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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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Pourtois JD, Kratochvil MJ, Chen Q, Haddock NL, Burgener EB, De Leo GA, Bollyky PL. Filamentous Bacteriophages and the Competitive Interaction between Pseudomonas aeruginosa Strains under Antibiotic Treatment: a Modeling Study. mSystems 2021; 6:e0019321. [PMID: 34156288 PMCID: PMC8269214 DOI: 10.1128/msystems.00193-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/24/2021] [Indexed: 01/22/2023] Open
Abstract
Pseudomonas aeruginosa (Pa) is a major bacterial pathogen responsible for chronic lung infections in cystic fibrosis patients. Recent work has implicated Pf bacteriophages, nonlytic filamentous viruses produced by Pa, in the chronicity and severity of Pa infections. Pf phages act as structural elements in Pa biofilms and sequester aerosolized antibiotics, thereby contributing to antibiotic tolerance. Consistent with a selective advantage in this setting, the prevalence of Pf-positive (Pf+) bacteria increases over time in these patients. However, the production of Pf phages comes at a metabolic cost to bacteria, such that Pf+ strains grow more slowly than Pf-negative (Pf-) strains in vitro. Here, we use a mathematical model to investigate how these competing pressures might influence the relative abundance of Pf+ versus Pf- strains in different settings. Our model suggests that Pf+ strains of Pa cannot outcompete Pf- strains if the benefits of phage production falls onto both Pf+ and Pf- strains for a majority of parameter combinations. Further, phage production leads to a net positive gain in fitness only at antibiotic concentrations slightly above the MIC (i.e., concentrations for which the benefits of antibiotic sequestration outweigh the metabolic cost of phage production) but which are not lethal for Pf+ strains. As a result, our model suggests that frequent administration of intermediate doses of antibiotics with low decay rates and high killing rates favors Pf+ over Pf- strains. These models inform our understanding of the ecology of Pf phages and suggest potential treatment strategies for Pf+ Pa infections. IMPORTANCE Filamentous phages are a frontier in bacterial pathogenesis, but the impact of these phages on bacterial fitness is unclear. In particular, Pf phages produced by Pa promote antibiotic tolerance but are metabolically expensive to produce, suggesting that competing pressures may influence the prevalence of Pf+ versus Pf- strains of Pa in different settings. Our results identify conditions likely to favor Pf+ strains and thus antibiotic tolerance. This study contributes to a better understanding of the unique ecology of filamentous phages in both environmental and clinical settings and may facilitate improved treatment strategies for combating antibiotic tolerance.
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Affiliation(s)
- Julie D. Pourtois
- Department of Biology, Stanford University, Stanford, California, USA
- Hopkins Marine Station, Stanford University, Pacific Grove, California, USA
| | - Michael J. Kratochvil
- Department of Materials Science and Engineering, Stanford University, Stanford, California, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Qingquan Chen
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Naomi L. Haddock
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Elizabeth B. Burgener
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Giulio A. De Leo
- Department of Biology, Stanford University, Stanford, California, USA
- Hopkins Marine Station, Stanford University, Pacific Grove, California, USA
| | - Paul L. Bollyky
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Expression of the MexXY Aminoglycoside Efflux Pump and Presence of an Aminoglycoside-Modifying Enzyme in Clinical Pseudomonas aeruginosa Isolates Are Highly Correlated. Antimicrob Agents Chemother 2020; 65:AAC.01166-20. [PMID: 33046496 PMCID: PMC7927871 DOI: 10.1128/aac.01166-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/15/2020] [Indexed: 12/26/2022] Open
Abstract
The impact of MexXY efflux pump expression on aminoglycoside resistance in clinical Pseudomonas aeruginosa isolates has been debated. In this study, we found that, in general, elevated mexXY gene expression levels in clinical P. aeruginosa isolates confer to slight increases in aminoglycoside MIC levels; however, those levels rarely lead to clinically relevant resistance phenotypes. The main driver of resistance in the clinical isolates studied here was the acquisition of aminoglycoside-modifying enzymes (AMEs). The impact of MexXY efflux pump expression on aminoglycoside resistance in clinical Pseudomonas aeruginosa isolates has been debated. In this study, we found that, in general, elevated mexXY gene expression levels in clinical P. aeruginosa isolates confer to slight increases in aminoglycoside MIC levels; however, those levels rarely lead to clinically relevant resistance phenotypes. The main driver of resistance in the clinical isolates studied here was the acquisition of aminoglycoside-modifying enzymes (AMEs). Nevertheless, acquisition of an AME was strongly associated with mexY overexpression. In line with this observation, we demonstrate that the introduction of a gentamicin acetyltransferase confers to full gentamicin resistance levels in a P. aeruginosa type strain only if the MexXY efflux pump was active. We discuss that increased mexXY activity in clinical AME-harboring P. aeruginosa isolates might affect ion fluxes at the bacterial cell membrane and thus might play a role in the establishment of enhanced fitness that extends beyond aminoglycoside resistance.
