-pseudomonas phage PEV31 (103, 105, and 108 PFU/mL) combined with ciprofloxacin (ranging from 1/8× MIC to 8× MIC) to treat the MDR P. aeruginosa strain FADD1-PA001 using time-kill studies. We determined the impact of phage growth kinetics in the presence of ciprofloxacin through one-step growth analysis. Single treatments with either phage PEV31 or ciprofloxacin (except at 8× MIC) showed limited bactericidal efficiency, with bacterial regrowth observed at 48 h. The most effective treatments were PEV31 at multiplicity of infection (MOI) of 0.1 and 100 combined with ciprofloxacin at concentrations above 1× MIC, resulting in a >4 log10 reduction in bacterial counts. While the burst size of phage PEV31 was decreased with increasing ciprofloxacin concentration, robust antimicrobial effects were still maintained in the combination treatment. Aerosol samples collected from vibrating mesh nebulization of the combination formulation at phage MOI of 100 with 2× MIC effectively inhibited bacterial density. In summary, our combination treatments eradicated in vitro bacterial growth and sustained antimicrobial effects for 48 h. These results indicated the potential application of nebulization-based strategies for the combination treatment against MDR lung infections.
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Affiliation(s)
- Qixuan Hong
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Rachel Yoon Kyung Chang
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Omar Assafiri
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | | | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia.
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10
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Cirilli N, Schiavoni V, Tagliabracci V, Gesuita R, Tiano L, Fabrizzi B, D'Antuono A, Peruzzi A, Cedraro N, Carle F, Moretti M, Ferrante L, Vignaroli C, Biavasco F, Mangiaterra G. Role of viable but non culturable cells in patients with cystic fibrosis in the era of highly effective modulator therapy. J Cyst Fibros 2024:S1569-1993(24)00026-2. [PMID: 38423895 DOI: 10.1016/j.jcf.2024.02.013] [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: 11/21/2023] [Revised: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Lung infections antibiotic treatment in Cystic Fibrosis patients (pwCF) is often complicated by bacterial persisters, including the so-called Viable but Non Culturable (VBNC) forms, live cells undetected by the routine cultural microbiological methods. This study investigated the occurrence of VBNC cells of five CF bacterial pathogens in 94 pwCF over one year and the possible associations with the patients' clinical features. METHODS Sputum samples, recovered at routine visits and during exacerbation episodes, were analyzed for the presence of the five pathogens by both routine culture-based assays and species-specific qPCR. VBNC cells were estimated as the difference between molecular and cultural counts and their presence was matched with the clinical data in particular the therapeutic regimens. RESULTS All but ten pwCF showed the presence of VBNC cells at least once during the study. Pseudomonas aeruginosa and methicillin-susceptible Staphylococcus aureus were the species most frequently found in the VBNC state. Only the former showed a significant association between chronic infection and VBNC cells presence; VBNC-MSSA positive patients significantly increased overtime. The presence of non culturable bacteria was generally concurrent with poor lung functionality and more frequent pulmonary exacerbations. No significant association with modulator treatment was evidenced. CONCLUSIONS The obtained data demonstrated the overwhelming occurrence of bacterial VBNC cells in CF lung infections, warranting a constant monitoring of pwCF and underlining the need of implementing the routine culture-based assays with culture-independent techniques. This is pivotal to understand the CF bacterial population dynamics and to efficiently contrast the lung infection progression and worsening.
