Chronic Lung Infections In Patients Research Articles

Bacterial sinusitis can be a focus for initial lung colonisation and chronic lung infection in patients with cystic fibrosis

A major purpose of treating patients with cystic fibrosis (CF) is to prevent or delay chronic lung infections with CF-pathogenic Gram-negative bacteria. In the intermittent stage, bacteria can usually be eradicated from the lungs with antibiotics, but following eradication, the next lung colonisations often occur with bacteria of identical genotype. This may be due to re-colonisation from the patient's paranasal sinuses. In our study, we found that approximately two-thirds of CF patients having sinus surgery (FESS) had growth of CF-lung-pathogenic Gram-negative bacteria in their sinuses (Pseudomonas aeruginosa, Achromobacter xylosoxidans, Burkholderia cepacia complex). The environment in the sinuses is in many ways similar to that of the lower respiratory tract, e.g. low oxygen concentration in secretions. Sinus bacteria are more difficult to eradicate than in the lungs, thus, having good conditions for adapting to the environment in the lungs. In the presence of bacteria, the environment of the sinuses differs from that of the lower respiratory tract by having a higher immunoglobulin A (IgA): IgG ratio, and reduced inflammation. We found a significant correlation between the concentration of IgA against P. aeruginosa (standard antigen and alginate) in nasal secretions and saliva and CF patients' infection status (not lung colonised, intermittently colonised or chronically lung-infected with P. aeruginosa). This supports the hypothesis that infections often originate in the sinuses and can be a focus for initial lung colonisation or for maintaining lung infections in CF patients. We are confident that anti-P. aeruginosa IgA can be used as an early supplementary tool to diagnose P. aeruginosa colonisation; P. aeruginosa being the microorganism causing most morbidity and mortality in CF patients. This is important since urgent treatment reduces morbidity when CF patients are early colonised with P. aeruginosa, however, there is a lack of diagnostic tools for detecting the early colonisation in the lungs and in the sinuses. We initiated a treatment strategy for CF patients to prevent sino-nasal bacteria being seeded into the lower airways: we recommended extensive functional endoscopic FESS with creation of sufficient drainage from all involved sinuses with subsequent i.v. antibiotics and at least 6 months of twice daily nasal irrigation with saline and antibiotics. By this strategy, sinus bacteria could be eradicated in a large proportion of patients. Essentially, growth of CF-pathogenic bacteria from the lower respiratory tract was decreased following the treatment. Furthermore, a number of patients have been free from CF-pathogenic bacteria for more than one year after FESS, and thus re-classified as "not lung colonised". We also corroborated that CF patients obtain an improved quality of life and reduction in their symptoms of chronic rhinosinusitis after FESS. It is primarily intermittently lung colonised CF patients with CF-pathogenic bacteria in their sinuses that seem to benefit from the treatment strategy. This is in accordance with the fact that we did not see a significant increase in lung function and only a small decrease in specific antibodies after FESS; a high systemic immune and inflammatory response and a decreasing lung function is generally not present in patients who primarily have sinus CF-pathogenic bacteria. It is important that guidelines are created for how CF patients with CF-pathogenic bacteria in the sinuses are to be treated, including criteria for who may likely benefit from FESS, and who may be treated exclusively with conservative therapy, e.g. saline and antibiotic irrigations.

Aztreonam (for inhalation solution) for the treatment of chronic lung infections in patients with cystic fibrosis: an evidence-based review

Cystic fibrosis (CF) is a genetic disease caused by abnormal chloride transport across cellular membranes. In the respiratory tract, this molecular defect causes obstruction of the airways by mucus and chronic endobronchial infection. The majority of patients suffer early death from chronic respiratory disease. Pseudomonas aeruginosa is the predominant chronic airway pathogen in older children and adults with CF and is associated with worse outcomes. However, overall survival in CF has been greatly improved in recent decades due in large part to the aggressive treatment of chronic infections such as P. aeruginosa. While intravenous and oral antibiotics are commonly used in the management of CF respiratory infections, inhaled anti-infective therapies offer the benefit of delivering the drug directly to the site of infection and avoiding potential toxicities associated with systemic absorption. Aztreonam lysine (AZLI) has recently been developed as an inhaled antibiotic for chronic use in CF patients with endobronchial P. aeruginosa infection. This paper reviews background data and the clinical studies which contributed to AZLI’s formal FDA approval and growing role in the management of CF pulmonary disease.