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Ciacci N, Boncompagni S, Valzano F, Cariani L, Aliberti S, Blasi F, Pollini S, Rossolini GM, Pallecchi L. In Vitro Synergism of Colistin and N-acetylcysteine against Stenotrophomonas maltophilia. Antibiotics (Basel) 2019; 8:antibiotics8030101. [PMID: 31349560 PMCID: PMC6784201 DOI: 10.3390/antibiotics8030101] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/20/2019] [Accepted: 07/23/2019] [Indexed: 11/22/2022] Open
Abstract
Stenotrophomonas maltophilia is an emerging global opportunistic pathogen, responsible for a wide range of human infections, including respiratory tract infections. Intrinsic multidrug resistance and propensity to form biofilms make S. maltophilia infections recalcitrant to treatment. Colistin is among the second-line options in case of difficult-to-treat S. maltophilia infections, with the advantage of being also administrable by nebulization. We investigated the potential synergism of colistin in combination with N-acetylcysteine (NAC) (a mucolytic agent with antioxidant and anti-inflammatory properties) against S. maltophilia grown in planktonic phase and biofilm. Eighteen S. maltophilia clinical isolates (comprising three isolates from cystic fibrosis (CF) and two trimethoprim-sulfamethoxazole (SXT)-resistant strains) were included. Checkerboard assays showed a synergism of colistin/NAC combinations against the strains with colistin Minimum Inhibitory Concentration (MIC) >2 µg/mL (n = 13), suggesting that NAC could antagonize the mechanisms involved in colistin resistance. Nonetheless, time–kill assays revealed that NAC might potentiate colistin activity also in case of lower colistin MICs. A dose-dependent potentiation of colistin activity by NAC was also clearly observed against S. maltophilia biofilms, also at sub-MIC concentrations. Colistin/NAC combinations, at concentrations likely achievable by topical administration, might represent a valid option for the treatment of S. maltophilia respiratory infections and should be examined further.
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Affiliation(s)
- Nagaia Ciacci
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Selene Boncompagni
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Felice Valzano
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Lisa Cariani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Microbiology Laboratory, 20122 Milan, Italy
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory unit and Adult Cystic Fibrosis Center, 20122 Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory unit and Adult Cystic Fibrosis Center, 20122 Milan, Italy
| | - Simona Pollini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, 50134 Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, 50134 Florence, Italy
| | - Lucia Pallecchi
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy.
