Gerd Döring, Institut für MedizinischeMikrobiologie and Hygiene,

Universitätsklinikum Tübingen

Tübingen, 14. December, 2011

Mukoviszidose

Lungeninfektionen: Pathophysiologie und

Therapie

Pseudomonas Biofilm Formation

Pseudomonasbiofilm

Pseudomonasbiofilm

Pseudomonasbiofilm

Neutrophils

Pseudomonasbiofilm

Pseudomonasbiofilm

Pseudomonasbiofilm

Neutrophils

Worlitzsch et al. 2002

0

50

100150

200

250

lumen mucus

pO2

[mm

Hg]

pO2

[mm

Hg]

time [min]

0

50

100

150

200

250

0 20 40 600

50

100150

200

250

lumen mucus

pO2

[mm

Hg]

lumen mucus

pO2

[mm

Hg]

pO2

[mm

Hg]

time [min]

0

50

100

150

200

250

0 20 40 60

Worlitzsch et al. 2002

0

50

100150

200

250

lumen mucus

pO2

[mm

Hg]

pO2

[mm

Hg]

time [min]

0

50

100

150

200

250

0 20 40 600

50

100150

200

250

lumen mucus

pO2

[mm

Hg]

lumen mucus

pO2

[mm

Hg]

pO2

[mm

Hg]

time [min]

0

50

100

150

200

250

0 20 40 60

Worlitzsch et al. 2002

0

50

100150

200

250

lumen mucus

pO2

[mm

Hg]

pO2

[mm

Hg]

time [min]

0

50

100

150

200

250

0 20 40 600

50

100150

200

250

lumen mucus

pO2

[mm

Hg]

lumen mucus

pO2

[mm

Hg]

pO2

[mm

Hg]

time [min]

0

50

100

150

200

250

0 20 40 60

Pseudomonas Transmission from the Environment to CF Patients

Sink CFU Air Hand1 1.4x107 - +2 2.1x108 +3 2.7x1010 +4 2.4x106 + 5 5.4x105 -6 5.2x1010 + +7 7.0x1010 + +8 1.0x1010 +

Döring et al., 1991

Döring et al., unpublished

Surveillance of P. aeruginosa Antimicrobial Resistance

% ResistantCF Isolates

Non-CF1 HPA 20032 BLT 20053 Mucoid Non-MucoidCiprofloxacin 20.2% 29.7% 49.3% 49.3% 49.4%Azlocillin - 38.9% 34.2% 43.1%Aztreonam - 36.4 % 25.3% 46.6%Gentamicin 22.9% 47% 35.5% 25.6% 44.2%Meropenem 10.8% 31.6% 24.5% 38%Imipenem 19% 31.5% 29.6% 33.3%Ticarcillin/clav - 28.8% 16.3% 41%Amikacin 16.6% 28.4% 18.4% 37.4%Ceftazidime 18.4% 39.6% 25.4% 22.3% 28.1%Pip/Taz 14.5% 31.9% * 23.3% 19.7% 26.4%Tobramycin 9.6% 10.1% 21.9% 14.4% 28.6%Colistin - 3.1% 0.9% 0% 1.7%

1MYSTIC Database 2Pitt et al, Thorax, 2003 3Soleimanian et al, ICAAC, 2006

Antibiotika-Therapie gegen Pseudomonas-Infektionen bei CF-Patienten

Bragonzi et al., 2005

50°C 4°C

Hermann et al. 2010

A

DC

BAA

DDCC

BB

Colistin Tobramycin

Colistin + Tobramycin Control

In vitro

P. a

erug

inos

aC

FU

101

102

103

104

105

106

107

108

LBColistin Tobra Colistin/TobraP.

