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Ding L, Wang G, Wang J, Peng Y, Cai S, Khan SU, Cui Z, Zhang X, Wu C, Smyth H. Targeted treatment for biofilm-based infections using PEGylated tobramycin. J Control Release 2024; 372:43-58. [PMID: 38866243 DOI: 10.1016/j.jconrel.2024.06.022] [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: 03/02/2024] [Revised: 05/24/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
Chronic infections often involve biofilm-based bacteria, in which the biofilm results in significant resistance against antimicrobial agents and prevents eradication of the infection. The physicochemical barrier presented by the biofilm matrix is a major impediment to the delivery of many antibiotics. Previously, PEGylation has been shown to improve antibiotic penetration into biofilms in vitro. In these studies, PEGylating tobramycin was investigated both in vitro and in vivo. Two distinct PEGylated tobramycin molecules were synthesized (mPEG-SA-Tob and mPEG-AA-Tob). Then, in a P. aeruginosa biofilm in vitro model, we found that mPEG-SA-Tob can operate as a prodrug and showed 7 times more effectiveness than tobramycin (MIC80: 14 μM vs.100 μM). This improved biofilm eradication is attributable to the fact that mPEG-SA-Tob can aid tobramycin to penetrate through the biofilm and overcome the alginate-mediated antibiotic resistance. Finally, we used an in vivo biofilm-based chronic pulmonary infection rat model to confirm the therapeutic impact of mPEG-SA-Tob on biofilm-based chronic lung infection. mPEG-SA-Tob has a better therapeutic impact than tobramycin in that it cannot only stop P. aeruginosa from multiplying in the lungs but can also reduce inflammation caused by infections and prevent a recurrence infection. Overall, our findings show that PEGylated tobramycin is an effective treatment for biofilm-based chronic lung infections.
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Affiliation(s)
- Li Ding
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Guanlin Wang
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou 510006, Guangdong, PR China
| | - Jieliang Wang
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Ying Peng
- Division of Chemical Biology and Medicinal Chemistry, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Shihao Cai
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Shafi Ullah Khan
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway 47500, Selangor, Malaysia; INSERM U1086 ANTICIPE (Interdisciplinary Research Unit for Cancers Prevention and Treatment), BioTICLA Laboratory (Precision Medicine for Ovarian Cancers), Université de Caen Normandie, Caen, France; Comprehensive Cancer Center François Baclesse, UNICANCER, Caen, France
| | - Zhengrong Cui
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Xuejuan Zhang
- College of Pharmacy, Jinan University, Guangzhou, Guangdong 511443, China.
| | - Chuanbin Wu
- College of Pharmacy, Jinan University, Guangzhou, Guangdong 511443, China
| | - Hugh Smyth
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA.
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Schwarz C, Bend J, Hebestreit H, Hogardt M, Hügel C, Illing S, Mainz JG, Rietschel E, Schmidt S, Schulte-Hubbert B, Sitter H, Wielpütz MO, Hammermann J, Baumann I, Brunsmann F, Dieninghoff D, Eber E, Ellemunter H, Eschenhagen P, Evers C, Gruber S, Koitschev A, Ley-Zaporozhan J, Düesberg U, Mentzel HJ, Nüßlein T, Ringshausen FC, Sedlacek L, Smaczny C, Sommerburg O, Sutharsan S, Vonberg RP, Weber AK, Zerlik J. [CF Lung Disease - a German S3 Guideline: Pseudomonas aeruginosa]. Pneumologie 2024; 78:367-399. [PMID: 38350639 DOI: 10.1055/a-2182-1907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Cystic Fibrosis (CF) is the most common autosomal recessive genetic multisystemic disease. In Germany, it affects at least 8000 people. The disease is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene leading to dysfunction of CFTR, a transmembrane chloride channel. This defect causes insufficient hydration of the airway epithelial lining fluid which leads to reduction of the mucociliary clearance.Even if highly effective, CFTR modulator therapy has been available for some years and people with CF are getting much older than before, recurrent and chronic infections of the airways as well as pulmonary exacerbations still occur. In adult CF life, Pseudomonas aeruginosa (PA) is the most relevant pathogen in colonisation and chronic infection of the lung, leading to further loss of lung function. There are many possibilities to treat PA-infection.This is a S3-clinical guideline which implements a definition for chronic PA-infection and demonstrates evidence-based diagnostic methods and medical treatment in order to give guidance for individual treatment options.
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Affiliation(s)
- Carsten Schwarz
- Klinikum Westbrandenburg GmbH, Standort Potsdam, Deutschland
| | - Jutta Bend
- Mukoviszidose Institut gGmbH, Bonn, Deutschland
| | | | - Michael Hogardt
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Frankfurt, Deutschland
| | - Christian Hügel
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | | | - Jochen G Mainz
- Klinikum Westbrandenburg, Standort Brandenburg an der Havel, Universitätsklinikum der Medizinischen Hochschule Brandenburg (MHB), Brandenburg an der Havel, Deutschland
| | - Ernst Rietschel
- Medizinische Fakultät der Universität zu Köln, Mukoviszidose-Zentrum, Klinik und Poliklinik für Kinder- und Jugendmedizin, Köln, Deutschland
| | - Sebastian Schmidt
- Ernst-Moritz-Arndt Universität Greifswald, Kinderpoliklinik, Allgemeine Pädiatrie, Greifswald, Deutschland
| | | | - Helmut Sitter
- Philipps-Universität Marburg, Institut für theoretische Medizin, Marburg, Deutschland
| | - Marc Oliver Wielpütz
- Universitätsklinikum Heidelberg, Klinik für Diagnostische und Interventionelle Radiologie, Heidelberg, Deutschland
| | - Jutta Hammermann
- Universitäts-Mukoviszidose-Zentrum "Christiane Herzog", Dresden, Deutschland
| | - Ingo Baumann
- Universität Heidelberg, Hals-Nasen-Ohrenklinik, Heidelberg, Deutschland
| | - Frank Brunsmann
- Allianz Chronischer Seltener Erkrankungen (ACHSE) e. V., Deutschland (Patient*innenvertreter)
| | | | - Ernst Eber
- Medizinische Universität Graz, Univ. Klinik für Kinder- und Jugendheilkunde, Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Graz, Österreich
| | - Helmut Ellemunter
- Tirolkliniken GmbH, Department für Kinderheilkunde, Pädiatrie III, Innsbruck, Österreich
| | | | | | - Saskia Gruber
- Medizinische Universität Wien, Universitätsklinik für Kinder- und Jugendheilkunde, Wien, Österreich
| | - Assen Koitschev
- Klinikum Stuttgart - Standort Olgahospital, Klinik für Hals-Nasen-Ohrenkrankheiten, Stuttgart, Deutschland
| | - Julia Ley-Zaporozhan
- Klinik und Poliklinik für Radiologie, Kinderradiologie, LMU München, Deutschland
| | | | - Hans-Joachim Mentzel
- Universitätsklinikum Jena, Sektion Kinderradiologie, Institut für Diagnostische und Interventionelle Radiologie, Jena, Deutschland
| | - Thomas Nüßlein
- Gemeinschaftsklinikum Mittelrhein, Klinik für Kinder- und Jugendmedizin Koblenz und Mayen, Koblenz, Deutschland
| | - Felix C Ringshausen
- Medizinische Hochschule Hannover, Klinik für Pneumologie und Infektiologie und Deutsches Zentrum für Lungenforschung (DZL), Hannover, Deutschland
| | - Ludwig Sedlacek
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | - Christina Smaczny
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | - Olaf Sommerburg
- Universitätsklinikum Heidelberg, Sektion Pädiatrische Pneumologie, Allergologie und Mukoviszidose-Zentrum, Heidelberg, Deutschland
| | | | - Ralf-Peter Vonberg
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | | | - Jovita Zerlik
- Altonaer Kinderkrankenhaus gGmbH, Abteilung Physiotherapie, Hamburg, Deutschland
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Porzio E, Andrenacci D, Manco G. Thermostable Lactonases Inhibit Pseudomonas aeruginosa Biofilm: Effect In Vitro and in Drosophila melanogaster Model of Chronic Infection. Int J Mol Sci 2023; 24:17028. [PMID: 38069351 PMCID: PMC10707464 DOI: 10.3390/ijms242317028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
Pseudomonas aeruginosa is one of the six antimicrobial-resistant pathogens known as "ESKAPE" that represent a global threat to human health and are considered priority targets for the development of novel antimicrobials and alternative therapeutics. The virulence of P. aeruginosa is regulated by a four-chemicals communication system termed quorum sensing (QS), and one main class of QS signals is termed acylhomoserine lactones (acyl-HSLs), which includes 3-Oxo-dodecanoil homoserine lactone (3-Oxo-C12-HSL), which regulates the expression of genes implicated in virulence and biofilm formation. Lactonases, like Paraoxonase 2 (PON2) from humans and the phosphotriesterase-like lactonases (PLLs) from thermostable microorganisms, are able to hydrolyze acyl-HSLs. In this work, we explored in vitro and in an animal model the effect of some lactonases on the production of Pseudomonas virulence factors. This study presents a model of chronic infection in which bacteria were administered by feeding, and Drosophila adults were treated with enzymes and the antibiotic tobramycin, alone or in combination. In vitro, we observed significant effects of lactonases on biofilm formation as well as effects on bacterial motility and the expression of virulence factors. The treatment in vivo by feeding with the lactonase SacPox allowed us to significantly increase the biocidal effect of tobramycin in chronic infection.