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Gatin L, Mghir AS, Mouton W, Laurent F, Ghout I, Rioux-Leclercq N, Tattevin P, Verdier MC, Cremieux AC. Colistin-containing cement spacer for treatment of experimental carbapenemase-producing Klebsiella pneumoniae prosthetic joint infection. Int J Antimicrob Agents 2019; 54:456-462. [PMID: 31319190 DOI: 10.1016/j.ijantimicag.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 06/29/2019] [Accepted: 07/10/2019] [Indexed: 11/29/2022]
Abstract
Carbapenemase-producing Enterobacteriaceae (CPE) are emerging multidrug-resistant bacteria responsible for invasive infections, including prosthetic joint infections (PJIs). Local administration of colistin may provide bactericidal concentrations in situ. This study evaluated the efficacy of a colistin-impregnated cement spacer, alone and in combination with systemic antibiotics, in a rabbit model of CPE-PJI. Elution of 3 MIU of colistimethate sodium (CMS) in 40 g of poly(methyl methacrylate) cement was studied in vitro. In vivo, 5 × 108 CFU of KPC-producing Klebsiella pneumoniae (colistin and meropenem MICs of 1 mg/L and 4 mg/L, respectively) were injected close to a prosthetic knee. Surgical debridement and prosthesis removal were performed 7 days later, and rabbits were assigned to six treatment groups (11-13 rabbits each): drug-free spacer; colistin-loaded spacer; colistin intramuscular (i.m.); colistin i.m. + colistin spacer; colistin i.m. + meropenem subcutaneous (s.c.); and colistin i.m. + meropenem s.c. + colistin spacer. Systemic treatment was administered at doses targeting pharmacokinetics in humans, and rabbits were euthanised 7 days later to evaluate bacterial counts in infected bones. In vitro, CMS elution was low (<0.1% at 24 h) but reached a local concentration of ≥20 mg/L (>20 × MIC). In vivo, combinations of local and systemic colistin, with or without meropenem, were the only regimens superior to the control group (P ≤ 0.05) in terms of viable bacterial counts and the proportion of rabbits with sterile bone, with no emergence of colistin-resistant strains. Colistin-loaded cement spacer in combination with systemic antibiotics were the most effective regimens in this CPE-PJI model.
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Affiliation(s)
- L Gatin
- UMR U1173 Université Versailles St-Quentin, Versailles, France; Service d'Orthopédie et traumatologie, Hôpital Raymond Poincaré, Garches, France
| | - A Saleh Mghir
- UMR U1173 Université Versailles St-Quentin, Versailles, France
| | - W Mouton
- Laboratoire de Bactériologie, Hôpital de la Croix Rousse, Centre National de Référence des Staphylocoques Unité Inserm 851, Faculté de Médecine Lyon Est, Lyon, France
| | - F Laurent
- Laboratoire de Bactériologie, Hôpital de la Croix Rousse, Centre National de Référence des Staphylocoques Unité Inserm 851, Faculté de Médecine Lyon Est, Lyon, France
| | - I Ghout
- URC Paris-Ouest, Laboratoire de Biostatistiques, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - N Rioux-Leclercq
- Service d'Anatomopathologie, Hôpital Pontchaillou, CHU de Rennes, Rennes, France
| | - P Tattevin
- Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, CHU de Rennes, 2 rue Henri Le Guilloux, 35033 Rennes Cedex, France.
| | - M C Verdier
- Laboratoire de Pharmacologie Biologique, Hôpital Pontchaillou, CHU de Rennes, Rennes, France
| | - A C Cremieux
- UMR U1173 Université Versailles St-Quentin, Versailles, France; Service des maladies infectieuses Hôpital Saint Louis AP-HP, Université Paris 7, Paris, France
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Stetten AZ, Iasella SV, Corcoran TE, Garoff S, Przybycien TM, Tilton RD. Surfactant-induced Marangoni transport of lipids and therapeutics within the lung. Curr Opin Colloid Interface Sci 2018; 36:58-69. [PMID: 30147429 PMCID: PMC6103298 DOI: 10.1016/j.cocis.2018.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Understanding the fundamentals of surface transport on thin viscous films has important application in pulmonary drug delivery. The human lung contains a large-area interface between its complex fluid lining and inhaled air. Marangoni flows driven by surface tension gradients along this interface would promote enhanced distribution of inhaled therapeutics by carrying them from where they are deposited in the upper airways, along the fluid interface to deeper regions of the lung. Motivated by the potential to improve therapies for acute and chronic lung diseases, we review recent progress in modeling and experimental studies of Marangoni transport induced by the deposition of surfactant-containing microliter drops and liquid aerosols (picoliter drops) onto a fluid interface. The roles of key system variables are identified, including surfactant solubility, drop miscibility with the subphase, and the thickness, composition and surface properties of the subphase liquid. Of particular interest is the unanticipated but crucial role of aerosol processing to achieve Marangoni transport via phospholipid vesicle dispersions, which are likely candidates for a biocompatible delivery system. Progress in this field has the potential to not only improve outcomes in patients with chronic and acute lung diseases, but also to further our understanding of surface transport in complex systems.