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Affiliation(s)
- Natalia Cirilli
- Cystic Fibrosis Centre, Department of Gastroenterology and Transplantation, University Hospital of Marche, Via Conca, 71, Ancona 60126, Italy.
| | - Valentina Schiavoni
- Department of Life and Environmental Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Valentina Tagliabracci
- Cystic Fibrosis Centre, Department of Gastroenterology and Transplantation, University Hospital of Marche, Via Conca, 71, Ancona 60126, Italy
| | - Rosaria Gesuita
- Center of Epidemiology, Biostatistics e Medical Information Technology, Polytechnic University of Marche, Ancona, Italy
| | - Luca Tiano
- Department of Life and Environmental Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Benedetta Fabrizzi
- Cystic Fibrosis Centre, Department of Gastroenterology and Transplantation, University Hospital of Marche, Via Conca, 71, Ancona 60126, Italy
| | - Anastasia D'Antuono
- Cystic Fibrosis Centre, Department of Gastroenterology and Transplantation, University Hospital of Marche, Via Conca, 71, Ancona 60126, Italy
| | - Arianna Peruzzi
- Cystic Fibrosis Centre, Department of Gastroenterology and Transplantation, University Hospital of Marche, Via Conca, 71, Ancona 60126, Italy
| | - Nicholas Cedraro
- Department of Life and Environmental Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Flavia Carle
- Center of Epidemiology, Biostatistics e Medical Information Technology, Polytechnic University of Marche, Ancona, Italy
| | - Marco Moretti
- Clinical Laboratory, University Hospital of Marche, Ancona, Italy
| | - Luigi Ferrante
- Center of Epidemiology, Biostatistics e Medical Information Technology, Polytechnic University of Marche, Ancona, Italy
| | - Carla Vignaroli
- Department of Life and Environmental Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Francesca Biavasco
- Department of Life and Environmental Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Gianmarco Mangiaterra
- Department of Life and Environmental Sciences, Polytechnic University of Marche, Ancona, Italy; Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
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11
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Scoffone VC, Barbieri G, Irudal S, Trespidi G, Buroni S. New Antimicrobial Strategies to Treat Multi-Drug Resistant Infections Caused by Gram-Negatives in Cystic Fibrosis. Antibiotics (Basel) 2024; 13:71. [PMID: 38247630 PMCID: PMC10812592 DOI: 10.3390/antibiotics13010071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
People with cystic fibrosis (CF) suffer from recurrent bacterial infections which induce inflammation, lung tissue damage and failure of the respiratory system. Prolonged exposure to combinatorial antibiotic therapies triggers the appearance of multi-drug resistant (MDR) bacteria. The development of alternative antimicrobial strategies may provide a way to mitigate antimicrobial resistance. Here we discuss different alternative approaches to the use of classic antibiotics: anti-virulence and anti-biofilm compounds which exert a low selective pressure; phage therapies that represent an alternative strategy with a high therapeutic potential; new methods helping antibiotics activity such as adjuvants; and antimicrobial peptides and nanoparticle formulations. Their mechanisms and in vitro and in vivo efficacy are described, in order to figure out a complete landscape of new alternative approaches to fight MDR Gram-negative CF pathogens.
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Affiliation(s)
| | | | | | | | - Silvia Buroni
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy; (V.C.S.); (G.B.); (S.I.); (G.T.)
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Gramegna A, Aliberti S, Calderazzo MA, Casciaro R, Ceruti C, Cimino G, Fabrizzi B, Lucanto C, Messore B, Pisi G, Taccetti G, Tarsia P, Blasi F, Cipolli M. The impact of elexacaftor/tezacaftor/ivacaftor therapy on the pulmonary management of adults with cystic fibrosis: An expert-based Delphi consensus. Respir Med 2023; 220:107455. [PMID: 37926181 DOI: 10.1016/j.rmed.2023.107455] [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: 05/17/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The advent of elexacaftor/tezacaftor/ivacaftor (ETI) resulted in unprecedented clinical benefits for eligible adults with CF. As a result, the question of whether chronic treatments can be safely stopped or adapted to this new situation has become a matter of great interest. Our objective was to derive a consensus among Italian experts on the impact of ETI on the current clinical management of CF lung disease. METHODS From December 2021 to April 2022 a panel of Italian experts endorsed by the national CF scientific society derived and graded a set of statements on the pulmonary management of adults with cystic fibrosis through a modified Delphi methodology. RESULTS The panel produced 13 statements exploring possible modifications in the fields of inhaled antibiotics and mucoactives; airway clearance and physical activity; chronic macrolides and bronchodilators; and lung transplant referral. The areas that the experts considered most urgent to explore were the impact of ETI on the role of inhaled antibiotics and lung transplant. CONCLUSIONS The list of priorities that emerged from this study could be useful to guide and inform clinical research on the most urgent area of impact of ETI on CF lung disease and its clinical management.