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Affiliation(s)
- Elena Porzio
- Institute of Biochemistry and Cell Biology, National Research Council of Italy, Via P. Castellino 111, 80131 Naples, Italy
| | - Davide Andrenacci
- CNR Institute of Molecular Genetics “Luigi-Luca Cavalli-Sforza” Unit of Bologna, 40136 Bologna, Italy
| | - Giuseppe Manco
- Institute of Biochemistry and Cell Biology, National Research Council of Italy, Via P. Castellino 111, 80131 Naples, Italy
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Li D, Schneider-Futschik EK. Current and Emerging Inhaled Antibiotics for Chronic Pulmonary Pseudomonas aeruginosa and Staphylococcus aureus Infections in Cystic Fibrosis. Antibiotics (Basel) 2023; 12:antibiotics12030484. [PMID: 36978351 PMCID: PMC10044129 DOI: 10.3390/antibiotics12030484] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 02/25/2023] [Accepted: 02/26/2023] [Indexed: 03/05/2023] Open
Abstract
Characterized by impaired mucus transport and subsequent enhanced colonization of bacteria, pulmonary infection causes major morbidity and mortality in patients with cystic fibrosis (CF). Pseudomonas aeruginosa (P. aeruginosa) and Staphylococcus aureus (S. aureus) are the two most common types of bacteria detected in CF lungs, which undergo multiple adaptational mechanisms such as biofilm formation resulting in chronic pulmonary infections. With the advantages of greater airway concentration and minimized systemic toxicity, inhaled antibiotics are introduced to treat chronic pulmonary infection in CF. Inhaled tobramycin, aztreonam, levofloxacin, and colistin are the four most common discussed inhaled antibiotics targeting P. aeruginosa. Additionally, inhaled liposomal amikacin and murepavadin are also in development. This review will discuss the virulence factors and adaptational mechanisms of P. aeruginosa and S. aureus in CF. The mechanism of action, efficacy and safety, current status, and indications of corresponding inhaled antibiotics will be summarized. Combination therapy and the strategies to select an optimal inhaled antibiotic protocol will also be discussed.
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Athanazio RA, Tanni SE, Ferreira J, Dalcin PDTR, Fuccio MBD, Esposito C, Canan MGM, Coelho LS, Firmida MDC, Almeida MBD, Marostica PJC, Monte LDFV, Souza EL, Pinto LA, Rached SZ, Oliveira VSBD, Riedi CA, Silva Filho LVRFD. Brazilian guidelines for the pharmacological treatment of the pulmonary symptoms of cystic fibrosis. Official document of the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association). J Bras Pneumol 2023; 49:e20230040. [PMID: 37194817 DOI: 10.36416/1806-3756/e20230040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 03/31/2023] [Indexed: 05/18/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease that results in dysfunction of the CF transmembrane conductance regulator (CFTR) protein, which is a chloride and bicarbonate channel expressed in the apical portion of epithelial cells of various organs. Dysfunction of that protein results in diverse clinical manifestations, primarily involving the respiratory and gastrointestinal systems, impairing quality of life and reducing life expectancy. Although CF is still an incurable pathology, the therapeutic and prognostic perspectives are now totally different and much more favorable. The purpose of these guidelines is to define evidence-based recommendations regarding the use of pharmacological agents in the treatment of the pulmonary symptoms of CF in Brazil. Questions in the Patients of interest, Intervention to be studied, Comparison of interventions, and Outcome of interest (PICO) format were employed to address aspects related to the use of modulators of this protein (ivacaftor, lumacaftor+ivacaftor, and tezacaftor+ivacaftor), use of dornase alfa, eradication therapy and chronic suppression of Pseudomonas aeruginosa, and eradication of methicillin-resistant Staphylococcus aureus and Burkholderia cepacia complex. To formulate the PICO questions, a group of Brazilian specialists was assembled and a systematic review was carried out on the themes, with meta-analysis when applicable. The results obtained were analyzed in terms of the strength of the evidence compiled, the recommendations being devised by employing the GRADE approach. We believe that these guidelines represent a major advance to be incorporated into the approach to patients with CF, mainly aiming to favor the management of the disease, and could become an auxiliary tool in the definition of public policies related to CF.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Suzana Erico Tanni
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | - Juliana Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo de Tarso Roth Dalcin
- . Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Marcelo B de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | - Liana Sousa Coelho
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | | | - Marina Buarque de Almeida
- . Unidade de Pneumologia, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo José Cauduro Marostica
- . Unidade de Pneumologia Infantil, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | | | - Edna Lúcia Souza
- . Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador (BA) Brasil
| | | | - Samia Zahi Rached
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Verônica Stasiak Bednarczuk de Oliveira
- . Hospital de Clínicas, Universidade Federal do Paraná, Curitiba (PR) Brasil
- . Unidos Pela Vida - Instituto Brasileiro de Atenção à Fibrose Cística, Curitiba (PR) Brasil
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Smith S, Rowbotham NJ. Inhaled anti-pseudomonal antibiotics for long-term therapy in cystic fibrosis. Cochrane Database Syst Rev 2022; 11:CD001021. [PMID: 36373968 PMCID: PMC9662285 DOI: 10.1002/14651858.cd001021.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. OBJECTIVES To evaluate the effects of long-term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug-sensitivity reactions and survival). SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. SELECTION CRITERIA We selected trials where people with cystic fibrosis received inhaled anti-pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi-randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). DATA COLLECTION AND ANALYSIS Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. MAIN RESULTS The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta-analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low-certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) -5.30 days, 95% CI -8.59 to -2.01; 1 trial, 245 participants; low-certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta-analyses. We are uncertain of the effect of the intervention on adverse events (very low-certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV1) % predicted compared to tobramycin (MD -3.40%, 95% CI -6.63 to -0.17; 1 trial, 273 participants; moderate-certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate-certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high-certainty evidence). Important treatment-related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. AUTHORS' CONCLUSIONS Long-term treatment with inhaled anti-pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer-term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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Abstract
BACKGROUND Cystic fibrosis is a genetic disorder in which abnormal mucus in the lungs is associated with susceptibility to persistent infection. Pulmonary exacerbations are when symptoms of infection become more severe. Antibiotics are an essential part of treatment for exacerbations and inhaled antibiotics may be used alone or in conjunction with oral antibiotics for milder exacerbations or with intravenous antibiotics for more severe infections. Inhaled antibiotics do not cause the same adverse effects as intravenous antibiotics and may prove an alternative in people with poor access to their veins. This is an update of a previously published review. OBJECTIVES To determine if treatment of pulmonary exacerbations with inhaled antibiotics in people with cystic fibrosis improves their quality of life, reduces time off school or work, and improves their long-term lung function. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Group's Cystic Fibrosis Trials Register. Date of the last search: 7 March 2022. We also searched ClinicalTrials.gov, the Australia and New Zealand Clinical Trials Registry and WHO ICTRP for relevant trials. Date of last search: 3 May 2022. SELECTION CRITERIA Randomised controlled trials in people with cystic fibrosis with a pulmonary exacerbation in whom treatment with inhaled antibiotics was compared to placebo, standard treatment or another inhaled antibiotic for between one and four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted data. They assessed the certainty of the evidence using the GRADE criteria. Authors of the included trials were contacted for more information. MAIN RESULTS Five trials with 183 participants are included in the review. Two trials (77 participants) compared inhaled antibiotics alone to intravenous antibiotics alone and three trials (106 participants) compared a combination of inhaled and intravenous antibiotics to intravenous antibiotics alone. Trials were heterogenous in design and two were only available in abstract form. Risk of bias was difficult to assess in most trials but, for four out of five trials, we judged there to be a high risk from lack of blinding and an unclear risk with regards to randomisation. Results were not fully reported and only limited data were available for analysis. One trial was a cross-over design and we only included data from the first intervention arm. Inhaled antibiotics alone versus intravenous antibiotics alone Only one trial (18 participants) reported a perceived improvement in lifestyle (quality of life) in both groups (very low-certainty evidence). Neither trial reported on time off work or school. Both trials measured lung function, but there was no difference reported between treatment groups (very low-certainty evidence). With regards to our secondary outcomes, one trial (18 participants) reported no difference in the need for additional antibiotics and the second trial (59 participants) reported on the time to next exacerbation. In neither case was a difference between treatments identified (both very low-certainty evidence). The single trial (18 participants) measuring adverse events and sputum microbiology did not observe any in either treatment group for either outcome (very low-certainty evidence). Inhaled antibiotics plus intravenous antibiotics versus intravenous antibiotics alone Inhaled antibiotics plus intravenous antibiotics may make little or no difference to quality of life compared to intravenous antibiotics alone. None of the trials reported time off work or school. All three trials measured lung function, but found no difference between groups in forced expiratory volume in one second (two trials; 44 participants; very low-certainty evidence) or vital capacity (one trial; 62 participants). None of the trials reported on the need for additional antibiotics. Inhaled plus intravenous antibiotics may make little difference to the time to next exacerbation; however, one trial (28 participants) reported on hospital admissions and found no difference between groups. There is likely no difference between groups in adverse events (very low-certainty evidence) and one trial (62 participants) reported no difference in the emergence of antibiotic-resistant organisms (very low-certainty evidence). AUTHORS' CONCLUSIONS We identified only low- or very low-certainty evidence to judge the effectiveness of inhaled antibiotics for the treatment of pulmonary exacerbations in people with cystic fibrosis. The included trials were not sufficiently powered to achieve their goals. Hence, we are unable to demonstrate whether one treatment was superior to the other or not. Further research is needed to establish whether inhaled tobramycin may be used as an alternative to intravenous tobramycin for some pulmonary exacerbations.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, The University of Nottingham, Nottingham, UK
| | - Edward Charbek
- Division of Pulmonary, Critical Care and Sleep Medicine, St Louis University School of Medicine, St Louis, MO, USA
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Therapeutic Approach of Chronic Pseudomonas Infection in Cystic Fibrosis-A Network Meta-Analysis. Antibiotics (Basel) 2021; 10:antibiotics10080936. [PMID: 34438986 PMCID: PMC8388982 DOI: 10.3390/antibiotics10080936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022] Open
Abstract
Pseudomonas infection is a major determinant of morbidity and mortality in cystic fibrosis (CF). Maintaining optimal lung function in CF patients carrying Pseudomonas remains a challenge. Our study aims to investigate the efficacy of antipseudomonal inhaled antibiotics in CF patients with chronic Pseudomonas infection. A Bayesian network meta-analysis of randomized controlled trials was conducted. The main outcomes were changes in: (a) forced respiratory volume (FEV1), (b) Pseudomonas aeruginosa sputum density, and (c) CF Questionnaire Revised Respiratory Symptom Score (CFQR-RSS) at 4 weeks follow-up. Eighteen trials which reported on treatment with aztreonam lysine, tobramycin, colistin, levofloxacin, fosfomycin/tobramycin, and amikacin in various dosages were eligible for inclusion. In terms of change in FEV1%, aztreonam lysine (t.i.d., 75 mg) with a 28-day run in the tobramycin phase, aztreonam lysine (b.i.d., 75 mg) with a 28-day run in the tobramycin phase had the highest probability of being the most effective treatment (SUCRAs were 77, 76%, respectively). Regarding change in Pseudomonas sputum density, aztreonam lysine (b.i.d., 75 mg) with a 28-day run in the tobramycin phase, aztreonam lysine (t.i.d., 75 mg) with a 28-day run in the tobramycin phase had the highest probability of being the most effective treatment (SUCRAs were 90, 86%, respectively). Regarding change in CFQR-RSS, aztreonam lysine (t.i.d., 75 mg) and aztreonam lysine (b.i.d., 75 mg) with a 28-day run in the tobramycin inhalation solution phase had the highest probability of being the most effective treatments (SUCRA:74% and 72%, respectively). Regarding changes in FEV1% and Pseudomonas sputum density, aztreonam lysine with a run in tobramycin phase may be the best treatment option in treating chronic Pseudomonas in CF. According to CFQR-RSS no significant differences were found. Given the limitations of the studies included, validation trials are called for.