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Affiliation(s)
- Amy Z. Stetten
- Carnegie Mellon Center for Complex Fluids Engineering, Department of Physics, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Steven V. Iasella
- Carnegie Mellon Center for Complex Fluids Engineering, Department of Chemical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | | | - Stephen Garoff
- Carnegie Mellon Center for Complex Fluids Engineering, Department of Physics, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Todd M. Przybycien
- Carnegie Mellon Center for Complex Fluids Engineering, Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA
- Carnegie Mellon Center for Complex Fluids Engineering, Department of Chemical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Robert D. Tilton
- Carnegie Mellon Center for Complex Fluids Engineering, Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA
- Carnegie Mellon Center for Complex Fluids Engineering, Department of Chemical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA
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7
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Ponzano S, Nigrelli G, Fregonese L, Eichler I, Bertozzi F, Bandiera T, Galietta LJV, Papaluca M. A European regulatory perspective on cystic fibrosis: current treatments, trends in drug development and translational challenges for CFTR modulators. Eur Respir Rev 2018; 27:27/148/170124. [PMID: 29653946 DOI: 10.1183/16000617.0124-2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/14/2018] [Indexed: 12/18/2022] Open
Abstract
In this article we analyse the current authorised treatments and trends in early drug development for cystic fibrosis (CF) in the European Union for the time period 2000-2016. The analysis indicates a significant improvement in the innovation and development of new potential medicines for CF, shifting from products that act on the symptoms of the disease towards new therapies targeting the cause of CF. However, within these new innovative medicines, results for CF transmembrane conductance regulator (CFTR) modulators indicate that one major challenge for turning a CF concept product into an actual medicine for the benefit of patients resides in the fact that, although pre-clinical models have shown good predictability for certain mutations, a good correlation to clinical end-points or biomarkers (e.g. forced expiratory volume in 1 s and sweat chloride) for all mutations has not yet been achieved. In this respect, the use of alternative end-points and innovative nonclinical models could be helpful for the understanding of those translational discrepancies. Collaborative endeavours to promote further research and development in these areas as well as early dialogue with the regulatory bodies available at the European competent authorities are recommended.
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Affiliation(s)
- Stefano Ponzano
- European Medicines Agency, London, UK.,D3 PharmaChemistry, Istituto Italiano di Tecnologia, Genova, Italy
| | | | | | | | - Fabio Bertozzi
- D3 PharmaChemistry, Istituto Italiano di Tecnologia, Genova, Italy
| | - Tiziano Bandiera
- D3 PharmaChemistry, Istituto Italiano di Tecnologia, Genova, Italy
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8
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Bruguera-Avila N, Marin A, Garcia-Olive I, Radua J, Prat C, Gil M, Ruiz-Manzano J. Effectiveness of treatment with nebulized colistin in patients with COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:2909-2915. [PMID: 29042767 PMCID: PMC5634377 DOI: 10.2147/copd.s138428] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives To analyze whether the introduction of nebulized colistin in patients with chronic obstructive pulmonary disease (COPD) and infection with Pseudomonas aeruginosa (PA) is associated with a decrease of the number and duration of severe exacerbations. Materials and methods Thirty six patients with COPD and infection with PA treated with nebulized colistin attending a day hospital during a 5-year (January 2010–December 2014) period were prospectively included. Repeated-measures t-tests were used to assess whether the introduction of colistin was associated with changes in the number of exacerbations or the length of the hospitalizations, comparing for each patient the year prior to the introduction of colistin with the year after. Results After the introduction of colistin, the number of admissions decreased from 2.0 to 0.9 per individual year (P=0.0007), and hospitalizations were shorter (23.3 vs 10.9 days, P=0.00005). These results persisted when patients with and without bronchiectasis or with and without persistence of Pseudomonas were separately analyzed. No pre–post differences were detected in the number of exacerbations not requiring admission. Conclusion Nebulized colistin seems associated with a strong decrease in the number and duration of hospitalizations due to exacerbation in patients with COPD and infection with PA. Clinical trials with a larger number of patients are needed in order to confirm these results.