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Affiliation(s)
- Andrea Gramegna
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | | | - Rosaria Casciaro
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, 16147, Genoa, Italy
| | - Clara Ceruti
- Health Professions Department Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Cimino
- Cystic Fibrosis Center, Policlinico Umberto I Hospital, Viale Regina Elena 324, 00161, Rome, Italy
| | - Benedetta Fabrizzi
- Cystic Fibrosis Regional Reference Center, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona 60126, Italy
| | - Cristina Lucanto
- Regional Centre for Cystic Fibrosis, A. O. U. Policlinico G.Martino, Messina, Italy
| | - Barbara Messore
- Adult Cystic Fibrosis Center, Azienda Ospedaliera Universitaria San Luigi Gonzaga, 10043, Orbassano, Italy
| | - Giovanna Pisi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, 43126, Parma, Italy
| | - Giovanni Taccetti
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Firenze, Italy
| | - Paolo Tarsia
- Respiratory Unit, Metropolitan Hospital Niguarda, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy
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Affiliation(s)
- Hartmut Grasemann
- From the Division of Respiratory Medicine, Department of Pediatrics, and Translational Medicine, Research Institute, Hospital for Sick Children, University of Toronto, Toronto
| | - Felix Ratjen
- From the Division of Respiratory Medicine, Department of Pediatrics, and Translational Medicine, Research Institute, Hospital for Sick Children, University of Toronto, Toronto
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14
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Graeber SY, Mall MA. The future of cystic fibrosis treatment: from disease mechanisms to novel therapeutic approaches. Lancet 2023; 402:1185-1198. [PMID: 37699417 DOI: 10.1016/s0140-6736(23)01608-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 09/14/2023]
Abstract
With the 2019 breakthrough in the development of highly effective modulator therapy providing unprecedented clinical benefits for over 90% of patients with cystic fibrosis who are genetically eligible for treatment, this rare disease has become a front runner of transformative molecular therapy. This success is based on fundamental research, which led to the identification of the disease-causing CFTR gene and our subsequent understanding of the disease mechanisms underlying the pathogenesis of cystic fibrosis, working together with a continuously evolving clinical research and drug development pipeline. In this Series paper, we focus on advances since 2018, and remaining knowledge gaps in our understanding of the molecular mechanisms of CFTR dysfunction in the airway epithelium and their links to mucus dysfunction, impaired host defences, airway infection, and chronic inflammation of the lungs of people with cystic fibrosis. We review progress in (and the remaining obstacles to) pharmacological approaches to rescue CFTR function, and novel strategies for improved symptomatic therapies for cystic fibrosis, including how these might be applicable to common lung diseases, such as bronchiectasis and chronic obstructive pulmonary disease. Finally, we discuss the promise of genetic therapies and gene editing approaches to restore CFTR function in the lungs of all patients with cystic fibrosis independent of their CFTR genotype, and the unprecedented opportunities to transform cystic fibrosis from a fatal disease to a treatable and potentially curable one.
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Affiliation(s)
- Simon Y Graeber
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Cystic Fibrosis Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Center for Lung Research, associated partner site, Berlin, Germany; Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus A Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Cystic Fibrosis Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Center for Lung Research, associated partner site, Berlin, Germany; Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.