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Ding L, Wang J, Cai S, Smyth H, Cui Z. Pulmonary biofilm-based chronic infections and inhaled treatment strategies. Int J Pharm 2021; 604:120768. [PMID: 34089796 DOI: 10.1016/j.ijpharm.2021.120768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/20/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022]
Abstract
Certain pulmonary diseases, such as cystic fibrosis (CF), non-CF bronchiectasis, chronic obstructive pulmonary disease, and ventilator-associated pneumonia, are usually accompanied by respiratory tract infections due to the physiological alteration of the lung immunological defenses. Recurrent infections may lead to chronic infection through the formation of biofilms. Chronic biofilm-based infections are challenging to treat using antimicrobial agents. Therefore, effective ways to eradicate biofilms and thus relieve respiratory tract infection require the development of efficacious agents for biofilm destruction, the design of delivery carriers with biofilm-targeting and/or penetrating abilities for these agents, and the direct delivery of them into the lung. This review provides an in-depth description of biofilm-based infections caused by pulmonary diseases and focuses on current existing agents that are administered by inhalation into the lung to treat biofilm, which include i) inhalable antimicrobial agents and their combinations, ii) non-antimicrobial adjuvants such as matrix-targeting enzymes, mannitol, glutathione, cyclosporin A, and iii) liposomal formulations of anti-biofilm agents. Finally, novel agents that have shown promise against pulmonary biofilms as well as traditional and new devices for pulmonary delivery of anti-biofilm agents into the lung are also discussed.
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Affiliation(s)
- Li Ding
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Jieliang Wang
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Shihao Cai
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Hugh Smyth
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA.
| | - Zhengrong Cui
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA.
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Taccetti G, Denton M, Hayes K, Drevinek P, Sermet-Gaudelus I, Bilton D, Campana S, Dolce D, Ferroni A, Héry-Arnaud G, Martin-Gomez MT, Nash E, Pereira L, Pressler T, Tümmler B. A critical review of definitions used to describe Pseudomonas aeruginosa microbiological status in patients with cystic fibrosis for application in clinical trials. J Cyst Fibros 2020; 19:52-67. [DOI: 10.1016/j.jcf.2019.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/23/2019] [Accepted: 08/15/2019] [Indexed: 01/23/2023]
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van Velzen AJ, Uges JWF, Heijerman HGM, Arets BGM, Nuijsink M, van der Wiel-Kooij EC, van Maarseveen EM, van Zanten GA, Pullens B, Touw DJ, Janssens HM. Pharmacokinetics and safety of tobramycin nebulization with the I-neb and PARI-LC Plus in children with cystic fibrosis: A randomized, crossover study. Br J Clin Pharmacol 2019; 85:1984-1993. [PMID: 31112621 PMCID: PMC6710527 DOI: 10.1111/bcp.13988] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/30/2019] [Accepted: 05/07/2019] [Indexed: 12/27/2022] Open
Abstract
AIMS We aimed to compare the pharmacokinetics (PK) and safety profile of tobramycin inhalation solution (TIS) using the I-neb device to the standard PARI-LC Plus nebulizer in children with cystic fibrosis. METHODS A randomized, open-label, crossover study was performed. In 2 separate study visits, blood samples from 22 children were collected following TIS nebulization with I-neb (75 mg) and PARI-LC Plus (300 mg). Study visits were separated by 1 month, in which 1 of the study nebulizers was used twice daily. Tobramycin PK for both nebulizers was established using measured tobramycin concentrations and Bayesian PK modelling software. Hearing and renal function tests were performed to test for aminoglycoside associated toxicity. In addition to standard estimated glomerular filtration rate values, biomarkers for tubular injury (KIM-1 and NAG) were measured. Patient and nebulizer satisfaction were assessed. RESULTS Inhalations were well tolerated and serum trough concentrations below the predefined toxic limit were reached with no significant differences in PK parameters between nebulizers. Results of audiometry and estimated glomerular filtration rate revealed no abnormalities. However, increased urinary NAG/creatinine ratios at visit 2 for both nebulizers suggest TIS-induced subclinical tubular kidney injury. Nebulization time was 50% shorter and patient satisfaction was significantly higher with the I-neb. CONCLUSIONS Nebulization of 75 mg TIS with the I-neb in children with cystic fibrosis resulted in comparable systemic exposure to 300 mg TIS with the PARI-LC Plus and was well tolerated and preferred over the PARI-LC Plus. Long-term safety of TIS nebulization should be monitored clinically, especially regarding the effects on tubular kidney injury.
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Affiliation(s)
| | | | - Harry G M Heijerman
- Department of Pulmonology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Bert G M Arets
- Department of Pediatric Pulmonology, University Medical Center Utrecht-Wilhelmina Children's hospital, Utrecht, The Netherlands
| | - Marianne Nuijsink
- Department of Pediatric Pulmonology, Haga Teaching Hospital-Juliana Children's hospital, The Hague, The Netherlands
| | - Els C van der Wiel-Kooij
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Erik M van Maarseveen
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijsbert A van Zanten
- Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bas Pullens
- Department of Otorhinolaryngology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hettie M Janssens
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
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12
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Abstract
BACKGROUND Cystic fibrosis is a genetic disorder in which abnormal mucus in the lungs is associated with susceptibility to persistent infection. Pulmonary exacerbations are when symptoms of infection become more severe. Antibiotics are an essential part of treatment for exacerbations and inhaled antibiotics may be used alone or in conjunction with oral antibiotics for milder exacerbations or with intravenous antibiotics for more severe infections. Inhaled antibiotics do not cause the same adverse effects as intravenous antibiotics and may prove an alternative in people with poor access to their veins. This is an update of a previously published review. OBJECTIVES To determine if treatment of pulmonary exacerbations with inhaled antibiotics in people with cystic fibrosis improves their quality of life, reduces time off school or work and improves their long-term survival. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Group's Cystic Fibrosis Trials Register. Date of the last search: 03 October 2018.We searched ClinicalTrials.gov, the Australia and New Zealand Clinical Trials Registry and WHO ICTRP for relevant trials. Date of last search: 09 October 2018. SELECTION CRITERIA Randomised controlled trials in people with cystic fibrosis with a pulmonary exacerbation in whom treatment with inhaled antibiotics was compared to placebo, standard treatment or another inhaled antibiotic for between one and four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted data. They assessed the quality of the evidence using the GRADE criteria. Authors of the included trials were contacted for more information. MAIN RESULTS Four trials with 167 participants are included in the review. Two trials (77 participants) compared inhaled antibiotics alone to intravenous antibiotics alone and two trials (90 participants) compared a combination of inhaled and intravenous antibiotics to intravenous antibiotics alone. Trials were heterogenous in design and two were only available in abstract form. Risk of bias was difficult to assess in most trials, but for all trials we judged there to be a high risk from lack of blinding and an unclear risk with regards to randomisation. Results were not fully reported and only limited data were available for analysis.Inhaled antibiotics alone versus intravenous antibiotics aloneOnly one trial (n = 18) reported a perceived improvement in lifestyle (quality of life) in both groups (very low-quality of evidence). Neither trial reported on time off work or school. Both trials measured lung function, but there was no difference reported between treatment groups (very low-quality evidence). With regards to our secondary outcomes, one trial (n = 18) reported no difference in the need for additional antibiotics and the second trial (n = 59) reported on the time to next exacerbation. In neither case was a difference between treatments identified (both very low-quality evidence). The single trial (n = 18) measuring adverse events and sputum microbiology did not observe any in either treatment group for either outcome (very low-quality evidence).Inhaled antibiotics plus intravenous antibiotics versus intravenous antibiotics aloneNeither trial reported on quality of life or time off work or school. Both trials measured lung function, but found no difference between groups in forced expiratory volume in one second (one trial, n = 28, very low-quality evidence) or vital capacity (one trial, n = 62). Neither trial reported on the need for additional antibiotics or the time to the next exacerbation; however, one trial (n = 28) reported on hospital admissions and found no difference between groups. Both trials reported no difference between groups in adverse events (very low-quality evidence) and one trial (n = 62) reported no difference in the emergence of antibiotic-resistant organisms (very low-quality evidence). AUTHORS' CONCLUSIONS There is little useful high-level evidence to judge the effectiveness of inhaled antibiotics for the treatment of pulmonary exacerbations in people with cystic fibrosis. The included trials were not sufficiently powered to achieve their goals. Hence, we are unable to demonstrate whether one treatment was superior to the other or not. Further research is needed to establish whether inhaled tobramycin may be used as an alternative to intravenous tobramycin for some pulmonary exacerbations.
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Affiliation(s)
- Sherie Smith
- The University of NottinghamDivision of Child Health, Obstetrics & Gynaecology, School of Medicine1701 E FloorEast Block Queens Medical CentreNottinghamNG7 2UHUK
| | - Nicola J Rowbotham
- The University of NottinghamDivision of Child Health, Obstetrics & Gynaecology, School of Medicine1701 E FloorEast Block Queens Medical CentreNottinghamNG7 2UHUK
| | - Edward Charbek
- St Louis University School of MedicineDivision of Pulmonary, Critical Care and Sleep Medicine1402 S. Grand Ave, 7‐S‐FDTSt LouisMOUSA63104‐1004
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Kukut Hatipoglu M, Hickey AJ, Garcia-Contreras L. Pharmacokinetics and pharmacodynamics of high doses of inhaled dry powder drugs. Int J Pharm 2018; 549:306-316. [PMID: 30077761 DOI: 10.1016/j.ijpharm.2018.07.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/17/2018] [Accepted: 07/22/2018] [Indexed: 12/13/2022]
Abstract
For many years, administration of drugs by inhalation has been the mainstay treatment for obstructive respiratory disorders such as asthma and chronic obstructive pulmonary disease. Antibiotics and other drugs have been administered for decades as aerosols to treat other pulmonary disease in a clinical setting, but it was until the early 1980's that colistin was formally marketed as a solution for nebulization in Europe (Colomycin, Pharmax, Bexley). The solubility of other drugs and the size of the dose required to achieve therapeutic concentrations at the site of action, made treatment times long and difficult to be performed at home. High dose dry powder delivery is a potentially effective way to deliver low potency drugs such as antibiotics. There are three major barriers to achieving the desired pharmacodynamic effect with these compounds: aerosol delivery, lung deposition and clearance. The powder formulation and device technology influence aerosol generation and may influence the size of the dose that can be achieved by inhalation in one puff. The site of deposition in the lungs is dictated by mechanisms of deposition which are influenced by the aerosol properties, particularly aerodynamic particle size distribution and the anatomy and physiology of the lungs. Finally, mechanisms of clearance dictate the local and systemic disposition of the drug, which in turn affects its pharmacokinetics and ultimately the pharmacodynamic effect and efficacy of treatment. Each of these factors will be considered and the implications for antimicrobial agent delivery as a high dose delivery example will be given.