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Affiliation(s)
- Nuria Bruguera-Avila
- Department of Medicine, Hospital Sant Jaume de Calella, Calella, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Bellatera, Spain.,Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
| | - Alicia Marin
- Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain.,Ciber de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
| | - Ignasi Garcia-Olive
- Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain.,Ciber de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
| | - Joaquim Radua
- Department of Statistics, FIDMAG Germanes Hospitalaries Research Unit, Sant Boi de Llobregat, Barcelona, Spain.,CiberSam - Ciber de Salud Mental, Madrid, Spain.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Cristina Prat
- Ciber de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Department of Microbiology, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain.,Department of Genetics and Microbiology of Universitat Autònoma de Barcelona, Bellatera, Spain
| | - Montserrat Gil
- Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
| | - Juan Ruiz-Manzano
- Department of Medicine, Universitat Autònoma de Barcelona, Bellatera, Spain.,Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain.,Ciber de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
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9
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Gupta PV, Nirwane AM, Belubbi T, Nagarsenker MS. Pulmonary delivery of synergistic combination of fluoroquinolone antibiotic complemented with proteolytic enzyme: A novel antimicrobial and antibiofilm strategy. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2017. [DOI: 10.1016/j.nano.2017.06.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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10
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Pollini S, Brunetti J, Sennati S, Rossolini GM, Bracci L, Pini A, Falciani C. Synergistic activity profile of an antimicrobial peptide against multidrug-resistant and extensively drug-resistant strains of Gram-negative bacterial pathogens. J Pept Sci 2017; 23:329-333. [PMID: 28176481 DOI: 10.1002/psc.2978] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 12/22/2022]
Abstract
Infection sustained by multidrug-resistant and extensively drug-resistant bacterial pathogens is often untreatable with the standard of care antibiotics, and the combination of anti-infective compounds often represents the only therapeutic strategy to face this major clinical treat. SET-M33 is a novel antimicrobial peptide (AMP) that has demonstrated in vitro and in vivo antimicrobial activity against Gram-negative bacteria and has shown interesting features in preclinical evaluations. Particularly, it showed efficacy against a number of multidrug-resistant and extensively drug-resistant clinical strains of Gram-negative pathogens, in in vitro and in vivo assessments. Here, we explored the potential synergistic activity of SET-M33 in combination with different standard of care antibiotics by the checkerboard method against a panel of six strains of Gram-negative pathogens including multidrug-resistant and extensively drug-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. SET-M33 showed synergistic activity with antibiotics of different families against these clinically relevant strains. A synergistic effect was observed for SET-M33 in combination with rifampin, meropenem, aztreonam, and tobramycin mostly on K. pneumoniae and A. baumannii strains, while the SET-M33 plus ciprofloxacin combination was additive with all tested strains. Synergy was not apparently linked to the bacterial species or phenotype but was rather strain-specific, highlighting the need for individual strain testing for synergistic antimicrobial combinations. These findings extend current knowledge on synergistic activity of AMPs in combination with conventional agents and support the potential role of SET-M33 as a novel therapeutic agent against antibiotic-resistant Gram-negative pathogens. Copyright © 2017 European Peptide Society and John Wiley & Sons, Ltd.