Epidemiology and Pathogenesis of Pseudomonas aeruginosa Infections

1. Nicholas M. Moore, MS, MLS(ASCP)[⇑][1] 1. Rush University, Department of Medical Laboratory Science, Chicago, IL 2. Maribeth L. Flaws, PhD, SM(ASCP)SI 1. Rush University, Department of Medical Laboratory Science, Chicago, IL 1. Address for Correspondence: Nicholas M. Moore, MS, MLS (ASCP), Department of Medical Laboratory Science, 600 S. Paulina St., Suite 1014, Chicago, IL 60612, 312-942-2111, Fax: (312) 942-6464, Nicholas_Moore{at}rush.edu Upon reading this article, the reader should be able to: 1. List the infections caused by Pseudomonas aeruginosa . 2. Compare and contrast between infections caused by P. aeruginosa in healthy hosts with those in compromised hosts. 3. Discuss the purpose of the National Healthcare Safety Network (NHSN). 4. Summarize the surveillance data reported by the NHSN and its predecessor National Nosocomial Infections Surveillance System (NNIS) with regards to P. aeruginosa infections. 5. Explain the mechanisms used by P. aeruginosa to evade host defense mechanisms and colonize its host. Pseudomonas aeruginosa is an opportunistic nonfermentive gram negative bacillus that is responsible for a wide variety of infections in humans ranging from relatively uncomplicated urinary tract infections (UTIs) to severe and life threatening infections including neonatal sepsis and chronic lung infections in patients with cystic fibrosis. P. aeruginosa produces a number of membrane bound and secreted virulence factors that aid in the attachment of the organism to host cells, the invasion of tissue, and the inhibition of the immune response. Epidemiology of P. aeruginosa It is almost impossible to prevent exposure to P. aeruginosa because it can be found anywhere. It is nonfastidious and requires little in terms of nutritional requirements, thus it can be found on inanimate objects such as hospital room sinks, toilets, showers and patient care equipment, especially respiratory ventilators. The surfaces of fresh fruits and vegetables may even harbor P. aeruginosa . The organism has a particular predilection for water and as a result, it has been isolated from soaps and disinfectants, contact lens solutions, cosmetics and hot tubs, all of which have been documented as sources of infection. Though not a major member of the human normal flora, it is most commonly found in small amounts in the gastrointestinal tract. It may transiently colonize a variety of moist skin surfaces including under the arm and on the perineum. The throat and nose have been shown to be sites that may be colonized with P. aeruginosa as well.1 P. aeruginosa can cause infection in almost any part… ABBREVIATIONS: HAI = Healthcare-associated infections, MRSA = methicillin resistant Staphylococcus aureus , NNIS = National Nosocomial Infection Surveillance System, CDC = Centers for Disease Control and Prevention, DSN = Dialysis Surveillance Network, NaSH = National Surveillance System for Healthcare Workers, NHSN = National Healthcare Safety Network Upon reading this article, the reader should be able to: 1. List the infections caused by Pseudomonas aeruginosa . 2. Compare and contrast between infections caused by P. aeruginosa in healthy hosts with those in compromised hosts. 3. Discuss the purpose of the National Healthcare Safety Network (NHSN). 4. Summarize the surveillance data reported by the NHSN and its predecessor National Nosocomial Infections Surveillance System (NNIS) with regards to P. aeruginosa infections. 5. Explain the mechanisms used by P. aeruginosa to evade host defense mechanisms and colonize its host. [1]: #corresp-1

Sit and Stay a While: How BfiSR Controls Irreversible Attachment in Pseudomonas aeruginosa Biofilms

Sit and Stay a While: How BfiSR Controls Irreversible Attachment in <i>Pseudomonas aeruginosa</i> Biofilms

Dynamics of Adaptive Microevolution of HypermutablePseudomonas aeruginosaduring Chronic Pulmonary Infection in Patients with Cystic Fibrosis

