Multidrug-Resistant Nontuberculous Mycobacteria Isolated from Cystic Fibrosis Patients

Worldwide, nontuberculous mycobacteria (NTM) have become emergent pathogens of pulmonary infections in cystic fibrosis (CF) patients, with an estimated prevalence ranging from 5 to 20%. This work investigated the presence of NTM in sputum samples of 129 CF patients (2 to 18 years old) submitted to longitudinal clinical supervision at a regional reference center in Rio de Janeiro, Brazil. From June 2009 to March 2012, 36 NTM isolates recovered from 10 (7.75%) out of 129 children were obtained. Molecular identification of NTM was performed by using PCR restriction analysis targeting the hsp65 gene (PRA-hsp65) and sequencing of the rpoB gene, and susceptibility tests were performed that followed Clinical and Laboratory Standards Institute recommendations. for evaluating the genotypic diversity, pulsed-field gel electrophoresis (PFGE) and/or enterobacterial repetitive intergenic consensus sequence PCR (ERIC-PCR) was performed. the species identified were Mycobacterium abscessus subsp. bolletii (n = 24), M. abscessus subsp. abscessus (n = 6), Mycobacterium fortuitum (n = 3), Mycobacterium marseillense (n = 2), and Mycobacterium timonense (n = 1). Most of the isolates presented resistance to five or more of the antimicrobials tested. Typing profiles were mainly patient specific. the PFGE profiles indicated the presence of two clonal groups for M. abscessus subsp. abscessus and five clonal groups for M. abscesssus subsp. bolletii, with just one clone detected in two patients. Given the observed multidrug resistance patterns and the possibility of transmission between patients, we suggest the implementation of continuous and routine investigation of NTM infection or colonization in CF patients, including countries with a high burden of tuberculosis disease.Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)PDTIS-FIOCRUZUniv Fed Rio de Janeiro, Programa Posgrad Clin Med, Hosp Univ Clementino Fraga Filho, Rio de Janeiro, BrazilUniv Fed Rio Grande do Sul, Programa Posgrad Ciencias Med, Porto Alegre, RS, BrazilUniv Fed Rio de Janeiro, Fac Ciencias Med, Dept Microbiol Imunol & Parasitol, Rio de Janeiro, BrazilInst Fernandes Figueira Fiocruz, Rio de Janeiro, BrazilUniv Estado Rio de Janeiro, Hosp Univ Pedro Ernesto, Rio de Janeiro, BrazilUniv Fed Rio de Janeiro, Inst Microbiol, BR-21941 Rio de Janeiro, BrazilFundacao Oswaldo Cruz, Inst Pesquisa Evandro Chagas, Rio de Janeiro, BrazilInst Doencas Torax, Rio de Janeiro, BrazilJohns Hopkins Univ, Baltimore, MD USAUniversidade Federal de São Paulo, Escola Paulista Med, Dept Microbiol Imunol & Parasitol, São Paulo, BrazilUniv Fed Fluminense, Inst Biomed, Niteroi, RJ, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Dept Microbiol Imunol & Parasitol, São Paulo, BrazilFAPERJ: 103.225/2011FAPERJ: 103.287/2011FAPERJ: 110.272/2010FAPERJ: 110.761/2010FAPERJ: 111.497/2008CNPq: 476536/2012-0CNPq: 473444/2010-0CNPq: 567037/2008-8Web of Scienc

Computed tomography in cystic fibrosis: tomography score in CF patients colonyzed with Pseudomonas aeruginosa and Staphylococcus aureus