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Affiliation(s)
- Simona Pollini
- Department of Medical Biotechnologies, University of Siena, Siena, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Jlenia Brunetti
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Samanta Sennati
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Clinical Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy.,Don Carlo Gnocchi Foundation, Florence, Italy
| | - Luisa Bracci
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Alessandro Pini
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Chiara Falciani
- Department of Medical Biotechnologies, University of Siena, Siena, Italy.,Setlance srl, Siena, Italy
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11
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Abstract
There is a high prevalence of Pseudomonas aeruginosa in patients with cystic fibrosis and clear epidemiologic links between chronic infection and morbidity and mortality exist. Prevention and early identification of infection are critical, and stand to improve with the advent of new vaccines and laboratory methods. Once the organism is identified, a variety of treatment options are available. Aggressive use of antipseudomonal antibiotics is the standard of care for acute pulmonary exacerbations in cystic fibrosis, and providers must take into account specific patient characteristics when making treatment decisions related to antibiotic selection, route and duration of administration, and site of care.
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Affiliation(s)
- Jaideep S Talwalkar
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208086, New Haven, CT 06520-8086, USA; Department of Pediatrics, Yale School of Medicine, 333 Cedar Street, PO Box 208084, New Haven, CT 06520-8084, USA.
| | - Thomas S Murray
- Department of Medical Sciences, Frank H Netter MD School of Medicine, Quinnipiac University, 275 Mount Carmel Avenue, Hamden, CT 06518, USA; Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, 282 Washington Street, Suite 2L, Hartford, CT 06106, USA
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12
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Abstract
PURPOSE OF REVIEW The current guidelines and recent clinical research in the management of Pseudomonas aeruginosa respiratory infections in cystic fibrosis (CF) are reviewed. Areas where further research is required will also be highlighted. RECENT FINDINGS P. aeruginosa is a key respiratory pathogen in CF. Inhaled tobramycin or colistin is recommended for early eradication to prevent establishment of chronic infection. Other antibiotic options are currently being investigated. The long-term success of eradication strategies is also now being assessed. The use of inhaled antibiotics in the management of chronic P. aeruginosa infection is an area of active investigation. Acute pulmonary exacerbations are still a major cause of morbidity and mortality. Guidelines continue to recommend combination intravenous therapy but further research is required to clarify the advantage of this approach. Multidrug resistance is common and potentially more effective antipseudomonal antibiotics may soon become available. SUMMARY The management of P. aeruginosa respiratory infection in CF remains a challenging area, especially in the setting of multidrug resistance. The role of inhaled antibiotics continues to be expanded. Further research is required in the key areas of eradication and management of chronic infection and acute pulmonary exacerbations to identify those treatments that optimize long-term, clinical benefits.
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13
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Garbacz K, Kamysz W, Piechowicz L. Activity of antimicrobial peptides, alone or combined with conventional antibiotics, against Staphylococcus aureus isolated from the airways of cystic fibrosis patients. Virulence 2016; 8:94-100. [PMID: 27450039 DOI: 10.1080/21505594.2016.1213475] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Katarzyna Garbacz
- a Department of Oral Microbiology , Medical University of Gdansk , Gdansk , Poland
| | - Wojciech Kamysz
- b Department of Inorganic Chemistry , Medical University of Gdansk , Gdansk , Poland
| | - Lidia Piechowicz
- c Department of Medical Microbiology , Medical University of Gdansk , Gdansk , Poland
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14
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Tewes F, Brillault J, Lamy B, O'Connell P, Olivier JC, Couet W, Healy AM. Ciprofloxacin-Loaded Inorganic-Organic Composite Microparticles To Treat Bacterial Lung Infection. Mol Pharm 2015; 13:100-12. [PMID: 26641021 DOI: 10.1021/acs.molpharmaceut.5b00543] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ciprofloxacin (CIP) is an antibiotic that has been clinically trialed for the treatment of lung infections by aerosolization. However, CIP is rapidly systemically absorbed after lung administration, increasing the risk for subtherapeutic pulmonary concentrations and resistant bacteria selection. In the presence of calcium, CIP forms complexes that reduce its oral absorption. Such complexation may slow down CIP absorption from the lung thereby maintaining high concentration in this tissue. Thus, we developed inhalable calcium-based inorganic-organic composite microparticles to sustain CIP within the lung. The aerodynamics and micromeritic properties of the microparticles were characterized. FTIR and XRD analysis suggest that the inorganic component of the particles comprised amorphous calcium carbonate and amorphous calcium formate, and that CIP and calcium interact in a 1:1 stoichiometry in the particles. CIP was completely released from the microparticles within 7 h, with profiles showing a slight dependence on pH (5 and 7.4) compared to the dissolution of pure CIP. Transport studies of CIP across Calu-3 cell monolayers, in the presence of various calcium concentrations, showed a decrease of up to 84% in CIP apparent permeability. The apparent minimum inhibitory concentration of CIP against Pseudomonas aeruginosa and Staphylococcus aureus was not changed in the presence of the same calcium concentration. These results indicate that the designed particles should provide sustained levels of CIP with therapeutic effect in the lung. With these microparticles, it should be possible to control CIP pharmacokinetics within the lung, based on controlled CIP release from the particles and reduced apparent permeability across the epithelial barrier due to the cation-CIP interaction.