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Affiliation(s)
- Manolya Kukut Hatipoglu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | | | - Lucila Garcia-Contreras
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States.
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14
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Smith S, Rowbotham NJ, Regan KH. Inhaled anti-pseudomonal antibiotics for long-term therapy in cystic fibrosis. Cochrane Database Syst Rev 2018; 3:CD001021. [PMID: 29607494 PMCID: PMC8407188 DOI: 10.1002/14651858.cd001021.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. OBJECTIVES To evaluate the effects long-term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug sensitivity reactions and survival). SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries.Date of last search: 13 February 2018. SELECTION CRITERIA We selected trials if inhaled anti-pseudomonal antibiotic treatment was used for at least three months in people with cystic fibrosis, treatment allocation was randomised or quasi-randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). DATA COLLECTION AND ANALYSIS Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the quality of the evidence using the GRADE system. MAIN RESULTS The searches identified 333 citations to 98 trials; 18 trials (3042 participants aged between five and 56 years) met the inclusion criteria. Limited data were available for meta-analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One of the trials (18 participants) compared to placebo and a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials.We found limited evidence that inhaled antibiotics improved lung function (four of the 11 placebo-controlled trials, n = 814). Compared to placebo, inhaled antibiotics also reduced the frequency of exacerbations (three trials, n = 946), risk ratio 0.66 (95% confidence interval (CI) 0.47 to 0.93). There were insufficient data for us to be able to report an effect on nutritional outcomes or survival and there were insufficient data for us to ascertain the effect on quality of life. There was no significant effect on antibiotic resistance seen in the two trials that were included in meta-analyses. Tinnitus and voice alteration were the only adverse events significantly more common in the inhaled antibiotics group. The overall quality of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates.Of the eight trials that compared different inhaled antibiotics or different antibiotic regimens, there was only one trial in each comparison. Forced expiratory volume at one second (FEV1) % predicted was only found to be significantly improved with aztreonam lysine for inhalation compared to tobramycin (n = 273), mean difference -3.40% (95% CI -6.63 to -0.17). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. No significant differences were found in the remaining comparisons with regard to lung function. Pulmonary exacerbations were measured in different ways, but one trial (n = 273) found that the number of people treated with antibiotics was lower in those receiving aztreonam than tobramycin, risk ratio 0.66 (95% CI 0.51 to 0.86). We found the quality of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. AUTHORS' CONCLUSIONS Inhaled anti-pseudomonal antibiotic treatment probably improves lung function and reduces exacerbation rate, but pooled estimates of the level of benefit were very limited. The best evidence is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer-term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes.
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Affiliation(s)
- Sherie Smith
- The University of NottinghamDivision of Child Health, Obstetrics & Gynaecology, School of Medicine1701 E FloorEast Block Queens Medical CentreNottinghamNG7 2UHUK
| | - Nicola J Rowbotham
- The University of NottinghamDivision of Child Health, Obstetrics & Gynaecology, School of Medicine1701 E FloorEast Block Queens Medical CentreNottinghamNG7 2UHUK
| | - Kate H Regan
- NHS LothianRoyal Infirmary of Edinburgh51 Little France CrescentEdinburghUKEH16 4SA
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Eckman MH, Kopras EJ, Montag-Leifling K, Kirby LP, Burns L, Indihar VM, Joseph PM. Shared Decision-Making Tool for Self-Management of Home Therapies for Patients With Cystic Fibrosis. MDM Policy Pract 2017; 2:2381468317715621. [PMID: 30288426 PMCID: PMC6136161 DOI: 10.1177/2381468317715621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 05/15/2017] [Indexed: 12/11/2022] Open
Abstract
Objective: Patients with cystic fibrosis (CF) undertake time-consuming programs of home therapies. Our objective was to develop a tool to help CF patients prioritize personal goals for some of these treatments. We describe the development and results of initial evaluation of this shared decision-making tool. Methods: Multicriteria decision-making method to develop a shared decision-making tool that integrates patient's values and perceptions of treatment impact on functionality/sense of well-being. Treatment efficacy data obtained through comprehensive review of English language literature and Cochrane reviews. Field study of 21 patients was performed to assess acceptability of the approach, understandability of the tool, and to determine whether there was sufficient patient-to-patient variability in treatment goals and patient preferences to make use of a personalized tool worthwhile. Results: Patients found the tool easy to understand and felt engaged as active participants in their care. The tool was responsive to variations in patient preferences. Priority scores were calculated (0-1.0 ± SD). Patients' most important treatment goals for improving lung health included improving breathing function (0.27 ± 0.11), improving functionality/sense of well-being (0.24 ± 0.13), preventing lung infection (0.21 ± 0.08), minimizing time to complete treatments (0.16 ± 0.12), and minimizing cost (0.11 ± 0.09). Conclusions: A shared decision-making tool that integrates patients' values and best evidence is feasible and could result in improved patient engagement in their own care.
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Affiliation(s)
- Mark H. Eckman
- Mark H. Eckman, MD, MS University of
Cincinnati Medical Center, PO Box 670535, Cincinnati, OH 45267-0535, USA;
telephone: (513) 558-7581; e-mail:
| | - Elizabeth J. Kopras
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Karen Montag-Leifling
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Lari P. Kirby
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Lisa Burns
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Veronica M. Indihar
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Patricia M. Joseph
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
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Elborn JS, Vataire AL, Fukushima A, Aballea S, Khemiri A, Moore C, Medic G, Hemels ME. Comparison of Inhaled Antibiotics for the Treatment of Chronic Pseudomonas aeruginosa Lung Infection in Patients With Cystic Fibrosis: Systematic Literature Review and Network Meta-analysis. Clin Ther 2016; 38:2204-2226. [DOI: 10.1016/j.clinthera.2016.08.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/29/2016] [Accepted: 08/30/2016] [Indexed: 12/26/2022]
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Mashat M, Clark B, Assi K, Chrystyn H. In vitro aerodynamic characterization of the dose emitted during nebulization of tobramycin high strength solution by novel and jet nebulizer delivery systems. Pulm Pharmacol Ther 2016; 37:37-42. [DOI: 10.1016/j.pupt.2015.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/24/2015] [Accepted: 12/26/2015] [Indexed: 10/22/2022]
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Tridello G, Volpi S, Assael BM, Meneghelli I, Passiu M, Circelli M. Lung function comparison between two decades in cystic fibrosis children: A single centre study. Pediatr Pulmonol 2015; 50:1237-43. [PMID: 26422228 DOI: 10.1002/ppul.23314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 08/03/2015] [Accepted: 08/28/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The purpose of this study was to compare two cohorts of cystic fibrosis (CF) patients born and treated in two different decades, diagnosed through a CF neonatal screening program. METHODOLOGY We compared pulmonary function decline from 10 to 15 years of age in patients with cystic fibrosis born between 1979 and 1984 (Cohort 1) and between 1991 and 1996 (Cohort 2). Forced expiratory volume in 1 sec (FEV1%) and forced expiratory flow from 25% to 75% (FEF 25-75%) were analyzed by a linear mixed model approach. The differences between the two cohorts were estimated and the overall cohort effect was tested. RESULTS Ninety-two patients (51 males, 41 females) fulfilled the selection criteria. Pancreatic insufficiency and CF related diabetes were present in 91% and 20% of patients, respectively. The mean absolute decrement of FEV1% was 9.2 (standard deviation [SD] 11.2) in Cohort 1 and 0.6 (SD 10.4) in Cohort 2 (P < 0.001). The mean decrement of FEF 25-75% was 16.3 (SD 19.5) in Cohort 1 and 1.3 (SD 16.8) in Cohort 2 (P < 0.001) and the Pseudomonas aeruginosa (Pa) colonization was 28% and 15% respectively (P = 0.1). CONCLUSIONS Our results show that pulmonary function has clearly ameliorated over a decade in young CF patients, in a period during which several significant therapeutic changes have been introduced, such as dornase alfa, tobramycin and hypertonic saline. To our knowledge this is the first study showing a cohort effect in patients diagnosed after neonatal screening.
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Schwarz C. Colobreathe® for the Treatment of Cystic Fibrosis-Associated Pulmonary Infections. Pulm Ther 2015. [DOI: 10.1007/s41030-015-0007-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Vázquez-Espinosa E, Girón RM, Gómez-Punter RM, García-Castillo E, Valenzuela C, Cisneros C, Zamora E, García-Pérez FJ, Ancochea J. Long-term safety and efficacy of tobramycin in the management of cystic fibrosis. Ther Clin Risk Manag 2015; 11:407-15. [PMID: 25792839 PMCID: PMC4362982 DOI: 10.2147/tcrm.s75208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Cystic fibrosis (CF) is a fatal inherited disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene whose mortality is conditioned by a progressive decline in lung function. Bacterial infections play a key role in this decline. Chronic bacterial infection in CF patients varies over time and the presence of Pseudomonas aeruginosa in sputum is a marker of poor prognosis. P. aeruginosa is eradicated from the airways using inhaled antibiotics administered in various formulations and devices. Antipseudomonal antibiotics have extended the survival of CF patients to 40 years. Tobramycin is a bactericidal aminoglycoside antibiotic with demonstrated activity against gram-negative microorganisms. Initially, the drug was administered as an inhaled parenteral solution. Subsequently, a specific tobramycin inhalation solution was developed. PulmoSphere™ technology enables dry tobramycin powder to be formulated for inhalation (tobramycin inhalation powder) using a small and portable capsule-based breath-activated device (T-326). Chronic colonization by P. aeruginosa is the main indication for aerosol antibiotic therapy. The American Cystic Fibrosis Foundation, European guidelines, and Spanish consensus guidelines provide different recommendations for eradication.