Na Fibrose Cística (FC) a infecção pulmonar crônica leva a lesão estrutural e disfunção pulmonar progressiva que precedem a insuficiência respiratória, maior causa de morbidade e mortalidade pela doença. As infecções bacterianas estão associadas a microrganismos específicos. Em geral, Staphylococcus aureus e Haemophilus influenzae estão associados a infecções respiratórias em pacientes mais jovens. Posteriormente a infecção por Pseudomonas aeruginosa marca a aceleração no declínio da função pulmonar e progressão das lesões estruturais pulmonares. A avaliação do comprometimento respiratório inclui culturas de secreção respiratória, provas de função respiratória e imagens de tórax. A tomografia computadorizada de tórax de alta resolução (TCAR) é capaz de avaliar precocemente o comprometimento estrutural de vias aéreas e parênquima pulmonar e tais alterações podem ser sistematicamente mensuradas através de diferentes escores de pontuação. O estudo tem como objetivo comparar a pontuação do escore de Bhalla modificado e as alterações pulmonares detectadas através da tomografia computadorizada de tórax de alta resolução em dois grupos de pacientes com FC vinculados ao Centro de Referência para FC do Instituto Fernandes Figueira, apresentando características microbiológicas distintas: colonizados cronicamente por Staphylococcus aeruginosa (n=26) e por Staphylococcus aureus (n=15). As imagens de tomografia computadorizada de tórax de alta resolução foram individualmente analisadas e pontuadas através do escore de Bhalla modificado, por dois radiologistas em dois momentos distintos. Houve boa concordância global tanto intraobservador (coeficiente de correlação intraclasse > 0.8) quanto interobservador (coeficiente de correlação intraclasse > 0.8) e essa avaliação demonstrou que as medidas são confiáveis e reprodutíveis. As pontuações obtidas através do escore adotado, bem como as alterações de imagem e a freqüência das mesmas, foram avaliadas e comparadas em cada grupo de pacientes. As médias dos escores totais do grupo cronicamente colonizado por Pseudomonas aeruginosa evidenciaram maior gravidade das lesões (observador 1: escore 13.5 e observador 2: escore 11.96) do que o grupo colonizado por Staphylococcus aureus (observador 1: escore 5.0 e observador 2: escore 5.07). A detecção precoce de lesões estruturais relacionadas à infecção e sua análise através de sistema de pontuação podem contribuir efetivamente para o ajuste de estratégias terapêuticas que venham alterar o prognóstico de pacientes portadores de FC.In Cystic Fibrosis (CF) chronic lung infection leads to irreversible structural abnormalities, progressive lung disease and respiratory failure, most common cause of death in CF. Bacterial infection in CF is usually related to specific agents: Staphylococcus aureus e Haemophilus influenzae usually infect younger patients. After this, Pseudomonas aeruginosa infection is associated with lung function deterioration and progression of structural lung disease. Assessment of CF lung disease includes monitoring of respiratory secretions microbiology, lung function and thoracic imaging. High resolution computed tomography of the lung (HRCT) is involved on early detection of structural airway and parenchymal abnormalities. These structural abnormalities can be assigned systematically through different scoring systems. The aim of this study was to compare the results of the modified Bhalla score for High resolution computed tomography of the lung from two groups of CF patients attending the CF Reference Center at Instituto Fernandes Figueira, Rio de Janeiro, Brazil. These two groups had different microbiological features: chronically infected by Pseudomonas aeruginosa (n = 26) and infected by Staphylococcus aureus (n = 15). High resolution computed tomography of the lung images were randomly and blindly scored using a modified Bhalla scoring system by two independent radiologists in two different moments. There was good intraobserver and interobserver variability and this observation indicates that the measurements are reliable and reproducible. Score results and abnormalities found in each group were compared. Final scores of Pseudomonas aeruginosa group showed more severe disease (radiologist 1: 13.5 and radiologist 2: 11.96) then the Staphylococcus aureus group (radiologist 1: 5.0 and radiologist 2: 5.07). Early detection of structural abnormalities associated to infection and its assessment through scoring systems may contribute to therapeutical approaches that can improve prognosis for CF patients

Escore tomográfico em pacientes com fibrose cística colonizados por Pseudomonas aeruginosa ou Staphylococcus aureus

OBJETIVO: Comparar achados de TCAR em pacientes com fibrose cística (FC) colonizados cronicamente por Pseudomonas aeruginosa ou Staphylococcus aureus, empregando o escore de Bhalla modificado, e avaliar as confiabilidades intraobservador e interobservador do método. MÉTODOS: Estudo transversal retrospectivo incluindo 41 pacientes portadores de FC, 26 dos quais colonizados cronicamente por P. aeruginosa (grupo Pa) e 15 por S. aureus (grupo Sa). Dois radiologistas analisaram independentemente em duas ocasiões, as imagens de TCAR desses pacientes e aplicaram o escore de Bhalla modificado. As confiabilidades intra e interobservador foram avaliadas segundo o coeficiente de correlação intraclasse (CCI). RESULTADOS: Houve boa concordância intraobservador e interobservador (CCI > 0,8). Os resultados dos escores do grupo Pa foram mais elevados que os do grupo Sa para o observador 1 (média de 13,50 ± 3,90 e mediana de 13,5 vs. média de 5,0 ± 5,28 e mediana de 3,0) e para o observador 2 (média de 11,96 ± 5,07 e mediana de 12,0 vs. média de 5,07 ± 5,65 e mediana de 5,0). Alterações tomográficas, como bronquiectasias, espessamento das paredes brônquicas, formação de tampões mucosos, comprometimento de gerações de divisões brônquicas e padrão de atenuação em mosaico, foram mais prevalentes no grupo colonizado por P. aeruginosa. CONCLUSÕES: O escore de Bhalla modificado se mostrou reprodutível e confiável para a avaliação de TCAR e permitiu a diferenciação entre os pacientes incluídos nos dois grupos. Escores mais altos no grupo Pa evidenciaram maior comprometimento estrutural pulmonar nesse grupo

