Neil E. Brown

Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial

BACKGROUND We did a randomised, double-blind, controlled clinical trial to prospectively assess whether use of combination antibiotic susceptibility testing improved clinical outcomes in patients with acute pulmonary exacerbations of cystic fibrosis who were infected with multiresistant bacteria. METHODS 251 patients with cystic fibrosis who were chronically infected with multiresistant gram negative bacteria gave sputum at 3-month intervals for conventional culture and sensitivity tests and for combination antibiotic susceptibility tests using multiple combination bactericidal antibiotic testing (MCBT). Patients who developed an exacerbation of pulmonary disease were randomised to receive a 14-day course of any two blinded intravenous antibiotics chosen on the basis of either results from conventional sputum culture and sensitivity testing or the result of MCBT. The primary outcome was time from randomisation until the patients next pulmonary exacerbation. Analysis was by intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN60187870. FINDINGS 132 patients had a pulmonary exacerbation and were randomised during the 4.5-year study period. The time to next pulmonary exacerbation was not prolonged in the MCBT-treated group (hazard ratio 0.86 in favour of the conventionally-treated group, 95% CI 0.60-1.23, p=0.40). There was no difference between the groups in treatment failure rate. After 14 days of intravenous antibiotic therapy, changes in lung function, dyspnoea, and sputum bacterial density were similar in both groups. INTERPRETATION Antibiotic therapy directed by combination antibiotic susceptibility testing did not result in better clinical and bacteriological outcomes compared with therapy directed by standard culture and sensitivity techniques. The non-bactericidal effects of antibiotic therapy might play an important part in determining improvement in patients with cystic fibrosis pulmonary exacerbations.

Human eosinophils release matrix metalloproteinase-9 on stimulation with TNF-α

BACKGROUND The eosinophil is a prominent cell in allergic lung inflammation and is exposed to a range of cytokines, including TNF-alpha, at the site of allergen challenge. Matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) produced by inflammatory cells are thought to play a crucial role in interstitial matrix turnover and tissue remodeling in acute and chronic lung diseases. In addition, protein kinase C is known to be important in MMP-9 expression and secretion. OBJECTIVE We investigated the regulation of eosinophil-derived MMP-9 and TIMP proteins by TNF-alpha. METHODS Using RT-PCR and gelatin zymography, we investigated the ability of human eosinophils to produce and secrete active MMP-9 on stimulation with TNF-alpha. We also studied the production of TIMP-1 and TIMP-2 in eosinophils by using Western blotting. RESULTS The gelatinolytic activity of MMP-9 in unstimulated eosinophils was low, but it increased by 95% after TNF-alpha stimulation. This increase was regulated at both the transcriptional and translational levels. The transcription inhibitor actinomycin D, the nuclear factor kappaB (NFkappaB) inhibitor N-CBZ-Leu-Leu-Leu-AL, the protein synthesis inhibitor cycloheximide, and the protein kinase C inhibitor H7 significantly decreased MMP-9 activity in TNF-alpha-treated cells. TIMP-1 and TIMP-2 gene expression and protein production varied significantly among different cell donors. CONCLUSION Eosinophils, on stimulation with TNF-alpha, may play a major role in asthmatic airway remodeling through increased MMP-9 production at the inflammatory site.

Predictors of pulmonary exacerbations in patients with cystic fibrosis infected with multi-resistant bacteria

Background: This study examined characteristics of adult and adolescent patients with cystic fibrosis (CF) to determine factors associated with an increased risk of pulmonary exacerbations. Methods: 249 patients with CF infected with multidrug resistant bacteria were recruited and prospectively followed for up to 4.5 years until they experienced a pulmonary exacerbation severe enough to require intravenous antibiotics. Multivariable regression analyses were used to compare the characteristics of patients who experienced an exacerbation with those who did not. Results: 124 of the 249 patients (50%) developed a pulmonary exacerbation during the first year and 154 (62%) experienced an exacerbation during the 4.5 year study period. Factors predictive of exacerbations in a multivariable survival model were younger age (OR 0.98, 95% CI 0.96 to 0.99), female sex (OR 1.45, 95% CI 1.07 to 1.95), lower forced expiratory volume in 1 second (FEV1) (OR 0.98, 95% CI 0.97 to 0.99), and a previous history of multiple pulmonary exacerbations (OR 3.16, 95% CI 1.93 to 5.17). Chronic use of inhaled corticosteroids was associated with an increased risk of exacerbation (OR 1.92, 95% CI 1.00 to 3.71) during the first study year. Conclusions: Patients who experience pulmonary exacerbations are more likely to be younger, female, using inhaled steroids, have a lower FEV1, and a history of multiple previous exacerbations. It is hoped that knowledge of these risk factors will allow better identification and closer monitoring of patients who are at high risk of exacerbations.

Cost of care for individuals with cystic fibrosis: a regression approach to determining the impact of recombinant human DNase.