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Affiliation(s)
- Emma Vázquez-Espinosa
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Rosa María Girón
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Rosa Mar Gómez-Punter
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Elena García-Castillo
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Claudia Valenzuela
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Carolina Cisneros
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Enrique Zamora
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - F Javier García-Pérez
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Julio Ancochea
- Pulmonology Department, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
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Cantón R, Máiz L, Escribano A, Olveira C, Oliver A, Asensio O, Gartner S, Roma E, Quintana-Gallego E, Salcedo A, Girón R, Barrio MI, Pastor MD, Prados C, Martínez-Martínez MT, Barberán J, Castón JJ, Martínez-Martínez L, Poveda JL, Vázquez C, de Gracia J, Solé A. Spanish Consensus on the Prevention and Treatment of Pseudomonas aeruginosa Bronchial Infections in Cystic Fibrosis Patients. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.arbr.2014.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Renal diseases in adults with cystic fibrosis: a 40 year single centre experience. J Nephrol 2015; 28:585-91. [PMID: 25712235 DOI: 10.1007/s40620-015-0179-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 02/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is a sizable literature describing renal disease in patients with cystic fibrosis. Previous studies have focused on single disease processes alone, most commonly renal stone disease or acute kidney injury. In this study we report for the first time on the prevalence of all forms of renal disease in a cystic fibrosis population. METHODS A retrospective review of adult patients with cystic fibrosis attending the Adult Cystic Fibrosis Department at the Royal Brompton Hospital was carried out by searching the department's database to identify patients with renal problems and subsequently retrieving clinical information from medical notes. RESULTS The prevalence of all renal diseases in our population was 5.1 %. The most commonly identified problem was renal stones. At 2.0 % the prevalence of renal stones in adult patients with cystic fibrosis was comparable to the general population. A range of other renal diseases were identified, the next most common being drug-induced acute kidney injury. CONCLUSIONS A range of cystic fibrosis independent and attributable diseases has been identified but no cystic fibrosis specific disease. In contrast to other cystic fibrosis centres no increased prevalence of renal stones was found.
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Cantón R, Máiz L, Escribano A, Olveira C, Oliver A, Asensio O, Gartner S, Roma E, Quintana-Gallego E, Salcedo A, Girón R, Barrio MI, Pastor MD, Prados C, Martínez-Martínez MT, Barberán J, Castón JJ, Martínez-Martínez L, Poveda JL, Vázquez C, de Gracia J, Solé A. Spanish consensus on the prevention and treatment of Pseudomonas aeruginosa bronchial infections in cystic fibrosis patients. Arch Bronconeumol 2015; 51:140-50. [PMID: 25614377 DOI: 10.1016/j.arbres.2014.09.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 09/22/2014] [Indexed: 01/22/2023]
Abstract
Pseudomonas aeruginosa is the main pathogen in bronchopulmonary infections in cystic fibrosis (CF) patients. It can only be eradicated at early infection stages while reduction of its bacterial load is the therapeutic goal during chronic infection or exacerbations. Neonatal screening and pharmacokinetic/pharmacodynamic knowledge has modified the management of CF-patients. A culture based microbiological follow-up should be performed in patients with no infection with P.aeruginosa. At initial infection, inhaled colistin (0,5-2MU/tid), tobramycin (300mg/bid) or aztreonam (75mg/tid) with or without oral ciprofloxacin (15-20mg/kg/bid, 2-3weeks) are recommended. In chronic infections, treatment is based on continuous administration of colistin or with a 28-day on-off regimen with tobramycin or aztreonam. During mild-moderate exacerbations oral ciprofloxacin (2-3weeks) can be administered while serious exacerbations must be treated with intravenous combination therapy (beta-lactam with an aminoglycoside or a fluoroquinolone). Future studies will support antibiotic rotation and/or new combination therapies. Epidemiological measures are also recommended to avoid new P.aeruginosa infections and "patient-to-patient transmission" of this pathogen.
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Affiliation(s)
- Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal e Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS), Madrid, España; Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, España.
| | - Luis Máiz
- Unidad de Bronquiectasias y Fibrosis Quística, Servicio de Neumología, Hospital Universitario Ramón y Cajal e Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS), Madrid, España
| | - Amparo Escribano
- Unidad de Neumología Pediátrica y Fibrosis Quística, Servicio de Pediatría, Hospital Clínico Universitario, Universidad de Valencia, Valencia, España
| | - Casilda Olveira
- Unidad de Gestión Clínica de Enfermedades Respiratorias, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, Málaga, España
| | - Antonio Oliver
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, España; Servicio de Microbiología y Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, España
| | - Oscar Asensio
- Unidad de Neumología y Alergia Pediátrica, Hospital Universitario de Sabadell. Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España
| | - Silvia Gartner
- Unidad de Neumología Pediátrica y Fibrosis Quística, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Eva Roma
- Servicio de Farmacia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Esther Quintana-Gallego
- Unidad de Fibrosis Quística, Servicio de Neumología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Antonio Salcedo
- Unidad de Fibrosis Quística Interhospitalaria Niño Jesús-Gregorio Marañón, Madrid, España
| | - Rosa Girón
- Unidad de Bronquiectasias y Fibrosis Quística, Hospital Universitario La Princesa, Instituto La Princesa de Investigación Sanitaria, Madrid, España
| | - María Isabel Barrio
- Sección de Neumología Pediátrica y Unidad de Fibrosis Quística, Hospital Universitario La Paz, Madrid, España
| | - María Dolores Pastor
- Unidad de Neumología Pediátrica y Fibrosis Quística, Hospital Universitario Virgen de la Arrixaca, Murcia, España
| | - Concepción Prados
- Unidad de Fibrosis Quística y Bronquiectasias, Servicio de Neumología, Hospital Universitario La Paz, Madrid, España
| | | | - José Barberán
- Departamento de Medicina Interna, Hospital Montepríncipe, Universidad CEU San Pablo, Madrid, España
| | - Juan José Castón
- Unidad de Enfermedades Infecciosas, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Luis Martínez-Martínez
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, España; Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla-IDIVAL y Departamento de Biología Molecular, Universidad de Cantabria, Santander, España
| | - José Luis Poveda
- Servicio de Farmacia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Carlos Vázquez
- Unidad de Neumología Pediátrica y Fibrosis Quística, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España
| | - Javier de Gracia
- Servicio de Neumología y CIBER en Enfermedades Respiratorias (CibeRES), Hospital Universitari Vall d'Hebron, Universidad Autónoma, Barcelona, España
| | - Amparo Solé
- Unidad de Trasplante Pulmonar y Fibrosis Quística, Hospital Universitario y Politécnico la Fe, Valencia, España.
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Olveira C, Muñoz A, Domenech A. Terapia nebulizada. Año SEPAR. Arch Bronconeumol 2014; 50:535-45. [DOI: 10.1016/j.arbres.2014.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/06/2014] [Accepted: 05/10/2014] [Indexed: 11/16/2022]
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Mazurek H, Chiron R, Kucerova T, Geidel C, Bolbas K, Chuchalin A, Blanco-Aparicio M, Santoro D, Varoli G, Zibellini M, Cicirello HG, Antipkin YG. Long-term efficacy and safety of aerosolized tobramycin 300 mg/4 ml in cystic fibrosis. Pediatr Pulmonol 2014; 49:1076-89. [PMID: 24464974 DOI: 10.1002/ppul.22989] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 12/02/2013] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Aerosolized tobramycin is a standard of care for chronic Pseudomonas aeruginosa (Pa) infection in patients with cystic fibrosis (CF). OBJECTIVES The long-term safety and efficacy of intermittent (28-day "on"/"off" cycles) inhaled tobramycin nebulization solution 300 mg/4 ml (TNS4, Bramitob(®)/Bethkis(®)) was assessed over 56 weeks in CF patients aged ≥6 years having baseline 1 sec forced expiratory volume (FEV(1)) 40-80% predicted. METHODS Patients were initially randomized in an 8-week open-label trial (core phase) to compare TNS4 (N = 159) and tobramycin 300 mg/5 ml (TNS5, TOBI(®)) (N = 165). A subset of patients continued in a 48-week, single-arm extension receiving TNS4 only. The primary endpoint of the core phase was to demonstrate the non-inferiority of TNS4 compared to TNS5 in terms of absolute change from baseline to week 4 in FEV(1) % predicted. The assessment of long-term safety was the primary purpose of the extension phase. Throughout all phases of the study, microbiological assessments, adverse events, and audiometry findings were also evaluated. RESULTS In the core phase (N = 321), FEV(1) (% predicted) increased from baseline (absolute change) following a single on-treatment cycle for both TNS4 (7.0%) and TNS5 (7.5%) and the non-inferiority between treatments was met [difference between treatments of -0.5 (95% CI: -2.6; 1.6)]. These improvements were maintained throughout the extension phase (N = 209), ranging throughout the study between 5.1% (95% CI: 3.2; 6.9) and 8.1% (95% CI: 6.8; 9.4) compared to baseline. Pa sputum count reductions ranged between 0.6 (95% CI: 0.2; 0.9) to 2.3 (95% CI: 2.0; 2.6) log10 CFU/g throughout the 56 weeks. No remarkable safety issues were identified throughout both study phases, with similar percentages of patients reporting adverse events in the two treatment groups during the 8-week core phase [TNS4 (31.4%); TNS5 (28.0%)]. CONCLUSIONS Overall, TNS4 demonstrated short-term clinical benefits similar to TNS5 which were maintained during the long-term use of TNS4 and was also associated with a favorable tolerability profile.