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Affiliation(s)
- Frederic Tewes
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France.,School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, University of Dublin , Dublin 2, Ireland
| | - Julien Brillault
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France
| | - Barbara Lamy
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France
| | - Peter O'Connell
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, University of Dublin , Dublin 2, Ireland
| | - Jean-Christophe Olivier
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France
| | - William Couet
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France
| | - Anne Marie Healy
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, University of Dublin , Dublin 2, Ireland
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15
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Magalhães AP, Azevedo NF, Pereira MO, Lopes SP. The cystic fibrosis microbiome in an ecological perspective and its impact in antibiotic therapy. Appl Microbiol Biotechnol 2015; 100:1163-1181. [PMID: 26637419 DOI: 10.1007/s00253-015-7177-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/11/2015] [Accepted: 11/13/2015] [Indexed: 01/24/2023]
Abstract
The recent focus on the cystic fibrosis (CF) complex microbiome has led to the recognition that the microbes can interact between them and with the host immune system, affecting the disease progression and treatment routes. Although the main focus remains on the interactions between traditional pathogens, growing evidence supports the contribution and the role of emergent species. Understanding the mechanisms and the biological effects involved in polymicrobial interactions may be the key to improve effective therapies and also to define new strategies for disease control. This review focuses on the interactions between microbe-microbe and host-microbe, from an ecological point of view, discussing their impact on CF disease progression. There are increasing indications that these interactions impact the success of antimicrobial therapy. Consequently, a new approach where therapy is personalized to patients by taking into account their individual CF microbiome is suggested.
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Affiliation(s)
- Andreia P Magalhães
- CEB-Centre of Biological Engineering, LIBRO-Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal
| | - Nuno F Azevedo
- LEPABE-Laboratory for Process Engineering, Environment, Biotechnology and Energy, Department of Chemical Engineering, Faculty of Engineering, University of Porto, 4200-465, Porto, Portugal
| | - Maria O Pereira
- CEB-Centre of Biological Engineering, LIBRO-Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal
| | - Susana P Lopes
- CEB-Centre of Biological Engineering, LIBRO-Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal.
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16
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Vazquez-Espinosa E, Marcos C, Alonso T, Giron RM, Gomez-Punter RM, Garcia-Castillo E, Zamora E, Cisneros C, Garcia J, Valenzuela C, Ancochea J. Tobramycin inhalation powder (TOBI Podhaler) for the treatment of lung infection in patients with cystic fibrosis. Expert Rev Anti Infect Ther 2015; 14:9-17. [PMID: 26559549 DOI: 10.1586/14787210.2016.1118344] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cystic fibrosis (CF) is an autosomal recessive inherited disease secondary to a defect in the CF transmembrane conductance regulator gene (CFTR). Mortality in CF is associated with impairment of lung function in which bacterial infection plays a fundamental role. The microorganism Pseudomonas aeruginosa (P. aeruginosa) is a marker of poor prognosis. Tobramycin was the first parenteral antibiotic to be used as inhaled medication in CF. Owing to its beneficial effects; it was subsequently used in designed inhaled formulations. The first formulation was the inhalation solution, which improved lung function, lowered hospitalization rates, and reduced the courses of intravenous antibiotic. However, the high associated costs and time necessary to administer the medication negatively affected quality of life. The recent development of tobramycin inhalation powder has optimized treatment. The dry powder inhaler is a simple device that reduces administration time and improves adherence. As there is no risk of bacterial contamination, disinfection is unnecessary.