In patients with cystic fibrosis (CF), the emergence of hypermutable Pseudomonas aeruginosa drives the selection of P. aeruginosa variants that are efficiently adapted to the inflamed lungs of these patients. To provide a detailed survey of adaptive changes in the physiology of P. aeruginosa during chronic lung infection in patients with CF. We performed a comparative proteome and transcriptome analysis of sequential, isogenic isolates recovered over a period of 3-5 years from 3 selected patients with CF. The isolates analyzed included both those with high mutation rates and defects in their methyl-directed mismatch repair system (hereafter, "mutators") and those without such changes (hereafter, "nonmutators"). In addition to attenuation of virulence, the P. aeruginosa adaptation process predominantly affects metabolic pathways. In mutator isolates recovered from patients with end-stage CF lung disease, we observed increases in the transcripts of genes or proteins involved in the metabolism of fatty acids and amino acids and the generation of energy. Of particular interest is the increased expression of genes involved in the following pathways and processes: (1) the anaerobic arginine-deiminase pathway, (2) anaerobic respiration (e.g., nitrate-uptake protein OprF, azurin, and cytochrome c551 peroxidase), (3) microaerobic respiration (e.g., cytochrome oxidase cbb3), and (4) the tricarboxylic acid cycle and glyoxylate shunt. Strikingly, increased transcription of the anaerobic regulator gene anr correlates with the up-regulation of ANR-dependent genes. These changes indicate an adaptive shift toward constitutive expression of genes required for growth under the nutritional and microaerobic conditions created by suppurative secretions in the lungs of patients with CF. In addition, these results provide important clues about the persistence strategies used by P. aeruginosa during progressive CF lung disease.

Delayed association of the NADPH oxidase complex with macrophage vacuoles containing the opportunistic pathogen Burkholderia cenocepacia

Burkholderia cenocepacia causes chronic lung infections in patients suffering from cystic fibrosis and chronic granulomatous disease. We have previously shown that B. cenocepacia survives intracellularly in macrophages within a membrane vacuole (BcCV) that delays acidification. Here, we report that after macrophage infection with live B. cenocepacia there is a approximately 6 h delay in the association of NADPH oxidase with BcCVs, while heat-inactivated bacteria are normally trafficked into NADPH oxidase-positive vacuoles. BcCVs in macrophages treated with a functional inhibitor of the cystic fibrosis transmembrane conductance regulator exhibited a further delay in the assembly of the NADPH oxidase complex at the BcCV membrane, but the inhibitor did not affect NADPH oxidase complex assembly onto vacuoles containing heat-inactivated B. cenocepacia or live Escherichia coli. Macrophages produced less superoxide following B. cenocepacia infection as compared to heat-inactivated B. cenocepacia and E. coli controls. Reduced superoxide production was associated with delayed deposition of cerium perhydroxide precipitates around BcCVs of macrophages infected with live B. cenocepacia, as visualized by transmission electron microscopy. Together, our results demonstrate that intracellular B. cenocepacia resides in macrophage vacuoles displaying an altered recruitment of the NADPH oxidase complex at the phagosomal membrane. This phenomenon may contribute to preventing the efficient clearance of this opportunistic pathogen from the infected airways of susceptible patients.

Investigation of the algT operon sequence in mucoid and non-mucoid Pseudomonas aeruginosa isolates from 115 Scandinavian patients with cystic fibrosis and in 88 in vitro non-mucoid revertants

Pseudomonas aeruginosa is the dominant pathogen causing chronic lung infections in patients with cystic fibrosis (CF). After an initial phase characterized by intermittent colonizations, a chronic infection is established upon conversion of P. aeruginosa from the non-mucoid to the mucoid, alginate-overproducing phenotype. During the chronic infection the isolation of both mucoid and non-mucoid isolates in CF sputum samples is very common. The purpose of the present study was to establish, by sequence analysis, the types of mutations present in the algTmucABD operon in a large number of mucoid and non-mucoid P. aeruginosa isolates from Scandinavian CF patients and in in vitro-derived non-mucoid revertants. Mucoid (83) and non-mucoid isolates (103) from 91 Scandinavian patients with chronic P. aeruginosa infection and 24 non-mucoid isolates from intermittently colonized CF patients were investigated. In addition, 88 spontaneous non-mucoid revertants obtained in vitro from nine mucoid CF isolates were also included in the study. Mutations in mucA were found in 92 % of the mucoid and in up to 70 % of the non-mucoid isolates from chronically infected patients, indicating that the majority of non-mucoid isolates are revertants. None of the non-mucoid isolates from intermittently colonized CF patients harboured mucA mutations. Although algT has been considered an important gene for secondary-site mutations responsible for reversion to non-mucoidy, only 30 % of the mucA-mutated non-mucoid CF isolates had mutations in algT. In contrast, 83 % of the in vitro-derived spontaneous non-mucoid revertants had mutations in algT, showing that in the CF lung there is a selection for non-mucoid revertants with secondary-site mutations in genes other than algT. In addition, we report, to our knowledge for the first time, loss-of-function mutations in the negative regulators mucB and mucD in CF clinical isolates. In some of the CF isolates these mutations are associated with moderate alginate production. In conclusion, most non-mucoid isolates from chronically infected CF patients are revertants and the mechanism of revertance is algT-independent in the CF lung.