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Affiliation(s)
- Henryk Mazurek
- Instytut Gruźlicy i Chorób Pluc, Oddzial Terenowy im. Jana i Ireny Rudników w Rabce-Zdrój, Klinika Pneumonologii i Mukowiscydozy, Rabka-Zdrój, Poland
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Koerner-Rettberg C, Ballmann M. Colistimethate sodium for the treatment of chronic pulmonary infection in cystic fibrosis: an evidence-based review of its place in therapy. CORE EVIDENCE 2014; 9:99-112. [PMID: 25278817 PMCID: PMC4178503 DOI: 10.2147/ce.s64980] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Chronic bacterial respiratory-tract infections are a major driving force in the pathogenesis of cystic fibrosis (CF) lung disease and promote chronic lung-function decline, destruction, and progression to respiratory failure at a premature age. Gram-negative bacteria colonizing the airways in CF are a major problem in CF therapy due to their tendency to develop a high degree of resistance to antibiotic agents over time. Pseudomonas aeruginosa is the dominating bacterial strain infecting the CF lung from early childhood on, and multiresistant strains frequently develop after years of therapy. Colistin has been used for treating pulmonary bacterial infections in CF for decades due to its very good Gram-negative activity. However, drawbacks include concerns regarding toxicity when being applied systemically, and the lack of approval for application by inhalation in the USA for many years. Other antibiotic substances for systemic use are available with good to excellent Gram-negative and anti-Pseudomonas activity, while there are only three substances approved for inhalation use in the treatment of chronic pulmonary infection with proven benefit in CF. The emergence of multiresistant strains leaving nearly no antibiotic substance as a treatment option, the limited number of antibiotics with high activity against P. aeruginosa, the concerns about increasing the risk of antibiotic resistance by continuous antibiotic therapy, the development of new drug formulations and drug-delivery devices, and, finally, the differing treatment strategies used in CF centers call for defining the place of this "old" drug, colistimethate, in today's CF therapy. This article reviews the available evidence to reflect on the place of colistimethate sodium in the therapy of chronic pulmonary infection in CF.
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Affiliation(s)
- Cordula Koerner-Rettberg
- Department of Pediatric Pneumology, University Children's Hospital of Ruhr University Bochum at St Josef-Hospital, Bochum, Germany
| | - Manfred Ballmann
- Department of Pediatric Pneumology, University Children's Hospital of Ruhr University Bochum at St Josef-Hospital, Bochum, Germany
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Nebulized Tobramycin in the Treatment of Adult CF Pulmonary Exacerbations. J Aerosol Med Pulm Drug Deliv 2014; 27:299-305. [DOI: 10.1089/jamp.2013.1055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Parkins MD, Elborn JS. Tobramycin Inhalation Powder™: a novel drug delivery system for treating chronicPseudomonas aeruginosainfection in cystic fibrosis. Expert Rev Respir Med 2014; 5:609-22. [DOI: 10.1586/ers.11.56] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abolhassani H, Sagvand BT, Shokuhfar T, Mirminachi B, Rezaei N, Aghamohammadi A. A review on guidelines for management and treatment of common variable immunodeficiency. Expert Rev Clin Immunol 2014; 9:561-74; quiz 575. [PMID: 23730886 DOI: 10.1586/eci.13.30] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in adults. As symptoms of CVID are usually heterogeneous and unspecific, diagnosis and follow-up of CVID can be challenging. In light of this, a broad review of advances in management and treatment of CVID is performed here in order to reach a distinct protocol. However, it should be noted that owing to the nature of the disease, it can only be treated symptomatically but not cured. There is little evidence to guide appropriate or universal guidelines to improve the current status of management of the disease. The most satisfactory treatments of CVID could be achieved by the use of immunoglobulin replacement, antibiotics, immunosuppressants and hematopoietic stem cell transplantation. This review is written based on the importance of clinical surveillance of asymptomatic CVID cases and early recognition of different clinical complications. Moreover, for each complication, appropriate interventions for improving outcomes are mentioned.
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Affiliation(s)
- Hassan Abolhassani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Das RR, Kabra SK, Singh M. Treatment of pseudomonas and Staphylococcus bronchopulmonary infection in patients with cystic fibrosis. ScientificWorldJournal 2013; 2013:645653. [PMID: 24489509 PMCID: PMC3893016 DOI: 10.1155/2013/645653] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 10/02/2013] [Indexed: 12/24/2022] Open
Abstract
The optimal antibiotic regimen is unclear in management of pulmonary infections due to pseudomonas and staphylococcus in cystic fibrosis (CF). We systematically searched all the published literature that has considered the evidence for antimicrobial therapies in CF till June 2013. The key findings were as follows: inhaled antipseudomonal antibiotic improves lung function, and probably the safest/most effective therapy; antistaphylococcal antibiotic prophylaxis increases the risk of acquiring P. aeruginosa; azithromycin significantly improves respiratory function after 6 months of treatment; a 28-day treatment with aztreonam or tobramycin significantly improves respiratory symptoms and pulmonary function; aztreonam lysine might be superior to tobramycin inhaled solution in chronic P. aeruginosa infection; oral ciprofloxacin does not produce additional benefit in those with chronic persistent pseudomonas infection but may have a role in early or first infection. As it is difficult to establish a firm recommendation based on the available evidence, the following factors must be considered for the choice of treatment for each patient: antibiotic related (e.g., safety and efficacy and ease of administration/delivery) and patient related (e.g., age, clinical status, prior use of antibiotics, coinfection by other organisms, and associated comorbidities ones).
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Affiliation(s)
- Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Sushil Kumar Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Meenu Singh
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Zarogoulidis P, Kioumis I, Porpodis K, Spyratos D, Tsakiridis K, Huang H, Li Q, Turner JF, Browning R, Hohenforst-Schmidt W, Zarogoulidis K. Clinical experimentation with aerosol antibiotics: current and future methods of administration. DRUG DESIGN DEVELOPMENT AND THERAPY 2013; 7:1115-34. [PMID: 24115836 PMCID: PMC3793595 DOI: 10.2147/dddt.s51303] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Currently almost all antibiotics are administered by the intravenous route. Since several systems and situations require more efficient methods of administration, investigation and experimentation in drug design has produced local treatment modalities. Administration of antibiotics in aerosol form is one of the treatment methods of increasing interest. As the field of drug nanotechnology grows, new molecules have been produced and combined with aerosol production systems. In the current review, we discuss the efficiency of aerosol antibiotic studies along with aerosol production systems. The different parts of the aerosol antibiotic methodology are presented. Additionally, information regarding the drug molecules used is presented and future applications of this method are discussed.
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Affiliation(s)
- Paul Zarogoulidis
- Pulmonary Department, G Papanikolaou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; Department of Interventional Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital, University Duisburg-Essen, Essen, Germany
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Wilson R, Sethi S, Anzueto A, Miravitlles M. Antibiotics for treatment and prevention of exacerbations of chronic obstructive pulmonary disease. J Infect 2013; 67:497-515. [PMID: 23973659 DOI: 10.1016/j.jinf.2013.08.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 08/14/2013] [Accepted: 08/16/2013] [Indexed: 11/18/2022]
Abstract
Acute exacerbations (AE) can be recurrent problems for patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) increasing morbidity and mortality. Evidence suggests that ≥50% of acute exacerbations involve bacteria requiring treatment with an antibiotic which should have high activity against the causative pathogens. However, sputum analysis is not a pre-requisite for antibiotic prescription in outpatients as results are delayed and patients are likely to be colonised with bacteria in the stable state. Clinicians rely on the clinical symptoms, sputum appearance and the patient's medical history to decide if an AE-COPD should be treated with antibiotics. This article reviews the available data of antibiotic trials in AE-COPD. Management of frequent exacerbators is particularly challenging for physicians. This may include antibiotic prophylaxis, especially macrolides because of anti-inflammatory properties; though successful in reducing exacerbations, concerns about resistance development remain. Inhalation of antibiotics achieves high local concentrations and minimal systemic exposure; therefore, it may represent an attractive alternative for antibiotic prophylaxis in certain COPD patients. Inhaled antibiotic prophylaxis has been successfully used in other respiratory conditions such as non-cystic fibrosis bronchiectasis which itself might be present in COPD patients who have chronic bacterial infection, particularly with Pseudomonas aeruginosa.
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Affiliation(s)
- Robert Wilson
- Host Defence Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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Galeva I, Konstan MW, Higgins M, Angyalosi G, Brockhaus F, Piggott S, Thomas K, Chuchalin AG. Tobramycin inhalation powder manufactured by improved process in cystic fibrosis: the randomized EDIT trial. Curr Med Res Opin 2013; 29:947-56. [PMID: 23672633 PMCID: PMC4086187 DOI: 10.1185/03007995.2013.805122] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Tobramycin inhalation powder (TIP) was reported to be effective in two Phase III studies in patients with cystic fibrosis (CF) chronically infected with Pseudomonas aeruginosa (Pa). The EDIT study evaluated the efficacy and safety of TIP manufactured by an improved process in CF subjects aged 6-21 years. METHODS CF patients with a forced expiratory volume in 1 second (FEV₁) ≥25% to ≤80% predicted, positive Pa cultures and inhaled antipseudomonal therapy naïve (or at least for past 4 months) were enrolled into this double-blind, multicenter trial. Patients were randomized to receive TIP or placebo (1:1) twice daily for one treatment cycle (28.5 days on drug, 28 days off drug). The primary endpoint was relative change in FEV₁ percentage predicted from baseline to day 29. A pre-specified sensitivity analysis evaluated absolute change in FEV₁% predicted. Other endpoints included Pa sputum density and safety. RESULTS A total of 62 patients out of a target of 100 (mean age 12.9 years, baseline FEV₁ 59.2% predicted, Pa sputum density 7.4 log₁₀ colony forming units [CFU] per gram) were randomized. Mean treatment differences (TIP - placebo) were 5.9% (p=0.148) and 4.4% (p<0.05) for relative and absolute change in FEV₁% predicted respectively. TIP significantly reduced Pa sputum density by -1.2 log10 CFU (p=0.002). Treatment with TIP was well tolerated. CONCLUSIONS Relative change in FEV₁% predicted with TIP treatment was in the expected range based on the literature, but did not reach statistical significance versus placebo. Placebo control and use of treatment naïve patients led to significant recruitment challenges and an underpowered study with consequent impact on the generated data. However, significant improvements in other outcomes including absolute change in FEV₁% predicted and reduction in Pa sputum density indicate that TIP is efficacious and well tolerated in CF patients. CLINICALTRIALS.GOV IDENTIFIER: NCT00918957.
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Affiliation(s)
- Ivanka Galeva
- Pediatric Clinic, UMHAT Alexandrovska, Sofia, Bulgaria.
