Publications by authors named "Wouter Hoefsloot"

57 Publications

RNA-sequencing elucidates drug-specific mechanisms of antibiotic tolerance and resistance in .

Antimicrob Agents Chemother 2021 Oct 11:AAC0150921. Epub 2021 Oct 11.

Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands.

is an opportunistic pathogen notorious for its resistance to most classes of antibiotics and low cure rates. carries an array of mostly unexplored defence mechanisms. A deeper understanding of antibiotic resistance and tolerance mechanisms is pivotal in development of targeted therapeutic regimens. We provide the first description of all major transcriptional mechanisms of tolerance to all antibiotics recommended in current guidelines, using RNA sequencing-guided experiments. ATCC 19977 bacteria were subjected to sub-inhibitory concentrations of clarithromycin, amikacin, tigecycline, cefoxitin and clofazimine for 4- and 24-hours, followed by RNA sequencing. To confirm key mechanisms of tolerance suggested by transcriptomic responses, we performed time-kill kinetic analysis using bacteria after pre-exposure to clarithromycin, amikacin or tigecycline for 24-hours and we constructed isogenic knockout and knockdown strains. To assess strain specificity, pan-genome analysis of 35 strains from all three subspecies was performed. shows both drug-specific and common transcriptomic responses to antibiotic exposure. Ribosome-targeting antibiotics clarithromycin, amikacin and tigecycline elicit a common response characterized by upregulation of ribosome structural genes, the WhiB7 regulon and transferases, accompanied by downregulation of respiration through NuoA-N. Exposure to any of these drugs decreases susceptibility to ribosome-targeting drugs from multiple classes. The cytochrome bd-type quinol oxidase contributes to clofazimine tolerance in and the sigma factor sigH but not anti-sigma factor MAB_3542c is involved in tigecycline resistance. The observed transcriptomic responses are not strain-specific, as all genes involved in tolerance, except erm(41), are found in all included strains.
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http://dx.doi.org/10.1128/AAC.01509-21DOI Listing
October 2021

Prediction of moxifloxacin concentrations in tuberculosis patient populations by physiologically-based pharmacokinetic modeling.

J Clin Pharmacol 2021 Sep 23. Epub 2021 Sep 23.

Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud university medical center, Nijmegen, The Netherlands.

Moxifloxacin has an important role in the treatment of tuberculosis (TB). Unfortunately, co-administration with the cornerstone TB drug rifampicin results in sub-optimal plasma exposure. We aimed to gain insight into the moxifloxacin pharmacokinetics and the interaction with rifampicin. Moreover, we provided a mechanistic framework to understand moxifloxacin pharmacokinetics. We developed a physiologically-based pharmacokinetic (PBPK) model in Simcyp version 19, with available and newly generated in vitro and in vivo data, to estimate PK parameters of moxifloxacin alone and when administered with rifampicin. By combining these strategies, we illustrate that the role of P-gp in moxifloxacin transport is limited and implicate MRP2 as transporter of moxifloxacin-glucuronide followed by rapid hydrolysis in the gut. Simulations of multiple dose area under the plasma concentration-time curves (AUC) of moxifloxacin (400 mg QD) with and without rifampicin (600 mg QD) were in accordance with clinically observed data (predicted/observed (P/O) ratio of 0.87 and 0.80, respectively). Importantly, increasing the moxifloxacin dose to 600 mg restored the plasma exposure both in actual TB patients as well as in our simulations. Furthermore, we extrapolated the single dose model to pediatric populations (P/O AUC ratios 1.04-1.52) and the multiple dose model to children with TB (P/O AUC ratio 1.51). In conclusion, our combined approach resulted in new insights into moxifloxacin PK and accurate simulations of moxifloxacin exposure with and without rifampicin. Finally, various knowledge gaps were identified, which may be considered as avenues for further PBPK refinement. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1002/jcph.1972DOI Listing
September 2021

Mycobacterium Growth Indicator Tube Time-To-Positivity Can Serve As an Early Biomarker of Treatment Response in Mycobacterium avium Complex Pulmonary Disease.

Chest 2021 Aug 13. Epub 2021 Aug 13.

Department of Medical Microbiology, Radboud University Medical Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands. Electronic address:

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http://dx.doi.org/10.1016/j.chest.2021.08.046DOI Listing
August 2021

Standard therapy of Mycobacterium avium complex pulmonary disease shows limited efficacy in an open source hollow fibre system that simulates human plasma and epithelial lining fluid pharmacokinetics.