aer

ugin

osa

CFU

101

102

103

104

105

106

107

108

LBColistin Tobra Colistin/Tobra

Hermann et al., 2010

Anti-entzündliche Therapie

0

110 06

210 06

310 06

410 06

510 06

* 0,0298

* 0,0268

* 0,0246

BA

LF to

tal

neut

roph

ils

P. + + + +-

0

110 06

210 06

310 06

410 06

510 06

* 0,0298

* 0,0268

* 0,0246

BA

LF to

tal

neut

roph

ils

P. aeru + + + +0 0.3 50 100100 0Drug 0.3 50 100100

-

10 4

10 5

10 6

10 7

10 8

10 9

** 0,0030

** 0,0097

ns

TOTA

L LU

NG

CFU

0Drug 0.3 50 10010 4

10 5

10 6

10 7

10 8

10 9

** 0,0030

** 0,0097

ns

TOTA

L LU

NG

CFU

0 0.3 50 100

Döring et al., unpublished

Bragonzi et al., 2005

_________________________________________________

% of infected mice p_______ ________________ _________

(mg/kg) blood spleen_________________________________________________

0 16 00.3 67 16 0.1

50 50 50 0.01100 57 50 0.005_________________________________________________

_________________________________________________

Drug % of infected mice p_______ ________________ _________

(mg/kg) blood spleen_________________________________________________

0 16 00.3 67 16 0.1

50 50 50 0.01100 57 50 0.005_________________________________________________

Proteolytic damage and tissue remodeling in CF alveoli

0

10

20

30

40

0 20 40 60

Age [years]

DES

and

IDES

[µg/

g cr

eatin

ine] D

Ulrich et al. 2010

0

20

40

60

Elas

tin

CF controls

CF controls020406080

CF controls

Col

lage

n

0

20

40

60

Elas

tin

CF controls

CF controls020406080

020406080

CF controls

Col

lage

n

Aerosol α1-antitrypsin treatment for CF

McElvany Lancet 1991; 337:392–394

baseline 2 weeks 4 weeks0

10

20

30

40

50

free

ela

stas

e ac

tivity

( g/

ml)

ns < 0.05

baseline 2 weeks 4 weeks0

10

20

30

40

50

1-

antit

ryps

in(

g/m

l)

< 0.01ns

baseline 2 weeks 4 weeks0

10

20

30

40

50

free

ela

stas

e ac

tivity

( g/

ml)

ns < 0.05

baseline 2 weeks 4 weeks0

10

20

30

40

50

free

ela

stas

e ac

tivity

( g/

ml)

ns < 0.05

baseline 2 weeks 4 weeks0

10

20

30

40

50

1-

antit

ryps

in(

g/m

l)

< 0.01ns

baseline 2 weeks 4 weeks0

10

20

30

40

50

1-

antit

ryps

in(

g/m

l)

< 0.01ns

M. Griese, personal information

Age

Patie

nts

%Age specific prevalence of bacterial organisms in CF airways

CF Foundation’s Patient Registry Annual Data Report 2009

2 d2 h+ O2 - O2

0

20

40

60

80

100

0

20

40

60

80

100

Sa113 Sa7 Tü Sa113 Sa7 Tü

killi

ng[%

]

killi

ng[%

]

A B

C D

E F

G H

* *

2 d2 h+ O2 - O2

0

20

40

60

80

100

0

20

40

60

80

100

0

20

40

60

80

100

0

20

40

60

80

100

Sa113 Sa7 Tü Sa113 Sa7 Tü

killi

ng[%

]

killi

ng[%

]

A B

C D

E F

G H

* *

Staphylococcus aureus produces the exopolysaccharide PNAG in the lung of CF patients under anaerobic growth conditions

Ulrich et al, Mol

SrrA P

icaADBC

-O 2

SrrB

icaADBCicaR

SrrA P

SrrA

SrrB

+O

SrrA PSrrA P

icaADBC

-O 2

SrrB

icaADBCicaR

SrrA PSrrA P

SrrA

SrrB

+O2

Ulrich et al, Mol Microbiol, 2007 Microbiol, 2007

0 min

-O2

6 min

12 min

0 min

-O2

6 min

12 min

Increased prevalence of MRSA among CF patients in USA– 0.1% in 1995– 7.0% in 2001– 18.9% in 2006