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Máiz L, Girón RM, Olveira C, Quintana E, Lamas A, Pastor D, Cantón R, Mensa J. Inhaled antibiotics for the treatment of chronic bronchopulmonary Pseudomonas aeruginosa infection in cystic fibrosis: systematic review of randomised controlled trials. Expert Opin Pharmacother 2013; 14:1135-49. [PMID: 23586963 DOI: 10.1517/14656566.2013.790366] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Inhaled antibiotics are probably the safest and most effective therapy for Pseudomonas aeruginosa chronic lung infection in cystic fibrosis (CF) patients. AREAS COVERED To summarise the available evidence, a systematic review of the three currently available inhaled antibiotics (aztreonam lysine (AZLI), colistin (COL) and tobramycin (TOB)) was performed. The three AZLI placebo-controlled studies showed that the improvements in FEV1 and mean sputum P. aeruginosa density were statistically significant better than with placebo. The two COL placebo-controlled studies involved few patients but showed that COL was better than placebo in terms of maintenance of some pulmonary function parameters. The tobramycin inhalation solution (TIS) and tobramycin inhalation powder studies showed that the efficacy of both formulations was similar but significantly better than placebo. In the comparative studies, TIS showed more efficacy than COL solution, colistin inhalation powder showed non-inferiority to TIS and AZLI was superior to TIS. EXPERT OPINION Placebo-controlled and comparative clinical trials have shown that clinical evidence of inhaled antibiotics is very different. The choice of treatment for each individual CF patient must be based on the features of the drug (clinical evidence on efficacy and safety), the inhalation system and the patient characteristics. Development of new inhaled antibiotics will allow new end points of efficacy and therapy regimens to be assessed.
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Affiliation(s)
- Luis Máiz
- Ramón y Cajal University Hospital, Unit of Bronchiestasis and Cystic Fibrosis, Respiratory Department , Madrid , Spain
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Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB, Lubsch L, Hazle L, Sabadosa K, Marshall B. Cystic Fibrosis Pulmonary Guidelines. Am J Respir Crit Care Med 2013; 187:680-9. [DOI: 10.1164/rccm.201207-1160oe] [Citation(s) in RCA: 455] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
BACKGROUND Cystic fibrosis is a genetic disorder in which abnormal mucus in the lungs is associated with susceptibility to persistent infection. Pulmonary exacerbations are when symptoms of infection become more severe. Antibiotics are an essential part of treatment for exacerbations and inhaled antibiotics may be used alone or in conjunction with oral antibiotics for milder exacerbations or with intravenous antibiotics for more severe infections. Inhaled antibiotics do not cause the same adverse effects as intravenous antibiotics and may prove an alternative in people with poor access to their veins. OBJECTIVES To determine if treatment of pulmonary exacerbations with inhaled antibiotics in people with cystic fibrosis improves their quality of life, reduces time off school or work and improves their long-term survival. SEARCH METHODS We searched ClinicalTrials.gov and the Australia and New Zealand Clinical Trials Registry for relevant trials. Date of last search: 15 March 2012We also searched the Cochrane Cystic Fibrosis Group's Cystic Fibrosis Trials Register. Date of the last search: 01 June 2012. SELECTION CRITERIA Randomised controlled trials in people with cystic fibrosis with a pulmonary exacerbation in whom treatment with inhaled antibiotics was compared to placebo, standard treatment or another inhaled antibiotic for between one and four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted data. Authors of the included trials were contacted for more information. MAIN RESULTS Six trials with 208 participants were included in the review. Trials were heterogenous in design and interventions (however, all included trials compared inhaled versus intravenous antibiotic regimens). Risk of bias was difficult to assess in most trials. Results were not fully reported and only limited data were available for analysis. Four trials reported some results on forced expiratory volume at one second and found no significant differences between the inhaled antibiotic and the comparison intervention. In two of these trials using 300 mg of inhaled tobramycin, the change in forced expiratory volume at one second was similar to intravenous tobramycin; and in one trial the time until the next exacerbation was not different. No important adverse effects were reported. AUTHORS' CONCLUSIONS There is little useful high-level evidence to judge the effectiveness of inhaled antibiotics for the treatment of pulmonary exacerbations in people with cystic fibrosis. The included trials were not sufficiently powered to achieve their goals. Hence, we are unable to demonstrate whether one treatment was superior to the other or not. Further research is needed to establish whether inhaled tobramycin may be used as an alternative to intravenous tobramycin for some pulmonary exacerbations.
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Affiliation(s)
- Gerard Ryan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Australia.
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Pharmacokinetic and tolerability profiles of tobramycin nebuliser solution 300 mg/4 ml administered by PARI eFlow(®) rapid and PARI LC Plus(®) nebulisers in cystic fibrosis patients. Pulm Pharmacol Ther 2012; 26:249-55. [PMID: 23232039 DOI: 10.1016/j.pupt.2012.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 11/30/2012] [Accepted: 12/02/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Tobramycin nebuliser solution (TNS) is indicated for maintenance therapy in cystic fibrosis (CF) patients with chronic Pseudomonas aeruginosa (PA) infections. Adherence to recommended therapy in CF has always been a challenge and new generation nebulisers are increasingly used "off label" to reduce the time required for inhalation, potentially improving patient compliance. METHODS In this open-label, randomised, multi-centre, two-period crossover study, 27 CF patients with PA infection received TNS 300 mg/4 mL (TNS4) via the PARI eFlow(®) rapid or PARI LC Plus(®) nebuliser twice daily for 28 days in two study periods separated by a 4-week washout. The pharmacokinetic profile in plasma and sputum were determined after single and multiple dose administration on Day 1 and Day 28, respectively. Nebulisation times and general safety and tolerability profiles were evaluated throughout the study. RESULTS Plasma tobramycin pharmacokinetic profiles were similar for the eFlow and LC Plus nebulisers both on Day 1 and Day 28. After multiple dose administration for 28 days, the eFlow/LC Plus ratio of geometric means for plasma C(max) and AUC(0-t), were 85.32 (90% CI, 61.24-118.86) and 87.44 (90% CI, 64.87-117.87), respectively. Despite the high variability, sputum tobramycin C(max) and AUC(0-t) for the eFlow on Day 28 tended to be higher than for the LC Plus (90% CI for the ratio, 86.11-226.45 and 81.81-236.71), respectively. Nebulisation times were significantly shorter for the eFlow with a median time for nebulisation of 5 min in comparison to 13 min for the LC Plus. Safety data confirmed a favourable safety profile for TNS4, with the majority of the findings being related to the underlying CF disease. CONCLUSIONS Plasma and sputum pharmacokinetic data in CF patients with chronic PA infection support comparable pulmonary delivery and safety of TNS4 administered using different nebulisers, with a significantly shorter nebulisation time for the eFlow.
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Treatment of lung infection in patients with cystic fibrosis: Current and future strategies. J Cyst Fibros 2012; 11:461-79. [DOI: 10.1016/j.jcf.2012.10.004] [Citation(s) in RCA: 368] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Soon G, Zhang Z, Tsong Y, Nie L. Assessing overall evidence from noninferiority trials with shared historical data. Stat Med 2012; 32:2349-63. [DOI: 10.1002/sim.5615] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Accepted: 08/25/2012] [Indexed: 11/10/2022]
Affiliation(s)
- Guoxing Soon
- Division of Biometrics IV; Office of Biostatistics/CDER/FDA; 10903 New Hampshire Avenue Silver Spring MD 20993 U.S.A
| | - Zhiwei Zhang
- Division of Biostatistics; Office of Surveillance and Biometrics/CDRH/FDA; 10903 New Hampshire Avenue Silver Spring MD 20993 U.S.A
| | - Yi Tsong
- Division of Biometrics VI; Office of Biostatistics/CDER/FDA; 10903 New Hampshire Avenue Silver Spring MD 20993 U.S.A
| | - Lei Nie
- Division of Biometrics IV; Office of Biostatistics/CDER/FDA; 10903 New Hampshire Avenue Silver Spring MD 20993 U.S.A
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Littlewood KJ, Higashi K, Jansen JP, Capkun-Niggli G, Balp MM, Doering G, Tiddens HAWM, Angyalosi G. A network meta-analysis of the efficacy of inhaled antibiotics for chronic Pseudomonas infections in cystic fibrosis. J Cyst Fibros 2012; 11:419-26. [PMID: 22717535 DOI: 10.1016/j.jcf.2012.03.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 03/26/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Various inhaled antibiotics are currently used for treating chronic Pseudomonas aeruginosa lung infection in cystic fibrosis (CF) patients, however their relative efficacies are unclear. We compared the efficacy of the inhaled antibiotics tobramycin (TIP, TIS-T, TIS-B), colistimethate sodium (colistin) and aztreonam lysine for inhalation (AZLI) based on data from randomised controlled trials. METHODS In the base case, efficacies of antibiotics were compared using a network meta-analysis of seven trials including change from baseline in forced expiratory volume in 1 second (FEV(1)) % predicted, P. aeruginosa sputum density and acute exacerbations. RESULTS The tobramycin preparations, AZLI and colistin, showed comparable improvements in efficacy in terms of FEV1% predicted at 4 weeks; the difference in % change from baseline (95%CrI) for TIP was compared to TIS-T (-0.55, -3.5;2.4), TIS-B (-0.64, -7.1;5.7), AZLI (3.64, -1.0;8.3) and colistin (5.77, -1.2;12.8). CONCLUSION We conclude that all studied antibiotics have comparable efficacies for the treatment of chronic P. aeruginosa lung infection in CF.
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Ballmann M, Smyth A, Geller DE. Therapeutic approaches to chronic cystic fibrosis respiratory infections with available, emerging aerosolized antibiotics. Respir Med 2012; 105 Suppl 2:S2-8. [PMID: 22208546 DOI: 10.1016/s0954-6111(11)70021-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic airway infection and inflammation are key events in the clinical course of cystic fibrosis (CF). The most relevant, best investigated strain of bacteria in these circumstances is Pseudomonas aeruginosa. Since pulmonary infection with P. aeruginosa is localized in the lower conducting airways, treatment is accessible with the use of inhaled aerosolized antibiotics. Tobramycin inhalation solution was the first antibiotic to be developed and approved (in 1998) for use as an aerosolized antibiotic in patients with CF. The only other aerosolized antibiotic indicated for this use is aztreonam lysine solution for inhalation, which has been approved by both European and US authorities. In prospective, randomized, controlled trails, both agents exhibited a very acceptable safety profile, along with an increase in forced expiratory volume in 1 second and other clinically relevant endpoints. New developments focus on such components as reducing the treatment burden by using dry power inhalers, decreasing inhalation frequency to once daily, penetrating P. aeruginosa biofilms, and combining two antibiotics in one solution for inhalation. However, the ideal aerosolized antibiotic regimen for the treatment of chronic P. aeruginosa infection has yet not been selected.