Clin Microbiol Infect 2021 Jul 28. Epub 2021 Jul 28.

Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands. Electronic address:

Objectives: Mycobacterium avium complex (MAC) bacteria can cause chronic pulmonary disease (PD). Current treatment regimens of azithromycin, ethambutol and rifampicin have culture conversion rates of around 65%. Dynamic, preclinical models to assess the efficacy of treatment regimens are important to guide clinical trial development. The hollow fibre system (HFS) has been applied but reports lack experimental details.

Methods: We simulated the human pharmacokinetics of azithromycin, ethambutol and rifampicin both in plasma and epithelial lining fluid (ELF) in a HFS, exposing THP-1 cells infected with M. avium to the triple-drug regimen for 3 weeks. We accounted for drug-drug interactions and protein-binding and provide all laboratory protocols. We differentiated the effects on the intracellular and extracellular mycobacterial population.

Results: The antibiotic concentrations in the HFS accurately reflected the time to peak concentration (T), the peak concentration (C) and half-life of azithromycin, rifampicin and ethambutol in plasma and ELF reported in literature. We find that plasma drug concentrations fail to hold the MAC bacterial load static (ΔLog10 CFU/mL = 0.66 ± 0.76 and 0.45 ± 0.28 at 3 and 21 days); ELF concentrations do hold the bacterial load static for 3 days and inhibit bacterial growth for the duration of the experiment (ΔLog10 CFU/mL = 1.1 ± 0.1 and 1.64 ± 0.59 at 3 and 21 days).

Discussion: In our model, the current therapy against MAC is ineffective, even when accounting for antibiotic accumulation at the site of infection and intracellularly. New treatment regimens need to be developed and be compared with currently recommended regimens in dynamic models prior to clinical evaluation. With the publication of all protocols we aim to open this technology to new users.
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http://dx.doi.org/10.1016/j.cmi.2021.07.015DOI Listing
July 2021

The role of amikacin in the treatment of nontuberculous mycobacterial disease.

Expert Opin Pharmacother 2021 Oct 22;22(15):1961-1974. Epub 2021 Jul 22.

Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.

: Guidelines recommend the use of amikacin in the treatment of nontuberculous mycobacterial (NTM) disease. The authors have evaluated the evidence for the position of amikacin in NTM disease treatment.: The authors performed a literature search for original research on amikacin in NTM disease, including its mechanism of action, emergence of resistance, pre-clinical and clinical investigations.: Amikacin shows moderate activity against the clinically most relevant NTM species ( complex and ). It is synergistic with ethambutol, clofazimine, and macrolides and these combinations are effective in animal models. Liposomal encapsulation increases amikacin efficacy. Clinically, the recommended dose of 15 mg/kg intravenous amikacin does not lead to PK/PD target attainment in all patients and a positive impact on long-term treatment outcomes remains unproven in both complex and disease. Adding the amikacin liposome inhalation suspension did prove to be effective in short and long term in patients not responding to recommended treatment for complex pulmonary disease. Its optimal use in complex and pulmonary disease warrants further evaluation.
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http://dx.doi.org/10.1080/14656566.2021.1953472DOI Listing
October 2021

The epidemiology of nontuberculous mycobacterial pulmonary disease in the Netherlands.

ERJ Open Res 2021 Jul 12;7(3). Epub 2021 Jul 12.

Dept of Medical Microbiology, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands.

Background: Nontuberculous mycobacteria (NTM) are emerging opportunistic pathogens of humans. Because NTM pulmonary disease (PD) is not a notifiable disease in Europe, the epidemiology of NTM-PD is not well known. However, the prevalence of NTM-PD is thought to be increasing, particularly in countries where tuberculosis rates have decreased. Here we aim to determine the prevalence of NTM-PD in the Netherlands.

Methods: Annual prevalence estimates of NTM-PD in the Netherlands (2012-2019) were derived from four separate databases, including two drug dispensing databases, an ICD-10 code database and a hospitalisation database. Databases covered a fraction of the Dutch population and were extrapolated. In addition, annual NTM-PD prevalence was also estimated by means of a pulmonologist survey.