Monitoring clinical and microbiological evolution of a cystic fibrosis patient over 26 years: experience of a Brazilian CF Centre

Abstract Background Burkholderia cepacia complex is a group of opportunistic pathogens in cystic fibrosis (CF) patients believed to be associated with poor prognosis and patient-to-patient transmissibility. Little is known about clinical outcomes after B. vietnamiensis chronic colonization/infection. Case presentation A 33 yo male patient had diagnosis of CF by 7 yo, after recurrent pneumonia during infancy and lobectomy (left upper lobe) at 6 yo. Burkholderia cepacia complex (Bcc) was first isolated by 13 yo, and the patient fulfilled the criteria for chronic colonization by 15 yo. In the following 16 years (1997–2013), there was intermittent isolation of P. aeruginosa and continuous isolation of Bcc, identified as B. vietnamiensis. There was clinical and laboratorial stability for 16 years with annual rate of decline in forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) of 1.61 and 1.35%, respectively. From 2013 to 2015, there was significant clinical and lung function deterioration: annual rate of decline in FEV1 and FVC was 3 and 4.1%, respectively while body mass index decreased from 18.1 to 17.1. Episodes of hemoptysis and respiratory exacerbations (with hospital admissions) became more frequent. CF related diabetes was diagnosed (fasting glycemia: 116 mg/dL, oral glucose tolerance test: 305 mg/dL). Because of the severity of the disease in the last years, in addition to traditional microbiological surveillance, microbiome analysis by next generation sequencing (NGS) was performed on respiratory secretions. The NGS showed that 97% of the sequencing data were attributed to genus Burkholderia. Conclusions We report the case of a 33-year-old male CF patient known to have chronic infection with B. vietnamiensis who remained clinically stable for 16 years and presented recent clinical and laboratorial deterioration. Microbiome analysis of respiratory secretions was performed in 3 samples collected in 2014–2015. Clinical deterioration overlapped with cystic fibrosis-related diabetes and microbiome composition revealed no significant differences when compared microbiome results to culture dependent methods

Achromobacter xylosoxidans infection in cystic fibrosis siblings with different outcomes: Case reports

Introduction: The clinical relevance of Achromobacter xylosoxidans infection in cystic fibrosis (CF) remains controversial. This emerging agent in CF has been associated with increased lung inflammation, more frequent exacerbations and more severe lung disease. We describe a pair of CF siblings chronically colonized by the same multilocus genotype of A. xylosoxidans with different clinical courses, and assess whether this species may have developed any virulence traits and antimicrobial resistance that could have contributed to their singular outcomes. Case presentation: Two siblings were positive for the F508del and Y1092X mutations, and were chronically colonized by Pseudomonas aeruginosa and Staphylococcus aureus. The female patient had a more severe CF phenotype and faster clinical deterioration than her brother. Her pulmonary function and computed tomography scan lesions were worse than those of her brother, and both parameters progressively declined. She died at 14 years of age, when he was 18. All isolates of A. xylosoxidans were biofilm producers. Achromobacter xylosoxidans showed less swarming motility in the female patient. Conclusions: Biofilm production and diminution of motility allow persistence. Only swarming motility differed between the isolates recovered from the two siblings, but this finding is not sufficient to explain the different clinical outcomes despite their similar genotypes. Modifier genes, unknown environmental factors and female gender can partially explain differences between these siblings. We were unable to correlate any microbiological findings with their clinical courses, and more translational studies are necessary to decrease the gap of knowledge between laboratory and clinical data to promote better clinical interventions