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Affiliation(s)
- E Vazquez-Espinosa
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - C Marcos
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - T Alonso
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - R M Giron
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - R M Gomez-Punter
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - E Garcia-Castillo
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - E Zamora
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - C Cisneros
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - J Garcia
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - C Valenzuela
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
| | - J Ancochea
- a Pulmonology Department, La Princesa Institute for Health Research , Hospital Universitario de La Princesa , Madrid , Spain
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17
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Gaspar MC, Sousa JJS, Pais AACC, Cardoso O, Murtinho D, Serra MES, Tewes F, Olivier JC. Optimization of levofloxacin-loaded crosslinked chitosan microspheres for inhaled aerosol therapy. Eur J Pharm Biopharm 2015; 96:65-75. [PMID: 26192459 DOI: 10.1016/j.ejpb.2015.07.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/09/2015] [Accepted: 07/11/2015] [Indexed: 01/08/2023]
Abstract
The aim of this work was the development of innovative levofloxacin-loaded swellable microspheres (MS) for the dry aerosol therapy of pulmonary chronicPseudomonas aeruginosainfections in Cystic Fibrosis patients. In a first step, a factorial design was applied to optimize formulations of chitosan-based MS with glutaraldehyde as crosslinker. After optimization, other crosslinkers (genipin, glutaric acid and glyceraldehyde) were tested. Analyses of MS included aerodynamic and swelling properties, morphology, drug loading, thermal and chemical characteristics,in vitroantibacterial activity and drug release studies. The prepared MS presented a drug content ranging from 39.8% to 50.8% of levofloxacin in an amorphous or dispersed state, antibacterial activity and fast release profiles. The highest degree of swelling was obtained for MS crosslinked with glutaric acid and genipin. These formulations also presented satisfactory aerodynamic properties, making them a promising alternative, in dry-powder inhalers, to levofloxacin solution for inhalation.
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Affiliation(s)
- Marisa C Gaspar
- Center for Neuroscience and Cell Biology, University of Coimbra, 3000-548 Coimbra, Portugal; Laboratory of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - João J S Sousa
- Center for Neuroscience and Cell Biology, University of Coimbra, 3000-548 Coimbra, Portugal; Laboratory of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal
| | | | - Olga Cardoso
- Laboratory of Microbiology, Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal
| | - Dina Murtinho
- Chemistry Department, University of Coimbra, 3004-535 Coimbra, Portugal
| | - M Elisa S Serra
- Chemistry Department, University of Coimbra, 3004-535 Coimbra, Portugal
| | - Frédéric Tewes
- INSERM, U 1070, Pôle Biologie Santé, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France; University of Poitiers, Faculty of Medicine and Pharmacy, 6 rue de la Milétrie, TSA 51115, 86073 Poitiers Cedex 9, France
| | - Jean-Christophe Olivier
- INSERM, U 1070, Pôle Biologie Santé, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France; University of Poitiers, Faculty of Medicine and Pharmacy, 6 rue de la Milétrie, TSA 51115, 86073 Poitiers Cedex 9, France
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18
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Mukker JK, Singh RSP, Derendorf H. Pharmacokinetic and pharmacodynamic implications in inhalable antimicrobial therapy. Adv Drug Deliv Rev 2015; 85:57-64. [PMID: 25770775 DOI: 10.1016/j.addr.2015.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/14/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
Inhaled antimicrobials provide a promising alternative to the systemically delivered drugs for the treatment of acute and chronic lung infections. The delivery of antimicrobials via inhalation route decreases the systemic exposure while increasing the local concentration in the lungs, enabling the use of antimicrobials with severe systemic side effects. The inhalation route of administration has several challenges in pharmacokinetic (PK) and pharmacodynamic (PD) assessments. This review discusses various issues that need to be considered during study, data analysis, and interpretation of PK and PD of inhaled antimicrobials. Advancements overcoming the challenges are also discussed.
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