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15
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Schnitker F, Liu Y, Keitsch S, Soddemann M, Verhasselt HL, Kehrmann J, Grassmé H, Kamler M, Gulbins E, Wu Y. Reduced Sphingosine in Cystic Fibrosis Increases Susceptibility to Mycobacterium abscessus Infections. Int J Mol Sci 2023; 24:14004. [PMID: 37762308 PMCID: PMC10530875 DOI: 10.3390/ijms241814004] [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: 07/26/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive disorder caused by the deficiency of the cystic fibrosis transmembrane conductance regulator (CFTR) and often leads to pulmonary infections caused by various pathogens, including Staphylococcus aureus, Pseudomonas aeruginosa, and nontuberculous mycobacteria, particularly Mycobacterium abscessus. Unfortunately, M. abscessus infections are increasing in prevalence and are associated with the rapid deterioration of CF patients. The treatment options for M. abscessus infections are limited, requiring the urgent need to comprehend infectious pathogenesis and develop new therapeutic interventions targeting affected CF patients. Here, we show that the deficiency of CFTR reduces sphingosine levels in bronchial and alveolar epithelial cells and macrophages from CF mice and humans. Decreased sphingosine contributes to the susceptibility of CF tissues to M. abscessus infection, resulting in a higher incidence of infections in CF mice. Notably, treatment of M. abscessus with sphingosine demonstrated potent bactericidal activity against the pathogen. Most importantly, restoration of sphingosine levels in CF cells, whether human or mouse, and in the lungs of CF mice, provided protection against M. abscessus infections. Our findings demonstrate that pulmonary sphingosine levels are important in controlling M. abscessus infection. These results offer a promising therapeutic avenue for CF patients with pulmonary M. abscessus infections.
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Affiliation(s)
- Fabian Schnitker
- Department of Molecular Biology, Institute of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (F.S.); (Y.L.); (S.K.); (M.S.); (H.G.); (E.G.)
| | - Yongjie Liu
- Department of Molecular Biology, Institute of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (F.S.); (Y.L.); (S.K.); (M.S.); (H.G.); (E.G.)
- West German Heart and Vascular Center, Thoracic Transplantation, Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, University Duisburg-Essen, 45122 Essen, Germany;
| | - Simone Keitsch
- Department of Molecular Biology, Institute of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (F.S.); (Y.L.); (S.K.); (M.S.); (H.G.); (E.G.)
| | - Matthias Soddemann
- Department of Molecular Biology, Institute of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (F.S.); (Y.L.); (S.K.); (M.S.); (H.G.); (E.G.)
| | - Hedda Luise Verhasselt
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (H.L.V.); (J.K.)
| | - Jan Kehrmann
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (H.L.V.); (J.K.)
| | - Heike Grassmé
- Department of Molecular Biology, Institute of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (F.S.); (Y.L.); (S.K.); (M.S.); (H.G.); (E.G.)
| | - Markus Kamler
- West German Heart and Vascular Center, Thoracic Transplantation, Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, University Duisburg-Essen, 45122 Essen, Germany;
| | - Erich Gulbins
- Department of Molecular Biology, Institute of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (F.S.); (Y.L.); (S.K.); (M.S.); (H.G.); (E.G.)
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Yuqing Wu
- Department of Molecular Biology, Institute of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany; (F.S.); (Y.L.); (S.K.); (M.S.); (H.G.); (E.G.)
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Batoni G, Catelli E, Kaya E, Pompilio A, Bianchi M, Ghelardi E, Di Bonaventura G, Esin S, Maisetta G. Antibacterial and Antibiofilm Effects of Lactobacilli Strains against Clinical Isolates of Pseudomonas aeruginosa under Conditions Relevant to Cystic Fibrosis. Antibiotics (Basel) 2023; 12:1158. [PMID: 37508254 PMCID: PMC10376640 DOI: 10.3390/antibiotics12071158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Therapy of lung infections sustained by Pseudomonas aeruginosa in cystic fibrosis (CF) patients is challenging due to the presence of a sticky mucus in the airways and the ability of the bacterium to form biofilm, which exhibits increased antibiotic tolerance. A lung-directed bacteriotherapy through the airway administration of probiotics could represent an alternative approach to probiotic diet supplementation to improve the benefits and clinical outcomes of this kind of intervention in CF patients. This study aims to evaluate the ability of probiotic strains to grow in artificial sputum medium (ASM), mimicking the CF lung microenvironment, and to affect the planktonic and biofilm growth of CF clinical strains of P. aeruginosa in the same conditions. The results demonstrate that Lacticaseibacillus rhamnosus and Lactiplantibacillus plantarum (LP) can grow in ASM. LP inhibited the planktonic growth of P. aeruginosa, while both lactobacilli reduced the pre-formed biofilm of P. aeruginosa. Interestingly, LP was demonstrated to reduce the amount of polysaccharides in the extracellular matrix of P. aeruginosa biofilms and to potentiate the antibiofilm effects of tobramycin. Overall, the results indicated that LP is a promising candidate as an adjuvant in the antimicrobial therapy of P. aeruginosa infections in CF patients.
