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Inhaled Antimicrobial Therapy – Barriers to Effective Treatment☆

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Inhaled Antimicrobial Therapy – Barriers to Effective Treatment☆ Advanced Drug Delivery Reviews 85 (2015) 24–43 Contents lists available at ScienceDirect Advanced Drug Delivery Reviews journal homepage: www.elsevier.com/locate/addr Inhaled antimicrobial therapy – Barriers to effective treatment☆ Jeffry Weers Novartis Pharmaceuticals Corporation, 150 Industrial Road, San Carlos, CA, USA article info abstract Available online 1 September 2014 Inhaled antibiotics dramatically improve targeting of drug to the site of respiratory infections, while simulta- neously minimizing systemic exposure and associated toxicity. The high local concentrations of antibiotic may Keywords: enable more effective treatment of multi-drug resistant pathogens. This review explores barriers to effective Biofilm treatment with inhaled antibiotics. In addition, potential opportunities for improvements in treatment are Dry powder inhaler reviewed. Endpoint © 2014 Elsevier B.V. All rights reserved. Fixed dose combination Nebulizer Partial liquid ventilation Tolerability Contents 1. Introduction...............................................................25 1.1. Chronic infections in cystic fibrosis(CF)...............................................25 1.2. Chronicinfectionsinnon-CFbronchiectasis(NCFBE)..........................................26 1.3. Acuteexacerbationsinchronicobstructivepulmonarydisease(AECOPD)................................26 1.4. Ventilator-associatedpneumonia(VAP)...............................................27 1.5. Otherinfections..........................................................27 1.6. Barrierstodevelopmentofinhaledantibiotics............................................27 2. Regulatoryandeconomicbarriers......................................................27 2.1. Endpoints in cystic fibrosis.....................................................28 2.2. Endpointsforotherindications...................................................28 3. Drugdeliverybarriers...........................................................28 3.1. Criticalerrors...........................................................28 3.1.1. Jetnebulizers.......................................................30 3.1.2. Vibratingmeshnebulizers.................................................30 3.1.3. Drypowderinhalers....................................................32 3.2. Tolerability............................................................33 4. Efficacybarriers.............................................................35 4.1. Treatmentdoseandregimen....................................................35 4.2. Combinationtherapy........................................................36 4.3. Alternative treatment regimens ....................................................36 5. Thefuture................................................................37 5.1. Novel adjuvants for the treatment of biofilms.............................................37 5.2. PartialliquidventilationinthetreatmentofVAP...........................................38 5.3. Themicrobiomeandairwaydisease.................................................39 6. Conclusions...............................................................39 Acknowledgements..............................................................39 References...................................................................39 ☆ This review is part of the Advanced Drug Delivery Reviews theme issue on "Inhaled antimicrobial chemotherapy for respiratory tract infections: Successes, challenges and the road ahead". E-mail address: [email protected]. http://dx.doi.org/10.1016/j.addr.2014.08.013 0169-409X/© 2014 Elsevier B.V. All rights reserved. J. Weers / Advanced Drug Delivery Reviews 85 (2015) 24–43 25 1. Introduction clearance often results in chronic colonization with the Gram-negative pathogen P. aeruginosa (Pa). Chronic infection with the mucoid form A critical question facing physicians is: will there be good therapeu- of Pa has been linked to decreases in lung function and survival [9,10]. tic options for the treatment of difficult to eradicate Gram-negative There are approximately 30,000 subjects living with CF in the U.S. pathogens like Pseudomonas aeruginosa, in the not-too-distant future? Chronic suppressive treatment of Pa infections with nebulized This concern is amplified, given that there are few new therapeutics in tobramycin (TOBI®, Novartis Pharmaceuticals Corporation, East Hano- development [1,2]. As a result, it is imperative that we approach treat- ver, NJ), has been proven to improve respiratory function, to decrease ment with existing agents in new ways. hospitalizations, and to reduce systemic antibiotic use [11]. The use of Although not a new treatment modality, aerosol