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Affiliation(s)
- Manfred Ballmann
- Ruhr University Paediatric Clinic at St Josef Hospital, Bochum, Germany.
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Geller DE, Madge S. Technological and behavioral strategies to reduce treatment burden and improve adherence to inhaled antibiotics in cystic fibrosis. Respir Med 2012; 105 Suppl 2:S24-31. [PMID: 22208547 DOI: 10.1016/s0954-6111(11)70024-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aerosolized antibiotics are a common treatment option for patients with cystic fibrosis and chronic airway infection, as high doses can be delivered topically to the site of the infection while systemic exposure is minimized. Patients also use other aerosolized therapies (e.g. mucus-active agents, airway-wetting agents, and bronchodilators), adding significantly increase timed and complexity to their daily regimen, and often leading to lower adherence rates. A number of novel technological strategies are available that may reduce dose frequency and increase the speed of drug delivery. Psychologically based therapies may also be used to help modify behavior and thus improve adherence to treatment. Clinicians need to explore both technological and psychological strategies that will assist in the successful maintenance of treatment requirements.
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Bothra M, Lodha R, Kabra SK. Tobramycin for the treatment of bacterial pneumonia in children. Expert Opin Pharmacother 2012; 13:565-71. [PMID: 22292783 DOI: 10.1517/14656566.2012.656090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Common etiological agents for community-acquired lower respiratory tract infection (LRTI) include Streptococcus pneumoniae, Hemophilus influenzae and Mycoplasma pneumoniae and can be easily managed with oral or intravenous antibiotics. However, LRTI in patients with underlying illnesses, such as cystic fibrosis (CF) and immune deficiency, or on ventilator support is difficult to manage because these are caused by Gram-negative bacilli. Tobramycin has been shown to be effective in the management of these patients. AREAS COVERED Information about the antimicrobial activity, pharmacological aspects (including pharmacokinetics and pharmacodynamics), clinical efficacy, safety and side effects of tobramycin have been covered in this review. EXPERT OPINION A major advance for the use of tobramycin has occurred with its use by the inhalational route, in children with CF. The inhalation route provides the advantage of ease of administration for prolonged periods at home and allows use of very high doses. Systematic reviews suggest that tobramycin inhalation improves outcome, decreases the need for hospitalization and decreases the need for use of frequent systemic antibiotics in CF patients colonized with pseudomonas. Data on the efficacy of inhaled tobramycin in non-CF bronchiectasis are scarce, as are data on the prevention and treatment of ventilator-associated pneumonia, and on the role of combining inhaled tobramycin with systemic tobramycin. Despite limitations, this drug has the potential to be used in various conditions other than CF.
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Affiliation(s)
- Meenakshi Bothra
- All India Institute of Medical Sciences, Department of Pediatrics, New Delhi 110029, India
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Aerosolized antibiotic therapy for chronic cystic fibrosis airway infections: continuous or intermittent? Respir Med 2011; 105 Suppl 2:S9-17. [DOI: 10.1016/s0954-6111(11)70022-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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VanDevanter DR, Ballmann M, Flume PA. Applying clinical outcome variables to appropriate aerosolized antibiotics for the treatment of patients with cystic fibrosis. Respir Med 2011; 105 Suppl 2:S18-23. [DOI: 10.1016/s0954-6111(11)70023-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Vandevanter DR, Geller DE. Tobramycin administered by the TOBI(®) Podhaler(®) for persons with cystic fibrosis: a review. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2011; 4:179-88. [PMID: 22915944 PMCID: PMC3417888 DOI: 10.2147/mder.s16360] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
From its introduction, the antibiotic tobramycin has been an important tool in the management of persons with cystic fibrosis (CF) and chronic Pseudomonas aeruginosa lung infections. Initially an intravenous rescue treatment for pulmonary exacerbations, tobramycin delivered by inhalation has become a mainstay of chronic suppressive CF infection management. Platforms for tobramycin aerosol delivery have steadily improved, with increased lung deposition complimented by decreased device complexities, loaded tobramycin doses, delivery times, and treatment burdens. Most recently, a unique tobramycin inhalation powder (TIP) formulation with a portable delivery system, the TOBI® Podhaler® (Novartis AG, Basel, Switzerland) has been developed and approved in Europe, Canada, and Chile. Four capsules, each containing 28 mg of TIP are successively pierced and inhaled via the T-326 Dry Powder Inhaler Device (Novartis AG, Basel, Switzerland). No external power source is required to deliver an efficacious tobramycin dose in minutes. By comparison, tobramycin inhalation solution (TIS) (TOBI®; Novartis), is delivered by LC® Plus (PARI Respiratory Equipment Inc, Midlothian, VA) jet nebulizer powered by an air compressor over 15–20 minutes. Comparative pharmacokinetics, safety, and efficacy studies of TIS and TIP in CF subjects with P. aeruginosa ≥ 6 years old demonstrate that: tobramycin lung deposition with 112 mg TIP is comparable to that attained with 300 mg TIS, TIP is more effective than placebo and not inferior to TIS with respect to pulmonary function benefit, and TIP has significantly faster treatment times and achieves higher patient satisfaction than TIS. TIP is associated with an increased frequency of mild to moderate local adverse events (cough, dysphonia, and dysgeusia) compared with TIS, however, these become less frequent as subjects gain TIP experience. These results suggest that the TOBI Podhaler may better meet the needs of many CF patients and families by reducing treatment time and complexity and improving patient satisfaction compared with TIS.
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Affiliation(s)
- Donald R Vandevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
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Abstract
BACKGROUND Inhaled antibiotics are commonly used to treat persistent airway infection that contributes to lung damage in people with cystic fibrosis (CF). OBJECTIVES To examine the evidence that inhaled antibiotic treatment in people with CF reduces frequency of exacerbations of infection, and improves lung function, quality of life and survival. To examine adverse effects of inhaled antibiotic treatment. SEARCH STRATEGY Trials were identified from the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register.Last search: 31 January 2011. SELECTION CRITERIA Trials were selected if inhaled antibiotic treatment was used for at least four weeks in people with CF, treatment allocation was randomised or quasi-randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). DATA COLLECTION AND ANALYSIS Two authors independently selected trials, judged the risk of bias and extracted data from these trials. MAIN RESULTS The searches identified 176 citations to 78 trials. Nineteen trials, with 1724 participants, met the inclusion criteria. Adequate meta-analysis was not possible because of the variability of study design and reporting of results. Seventeen trials with 1562 participants compared an inhaled antibiotic with placebo or usual treatment for a duration between 1 and 32 months. Inhaled tobramycin was studied in eight trials. Lung function (measured as forced expired volume in one second) was higher and exacerbations of lung infection (by different measures) were less in the antibiotic-treated group. Resistance to antibiotics increased more in the antibiotic-treated group than in placebo group when results were reported. No auditory or renal impairment was found; analysis showed tinnitus, voice alteration, hemoptysis and cough were more frequent with tobramycin than placebo. One trial, compared tobramycin with colistin in 115 participants, after one month the mean difference in forced expiratory volume at one second was 6.33 (95% confidence interval -0.04 to 12.70) favouring tobramycin. AUTHORS' CONCLUSIONS Inhaled antibiotic treatment probably improves lung function and reduces exacerbation rate, but a pooled estimate of the level of benefit is not possible. The best evidence is for inhaled tobramycin. More evidence, from trials of longer duration, is needed to determine whether this benefit is maintained and to determine the significance of development of antibiotic-resistant organisms.
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Affiliation(s)
- Gerard Ryan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Ground Floor B Block, Verdun Street, Nedlands, Western Australia 6009, Australia
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"A rose is a rose is a rose," but CVID is Not CVID common variable immune deficiency (CVID), what do we know in 2011? Adv Immunol 2011; 111:47-107. [PMID: 21970952 DOI: 10.1016/b978-0-12-385991-4.00002-7] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Common variable immune deficiency (CVID) is the commonest symptomatic primary immunodeficiency and represents a heterogenous collection of disorders resulting mostly in antibody deficiency and recurrent infections. However, autoimmunity, granulomatous inflammation and malignancy frequently occur as part of the syndrome. The etiology of the condition has been poorly understood although in recent years, significant progress has been made in elucidating genetic mechanisms that can result in a CVID phenotype. In parallel to this, advances in treatment of the condition have also resulted in improved survival and quality of life for patients. There still remains significant work to be done in improving our understanding of the disease. In addition, recognition of the condition remains poor with significant diagnostic delays and avoidable morbidity. In this article, we review CVID with a particular focus on the areas of improving diagnosis and classification, recent developments in understanding the underlying etiology and genetics; and current treatment and monitoring recommendations for patients.
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Microbiological insights into respiratory infections and the opportunities for inhaled therapy. J Drug Deliv Sci Technol 2011. [DOI: 10.1016/s1773-2247(11)50047-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Parkins MD, Elborn JS. Aztreonam lysine: a novel inhalational antibiotic for cystic fibrosis. Expert Rev Respir Med 2010; 4:435-44. [PMID: 20658904 DOI: 10.1586/ers.10.48] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acquisition of Pseudomonas aeruginosa, the most prevalent organism isolated from cystic fibrosis (CF) airways, is associated with an accelerated clinical deterioration and reduced survival. Strategies to chronically suppress P. aeruginosa infections in individuals with CF have evolved over the last four decades and now largely focus on regular administration of aerosolized antibiotics. Aztreonam lysine (AZLI; Cayston, Gilead Pharmaceuticals [Foster City, CA, USA]), a novel formulation of the monobactam aztreonam suitable for aerosol delivery has recently been developed. AZLI is administered as 75 mg three-times daily for 28 days in 'on/off' cycles using the Altera/eFlow electronic nebulizer (PARI Innovative Manufacturers [Midlothian, VA, USA]). In individuals with CF chronically infected with P. aeruginosa, AZLI improved healthcare-associated quality-of-life scores, pulmonary function and weight, prolonged time to requirement of antibacterial therapy for symptoms of pulmonary exacerbation and reduced P. aeruginosa sputum burdens. These outcomes were durable over 18 months of cycled use. AZLI has been demonstrated to be safe and effective, and expands available chronic maintenance therapies in CF.
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Affiliation(s)
- Michael D Parkins
- Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
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