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Affiliation(s)
- Giovanna Batoni
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via S. Zeno 37, 56123 Pisa, Italy
| | - Elisa Catelli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via S. Zeno 37, 56123 Pisa, Italy
| | - Esingül Kaya
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via S. Zeno 37, 56123 Pisa, Italy
| | - Arianna Pompilio
- Department of Medical, Oral, and Biotechnological Sciences, G. d'Annunzio University of Chieti-Pescara, Via dei Vestini, 31, 66100 Chieti, Italy
- Center for Advanced Studies and Technology, G. d'Annunzio University of Chieti-Pescara, Via L. Polacchi 11, 66100 Chieti, Italy
| | - Marta Bianchi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via S. Zeno 37, 56123 Pisa, Italy
| | - Emilia Ghelardi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via S. Zeno 37, 56123 Pisa, Italy
| | - Giovanni Di Bonaventura
- Department of Medical, Oral, and Biotechnological Sciences, G. d'Annunzio University of Chieti-Pescara, Via dei Vestini, 31, 66100 Chieti, Italy
- Center for Advanced Studies and Technology, G. d'Annunzio University of Chieti-Pescara, Via L. Polacchi 11, 66100 Chieti, Italy
| | - Semih Esin
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via S. Zeno 37, 56123 Pisa, Italy
| | - Giuseppantonio Maisetta
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via S. Zeno 37, 56123 Pisa, Italy
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Gambazza S, Storms V, Purohit V. Adherence to inhaled antibiotics in people with cystic fibrosis: insights from a virtual patient advisory board. Expert Rev Respir Med 2023; 17:961-963. [PMID: 37817635 DOI: 10.1080/17476348.2023.2267427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/03/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Chronic airway infection by Pseudomonas aeruginosa significantly impacts the health of people with cystic fibrosis (PwCF), presenting complex treatment challenges. RESEARCH DESIGN AND METHODS To gain insights into PwCF's experiences, a virtual European Patient Advisory Board was convened. Board explored inhaled antibiotic usage, treatment adherence, and associated challenges. Additionally, an online survey was conducted among PwCF to further understand real-life experiences and unmet needs, particularly related to CFTR modulators. RESULTS The Advisory Board proved instrumental in collecting valuable real-world perspectives, offering potential avenues for reshaping the care model for complex diseases like cystic fibrosis. CONCLUSIONS PwCF on CFTR modulators are questioning the necessity of continuing chronic medications and therapies. Physicians are urged to carefully consider the balance between simplifying antibiotic treatment and the risk of clinical deterioration due to bacterial infections when making treatment decisions. Furthermore, the development and global harmonization of diagnostic tools for chronic lung damage and treatment guidelines are crucial to justify the demanding routines that PwCF must endure to manage their condition.The heterogeneity in patient journeys, diagnostic challenges, treatment complexity, and issues related to adherence highlight the need for patient-centric, personalized care that emphasizes improving and maintaining treatment adherence to optimize cystic fibrosis management.
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Affiliation(s)
- Simone Gambazza
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Vinay Purohit
- Global Medical Affairs, Mylan Pharmaceuticals Private Limited (A Viatris Company), Bengaluru, India
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