delivery of antibi- TOBI has contributed to the significant increase in survival noted for otics to the lungs enables high local concentrations of drug to be CF patients in the last decade [12]. achieved at the site of the infection, while only low concentrations of There is a clear progression in the pathophysiology of Pa infections drug are delivered systemically [3–8]. The improvements in “lung (Fig. 2) [13]. Bronchoalveolar lavage studies in CF infants have shown targeting” afforded by aerosol delivery are illustrated in Fig. 1. that Pa infection results in significant increases in polymorphonuclear The development of effective treatments based on inhaled antibi- leukocytes (PMNs) and alveolar macrophages. Phagocytosis of the bac- otics is complex. Consideration must be given to the specific patient teria leads to the release of reactive oxygen species (ROS), which kill or population, the type of infection, where the infection resides within induce mutations in the bacteria. For wild type Pa, mutations in the the respiratory tree, and where the patient is in terms of the progression mucA gene lead to changes to the mucoid phenotype. of the disease. In this regard, infectious agents may be Gram negative or Mucoid Pa forms biofilms, which have been described as a “struc- Gram positive, mucoid or non-mucoid, planktonic or organized in a bio- tured community of bacterial cells enclosed in a self-produced polymeric film. The target may be in the airways or in the alveoli, intracellular or matrix that are adherent to an inert or living surface” [14]. The alginate- extracellular. The therapeutic agent may exhibit concentration- based polymeric matrix is an oxygen radical scavenger, protecting Pa dependent killing or time-dependent killing. The treatment may be to against phagocytosis and clearance. Bacteria present in biofilms com- eradicate the organism, to suppress a chronic infection, or to treat or municate via quorum sensing to synchronize target gene expression prevent a pulmonary exacerbation. The development of the dosage and coordinate biological activity within the biofilm [15].Biofilms may form will be influenced by whether the treatment is to be administered contain “persister cells”, a small fraction of bacteria that are dormant chronically at home, versus acutely in the intensive care unit (ICU) to an in a slow or non-growing state [15]. These bacteria may be ineffectively intubated patient. In short, development must consider the unique con- attacked by antibiotics that typically target rapidly growing cells. Hence, straints of the bug, the drug, the drug delivery system, and the patient. antimicrobial treatment may eradicate the susceptible population of There are four primary areas in which aerosolized antibiotics may find bacteria, but leave behind the persisters that are able to reconstitute utility in clinical practice. the biofilm after conclusion of the treatment. In the early stages of CF, the non-mucoid phenotype of Pa is present 1.1. Chronic infections in cystic fibrosis (CF) as planktonic organisms in sputum in the conducting airways [13,16]. The non-mucoid, planktonic form does not form biofilms. Moreover, Cystic fibrosis (CF) is an autosomal recessive genetic disorder the planktonic bacteria do not induce antibody responses, nor do they afflicting about 30,000 subjects in the U.S. CF is characterized by abnor- result in significant lung tissue damage. The non-mucoid phenotype mal transport of chloride ions across the pulmonary epithelium. This may be eradicated via treatment with inhaled antibiotics, or a combina- leads to increases in viscosity of secretions in the airways, and poor tion of inhaled and oral/parenteral antibiotics [17,18]. The transition to clearance of these secretions on the mucociliary escalator. The impaired the mucoid form of Pa results in bacteria with increased resistance to 12000 10000 8000 Target lung concentration: 256 x MIC = 6400 g/ml 6000 300 Serum 250 (µg/ml) Lung 200 Concentration 150 100 Toxic serum level: 35 g/ml 50 IV Amikacin, Amikacin Inhale Dose = 500 mg BID Dose = 400 mg BID Fig. 1. Comparison of mean serum and bronchial secretion concentrations of amikacin following intravenous administration of a 500 mg dose twice daily [202], and inhalation adminis- tration of a 400 mg dose of Amikacin Inhale (Bayer) twice daily to pneumonia patients [51].Significant improvements in lung targeting are observed following aerosol administration with corresponding low systemic concentrations. 26 J. Weers / Advanced Drug Delivery Reviews 85 (2015) 24–43 Planktonic non-mucoid Biofilm formation (mucoid phenotype) P. aeruginosa antibodies Negative culture Consecutive Birth positive First Second cultures positive positive culture culture Evolution of Pseudomonas aeruginosa infection Intermittent infection Chronic infection (eradication) (suppression) Fig. 2. Evolution
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