TheBurkholderia cepaciarpoEgene is not involved in exopolysaccharide production and onion pathogenicity

Burkholderia cepacia was originally described as the causative agent of bacterial rot of onions, and it has now emerged as an important opportunistic pathogen causing severe chronic lung infections in patients having cystic fibrosis. Burkholderia cepacia is now classified into nine very closely related species (previously designated as genomovars), all of which have been isolated from both environmental and clinical sources and are collectively known as the B. cepacia complex. The alternative extracytoplasmic function sigma factor, sigmaE, has been determined in several bacterial species as making substantial contributions to bacterial survival under stress conditions. Here, we report the identification and characterization of the rpoE gene, encoding sigmaE, of B. cepacia. It is highly similar to sigmaE of other bacteria, including Escherichia coli and Pseudomonas aeruginosa. Studies using an rpoE knockout mutant of B. cepacia revealed that many stress adaptations, including osmotic, oxidative, desiccation, carbon, and nitrogen stress, were independent of sigmaE. Similarly, biofilm formation; production of exopolysaccharides, N-acyl homoserine lactones, and several exoenzymes; and onion pathogenicity were not affected by the absence of sigmaE. In contrast, sigmaE contributed to the adaptation to heat stress and phosphate starvation.

The ability to form biofilm influences Mycobacterium avium invasion and translocation of bronchial epithelial cells

Organisms of the Mycobacterium avium complex (MAC) are widely distributed in the environment, form biofilms in water pipes and potable water tanks, and cause chronic lung infections in patients with chronic obstructive pulmonary disease and cystic fibrosis. Pathological studies in patients with pulmonary MAC infection revealed granulomatous inflammation around bronchi and bronchioles. BEAS-2B human bronchial epithelial cell line was used to study MAC invasion. MAC strain A5 entered polarized BEAS-2B cells with an efficiency of 0.1 +/- 0.03% in 2 h and 11.3 +/- 4.0% in 24 h. In contrast, biofilm-deficient transposon mutants 5G4, 6H9 and 9B5 showed impaired invasion. Bacteria exposed to BEAS-2B cells for 24 h had greater ability to invade BEAS-2B cells compared with bacteria incubated in broth. M. avium had no impact on the monolayer transmembrane resistance. Scanning electron microscopy showed that MAC A5 forms aggregates on the surface of BEAS-2B cell monolayers, and transmission electron microscopy evidenced MAC within vacuoles in BEAS-2B cells. Cells infected with the 5G4 mutant, however, showed significantly fewer bacteria and no aggregates on the cell surface. Mutants had impaired ability to cause infection in mice, as well. The ability to form biofilm appeared to be associated with the invasiveness of MAC A5.