Risk for CF patients to become MRSA-positive

1. Increased susceptibility for S. aureus colonization

2. Frequently treated with S. aureus-specific antibiotics

3. Frequently hospitalized

The anaerobes

1,00E+03

1,00E+04

1,00E+05

1,00E+06

1,00E+07

1,00E+08

1A 1B 3A 4A 4B 7A 7B 8A 8B 10A 10B 15A 15B 16A 16B 18A 19A 21A 22A 23A 24A 27A 28A 31A 33A 42A 44APatient and sample number

Tota

l Via

ble

Cou

nt (C

FU/g

)P. aeruginosa Anaerobe

Tunney et al. 2008

Stressmann et al. 2011

Median FEV1 Percent Predicted vs. Age, 1990 and 2009Pe

rcen

tPre

dict

ed

Age (Years)

CF Foundation’s Patient Registry Annual Data Report 2009

Pseudomonas Antibiotic Therapy

Ratjen et al. 2010

0102030405060708090

100

0 5 10 15 20 25 30 35 40 45 50 55

1975 (n= 55)1980 (n=107)1985 (n=123)1990 (n=130)1995 (n=131)2002 (n=125)

0102030405060708090

100

0 5 10 15 20 25 30 35 40 45 50 55

1975 (n= 55)1980 (n=107)1985 (n=123)1990 (n=130)1995 (n=131)2002 (n=125)

Mea

n∆

FEV 1

/yea

r

Chronic P. aeruginosa colonisationEarly eradication ∆FEV1/yr: -1.65%

∆FEV1/yr: -4.74% -14 -12 -10 -8

-6 -4 -2 0

Taccetti et al. Eur Respir J 2005; 26:1-4

Mea

n∆

FEV 1

/yea

r

Chronic P. aeruginosa colonisationEarly eradication ∆FEV1/yr: -1.65%

∆FEV1/yr: -4.74% -14 -12 -10 -8

-6 -4 -2 0

Taccetti et al. Eur Respir J 2005; 26:1-4

Vaccination against Pseudomonas

First Infection Chronic InfectionITT PP ITT PP

Verum 82 37 26 6

Placebo 105 59 29 12p 0.05 0.01 0.70 0.15NNT 11 11 100 32

Döring et al., 2007

483 CF Patients1997-2002 0

2000

4000

6000

8000

10000

Rec

ipro

cal t

iters

before 1 2 3 4 Placebo

CF and Ceramide CF

C CF C CF+ Amitriptyline

Cer

amid

e

C CF C CF+ Amitriptyline

Cer

amid

e

Teichgräber V et al., 2008 C CF C CF

+ AmitriptylineC CF C CF

+ Amitriptyline

Pseu

dom

onas

CFU

NO ? YES !

X-ray score of a CF patient who has received pulsed high-dose NO inhalation therapy. Left: before, right: after 2 days of 3 x 30 min of 100 ppm NO. Courtesy of Hubert Wirtz, Leipzig

Impact of gaseous NO on survival of microbes. Red: 200 ppm NO, blue: air. (Ghaffari A, 2006).

1. Die Zahl bakterieller Spezies in infizierten Atemwegen der CF Patienten hat sich erheblich vergrößert und umfasst viele strikteAnaerobier.

2. Antimikrobielle Resistenz der CF-spezifischen Pathogene nimmtzu.

3. Antibiotische Kombinationstherapie ist eine Alternative zurMonotherapie für chronische P. aeruginosa Infektionen.

4. Neben P. aeruginosa and S. aureus sollten möglicherweise auchstrikte Anaerobier antibiotisch behandelt werden.

5. Hochdosierte NO Therapie könnte Probleme mit resistentenBakterien lösen.

Zusammenfassung

1. Bessere anti-inflammatorischen Medikameente werden benötigt, jedoch stellt diese Therapie ein zweischneidiges Schwert dar.

2. Anti-Proteasen Therapie bleibt unbefriedigend.

3. Die Antibiotika-Frühtherapie hat die Lungenfunktion und die Lebenserwartung der Patienten erheblich gesteigert.

4. Die Vakzine-Entwicklung ist unbefriedigend

Zusammenfassung