We estimated direct medical costs of care and important determinants of the costs in patients with cystic fibrosis (CF), including therapy with recombinant human DNase (rhDNase). Costs were estimated with resource use data from the Epidemiologic Study of Cystic Fibrosis. Ordinary least squares regression was used to determine the effect of clinical and demographic variables on individual cost of care. The estimated cost of caring for 303 patients in Alberta was

An Unusual Case of Pulmonary Invasive Aspergillosis and Aspergilloma Cured with Voriconazole in a Patient with Cystic Fibrosis

2,279,801 in 1996. The mean cost of care was

Effects of sputum oscillations and rhDNase in vitro: A combined approach to treat cystic fibrosis lung disease

7524 (range

Essential fatty acid metabolism in cultured human airway epithelial cells

386–92,376)/patient. Regression results indicated that age and forced expiratory volume predicted had a negative association with costs. Being female, receiving rhDNase, and having Pseudomonas aeruginosa or Burkholderia cepacia were all associated with high costs. Our estimates indicated large interindividual variation in cost of care for patients with CF.

Implementation of a cystic fibrosis lung transplant referral patient decision aid in routine clinical practice: an observational study.

The development of pulmonary aspergilloma and invasive aspergillosis is a rare complication of cystic fibrosis. We describe a 29-year-old patient with cystic fibrosis who had invasive pulmonary aspergillosis that was not cured by amphotericin B, liposomal amphotericin B, or itraconazole. This patient was subsequently successfully treated and cured with the novel antifungal agent voriconazole.

The use of fructosamine in cystic fibrosis-related diabetes (CFRD) screening

Mucolytic treatment with rhDNase is part of the current therapy for cystic fibrosis (CF) lung disease. The Flutter® valve, a device for enhancing airway mucus clearance, has recently been approved for use in CF patients. Exhalation through the Flutter® valve leads to oscillations of expiratory airflow, improving mucus viscoelasticity and stimulating clearance. The goal of our in vitro study was to evaluate the individual and combined effects of Flutter® valve oscillations and rhDNase treatment on the viscoelastic (rheological) properties of CF sputum. Sputum specimens were collected from 19 CF patients and subjected to the following protocols: (1) baseline sample with no treatment applied; (2) application of oscillations generated by airflow through the Flutter® valve; (3) incubation at 37°C for 30 min with 10% vol/wt rhDNase (Pulmozyme®) to achieve a final concentration of 2.5 μg/mL (∼100 nM); (4) combination of Flutter® valve oscillations and 10% vol/wt normal saline (0.9% NaCl); (5) combination of Flutter® valve oscillations and 10% vol/wt rhDNase at 2.5 μg/mL final concentration. For each protocol, the mucus rigidity index (log G* at 1 rad/s) was measured at baseline and at 30 min. Values are presented as mean ±SEM. The cough clearability index (CCI) was computed from measurements of mucus viscoelasticity, based on relationships established in model studies.

Comparison of home and hospital intravenous antibiotic therapy for clinical outcome in patients with a pulmonary exacerbation of cystic fibrosis. Do they always need to be admitted

To characterize essential fatty acid metabolism of human airway epithelium, we examined the capacity of epithelial cells to incorporate and desaturate/elongate 18:2(n - 6) and the turnover of phospholipid fatty acyl chains in these cells. Epithelial cells were cultured for 5-7 days and incubated with [1-14C]18:2(n - 6) (1 microCi, 100 nmol). The essential fatty acid profile of the cells was readily modified by 18:2(n - 6) supplementation to culture medium. After 4 h incubation, 32 +/- 5.6 nmol of [1-14C]18:2(n - 6) was incorporated into phospholipids (65 +/- 9.5%, of which 74% was incorporated into phosphatidylcholine (PC)) and neutral lipid (31 +/- 10%) per mg protein of cultured cells. 30 +/- 8% of [1-14C]18:2(n - 6) incorporated, was converted to homologous trienes, tetraenes and pentaenes, the major products being 20:3(n - 6) and 20:4(n - 6). The conversion of 18:2(n - 6) was time-dependent and donor age-related. A higher proportion of 20:3(n - 6) and 20:4(n - 6) was incorporated into phosphatidylinositol (PI) and phosphatidylethanolamine (PE). About 10-15% of total products formed from 18:2(n - 6) was released from membrane to culture medium. Both 20:4(n - 6) and 20:5(n - 3) inhibited 18:2(n - 6) incorporation and desaturation. Rate of incorporation of 18:2(n - 6) was more than either 18:1(n - 9) or 16:0. With pulse-chase studies, the half-life of 18:2(n - 6) in PC, PI and PE was estimated to be 5.5, 6.0 and 7.3 h, respectively. These data indicate active metabolism of essential fatty acids in human airway epithelial cells. This metabolism may play a key role in the regulation of membrane properties and function in these cells.