Effect of oxygen limitation on the in vitro antimicrobial susceptibility of clinical isolates of Pseudomonas aeruginosa grown planktonically and as biofilms

Pseudomonas aeruginosa, the predominant causative pathogen of chronic lung infection in patients with cystic fibrosis, may grow under anaerobic conditions as biofilms in the lungs of cystic fibrosis patients. To determine if growth under anaerobic conditions affects the antimicrobial susceptibility of P. aeruginosa, the susceptibility of clinical isolates of P. aeruginosa grown planktonically and as biofilms to a range of antibiotics was determined. Growth under anaerobic conditions did not reduce the ability of ceftazidime, meropenem, aztreonam, piperacillin, or piperacillin/tazobactam to inhibit planktonic growth, with MIC50 values for these antibiotics remaining unchanged or decreasing. However, tobramycin was less effective at inhibiting planktonic bacterial growth under anaerobic conditions, with the MIC50 of tobramycin increasing twofold. Growth under anaerobic conditions also decreased the bactericidal activity of tobramycin, with the MBC50 of tobramycin increasing fourfold. The killing kinetics of tobramycin was also examined under aerobic and anaerobic conditions for selected isolates. When isolates 6A and 12A were grown aerobically, concentration-dependent decreases in total viable count were apparent with tobramycin. In contrast, when these isolates were grown anaerobically, tobramycin at the same concentrations did not decrease the total viable count. When isolates were grown as biofilms under both aerobic and anaerobic conditions, isolate- and concentration-dependent differences in killing of the biofilms by tobramycin were apparent. However, tobramycin at concentrations up to 128 mg/l was unable to eradicate biofilms of any of the isolates tested, whether biofilms were grown aerobically or anaerobically. These results show that oxygen limitation may reduce, in a strain-dependent manner, the susceptibility to tobramycin of P. aeruginosa grown planktonically and as biofilms.

Hypermutation is a key factor in development of multiple-antimicrobial resistance in Pseudomonas aeruginosa strains causing chronic lung infections.

Pseudomonas aeruginosa is the most relevant pathogen producing chronic lung infections in patients with chronic underlying diseases such as cystic fibrosis (CF), bronchiectasis, and chronic obstructive pulmonary disease (COPD). Hypermutable (or mutator) P. aeruginosa strains, characterized by increased (up to 1,000-fold) spontaneous mutation rates due to alterations of the DNA mismatch repair (MMR) system have been found at high frequencies in the lungs of CF patients, but their role in other chronic processes is still unknown. Sixty-two P. aeruginosa isolates from 30 patients with underlying non-CF chronic respiratory diseases (22 with bronchiectasis and 8 with COPD) and documented chronic infection were studied. Antibiotic susceptibility profiles and mutation frequencies were determined, and complementation assays using the cloned wild-type mutS gene and molecular epidemiology studies (pulsed-field electrophoresis, [PFGE]) were performed with these strains. Thirty-three (53%) of the isolates were hypermutable, and 17 (57%) of the 30 patients were colonized by hypermutable strains. Strains from 11 of the 17 patients were found to be defective in the MMR mutS gene by complementation assays. Interpatient transmission of strains was ruled out by PFGE. Multiple-antimicrobial resistance was documented in 42% of the hypermutable strains in contrast to 0% resistance in the nonhypermutable strains (P < 0.0001). Hypermutable P. aeruginosa strains are extremely prevalent in chronic infections in contrast to what has been described in acute processes, suggesting a role of hypermutation in bacterial adaptation for long-term persistence. Furthermore, hypermutation is found to be a key factor for the development of multiple-antimicrobial resistance, and therefore these findings are expected to have important consequences for the treatment of chronic infections.

Identification of Burkholderia cenocepacia genes required for bacterial survival in vivo.

Burkholderia cenocepacia (formerly Burkholderia cepacia complex genomovar III) causes chronic lung infections in patients with cystic fibrosis. In this work, we used a modified signature-tagged mutagenesis (STM) strategy for the isolation of B. cenocepacia mutants that cannot survive in vivo. Thirty-seven specialized plasposons, each carrying a unique oligonucleotide tag signature, were constructed and used to examine the survival of 2,627 B. cenocepacia transposon mutants, arranged in pools of 37 unique mutants, after a 10-day lung infection in rats by using the agar bead model. The recovered mutants were screened by real-time PCR, resulting in the identification of 260 mutants which presumably did not survive within the lungs. These mutants were repooled into smaller pools, and the infections were repeated. After a second screen, we isolated 102 mutants unable to survive in the rat model. The location of the transposon in each of these mutants was mapped within the B. cenocepacia chromosomes. We identified mutations in genes involved in cellular metabolism, global regulation, DNA replication and repair, and those encoding bacterial surface structures, including transmembrane proteins and cell surface polysaccharides. Also, we found 18 genes of unknown function, which are conserved in other bacteria. A subset of 12 representative mutants that were individually examined using the rat model in competition with the wild-type strain displayed reduced survival, confirming the predictive value of our STM screen. This study provides a blueprint to investigate at the molecular level the basis for survival and persistence of B. cenocepacia within the airways.

Increased Frequency of Genomic Alterations inStaphylococcus aureusduring Chronic Infection Is in Part Due to Phage Mobilization

We assessed the nature and frequency of genome alterations in Staphylococcus aureus during chronic lung infection in patients with cystic fibrosis (CF) and during colonization of the nares in healthy individuals. Only individuals harboring the same S. aureus clone on consecutive samplings were included in the present study. Clone definition was based on pulsed-field gel electrophoresis (PFGE) analysis. Minor fragment variations in consecutive clones were interpreted as genome alterations. The frequency of genome alterations was significantly higher in S. aureus derived from patients with CF (mean time, 1.03 years) than in isolates derived from healthy individuals (mean time, 13.4 years). In total, 19 S. aureus strain pairs showing genome alterations were available for molecular analysis to clarify the nature of recombinational events in the host environment. In 8 cases, genome alteration could be linked to phage mobilization. Phage conversion of beta-toxin production was evident in 7 pairs. In 1 strain pair, changes in the PFGE pattern were accompanied by deletion of a phage similar to ETA. Obviously, phage mobilization plays an important role in vivo. During long-term lung infection in patients with CF, the specific host response and/or the regular exposure to antibiotics exercises strong selective pressure on the pathogen. Genome plasticity may facilitate the adaptation to various host conditions.

Effect of inhaled tobramycin on early Pseudomonas aeruginosa colonisation in patients with cystic fibrosis

Early antibiotic treatment of airway colonisation with Pseudomonas aeruginosa can delay onset of chronic lung infection in patients with cystic fibrosis. Whether the pathogen is eradicated by this treatment is unclear. We successfully eradicated the organism in 14 of 15 patients with cystic fibrosis who had been colonised by P aeruginosa. Patients inhaled 80 mg tobramycin twice daily for 12 months. Eradication was confirmed by sequential respiratory cultures and serum antibody titres that were negative for P aeruginosa. Our antibiotic therapy regimen maintained pulmonary function at high levels.

Integration host factor and sequences downstream of the Pseudomonas aeruginosa algD transcription start site are required for expression.

Pseudomonas aeruginosa is an extremely important opportunistic pathogen in immunocompromised individuals. Strains of P. aeruginosa isolated from chronic lung infections in patients with the genetic disease cystic fibrosis have a mucoid colony morphology. This phenotype is due to overproduction of the exopolysaccharide alginate, which is believed to confer a selective advantage on P. aeruginosa in cystic fibrosis lungs. Alginate biosynthesis is controlled by a complex regulatory mechanism. Genes located in the 34-min region of the P. aeruginosa chromosome form an operon which encodes most of the biosynthetic enzymes necessary for alginate production. algD, the first gene in the operon and a critical point for the transcriptional regulation of alginate biosynthesis, is controlled by several trans, cis, and environmental factors. In this study, the involvement of the histone-like protein integration host factor (IHF) in algD expression was examined. Sequences with similarity to consensus IHF-binding sites of Escherichia coli were identified 75 bp upstream (site 1) and 90 bp downstream (site 2) of the start of algD transcription. In gel band mobility shift assays, DNA fragments containing either site bind IHF but site 2 has an approximately 90-fold higher affinity for IHF. Mutations in each of the elements were generated, and they resulted in the reduction or loss of in vitro IHF binding and a three- to fourfold decrease in algD-cat expression. This indicates that IHF binding is necessary for high-level algD transcription. The presence of a high-affinity IHF-binding site located 3' of the algD transcription start site suggested that sequences further downstream of this element are involved in algD expression. When a fragment located downstream of site 2 and upstream of the promoterless cat gene (+110 to +835) was deleted, algD-cat expression was reduced 10-fold supporting the notion that 3' enhancer elements are required for algD transcription. This is the first direct evidence of a 3' element involved in the control of a P. aeruginosa gene. It is postulated that IHF mediates the formation of a higher-order looped structure which is necessary for efficient algD transcription.