Results: The estimated annual prevalence of NTM-PD using databases is between 2.3 and 5.9 patients per 100 000 inhabitants. Prevalence estimates derived from the drug dispensing databases, the hospitalisation database and the claims database were 2.3, 5.9, 3.5 and 4.5 per 100 000 inhabitants, respectively. The annual prevalence estimated in the pulmonologist survey was between 6.2 and 9.9 per 100 000 inhabitants. The annual prevalence remained stable over the included period.

Conclusion: The estimated annual prevalence of NTM-PD using databases was between 2.3 and 5.9 patients per 100 000 inhabitants. Due to the possible presence of tuberculosis patients and low coverage in one dispensing database, we believe an annual prevalence of between 2.3 and 4.5 patients per 100 000 inhabitants is more probable, which still renders NTM-PD a serious health threat. This estimate is lower than the estimate from the pulmonologist survey, indicating physicians likely overestimate prevalence.
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http://dx.doi.org/10.1183/23120541.00207-2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8273392PMC
July 2021

Imatinib in patients with severe COVID-19: a randomised, double-blind, placebo-controlled, clinical trial.

Lancet Respir Med 2021 09 18;9(9):957-968. Epub 2021 Jun 18.

Department of Internal Medicine, Haaglanden Medisch Centrum, The Hague, Netherlands.

Background: The major complication of COVID-19 is hypoxaemic respiratory failure from capillary leak and alveolar oedema. Experimental and early clinical data suggest that the tyrosine-kinase inhibitor imatinib reverses pulmonary capillary leak.

Methods: This randomised, double-blind, placebo-controlled, clinical trial was done at 13 academic and non-academic teaching hospitals in the Netherlands. Hospitalised patients (aged ≥18 years) with COVID-19, as confirmed by an RT-PCR test for SARS-CoV-2, requiring supplemental oxygen to maintain a peripheral oxygen saturation of greater than 94% were eligible. Patients were excluded if they had severe pre-existing pulmonary disease, had pre-existing heart failure, had undergone active treatment of a haematological or non-haematological malignancy in the previous 12 months, had cytopenia, or were receiving concomitant treatment with medication known to strongly interact with imatinib. Patients were randomly assigned (1:1) to receive either oral imatinib, given as a loading dose of 800 mg on day 0 followed by 400 mg daily on days 1-9, or placebo. Randomisation was done with a computer-based clinical data management platform with variable block sizes (containing two, four, or six patients), stratified by study site. The primary outcome was time to discontinuation of mechanical ventilation and supplemental oxygen for more than 48 consecutive hours, while being alive during a 28-day period. Secondary outcomes included safety, mortality at 28 days, and the need for invasive mechanical ventilation. All efficacy and safety analyses were done in all randomised patients who had received at least one dose of study medication (modified intention-to-treat population). This study is registered with the EU Clinical Trials Register (EudraCT 2020-001236-10).

Findings: Between March 31, 2020, and Jan 4, 2021, 805 patients were screened, of whom 400 were eligible and randomly assigned to the imatinib group (n=204) or the placebo group (n=196). A total of 385 (96%) patients (median age 64 years [IQR 56-73]) received at least one dose of study medication and were included in the modified intention-to-treat population. Time to discontinuation of ventilation and supplemental oxygen for more than 48 h was not significantly different between the two groups (unadjusted hazard ratio [HR] 0·95 [95% CI 0·76-1·20]). At day 28, 15 (8%) of 197 patients had died in the imatinib group compared with 27 (14%) of 188 patients in the placebo group (unadjusted HR 0·51 [0·27-0·95]). After adjusting for baseline imbalances between the two groups (sex, obesity, diabetes, and cardiovascular disease) the HR for mortality was 0·52 (95% CI 0·26-1·05). The HR for mechanical ventilation in the imatinib group compared with the placebo group was 1·07 (0·63-1·80; p=0·81). The median duration of invasive mechanical ventilation was 7 days (IQR 3-13) in the imatinib group compared with 12 days (6-20) in the placebo group (p=0·0080). 91 (46%) of 197 patients in the imatinib group and 82 (44%) of 188 patients in the placebo group had at least one grade 3 or higher adverse event. The safety evaluation revealed no imatinib-associated adverse events.

Interpretation: The study failed to meet its primary outcome, as imatinib did not reduce the time to discontinuation of ventilation and supplemental oxygen for more than 48 consecutive hours in patients with COVID-19 requiring supplemental oxygen. The observed effects on survival (although attenuated after adjustment for baseline imbalances) and duration of mechanical ventilation suggest that imatinib might confer clinical benefit in hospitalised patients with COVID-19, but further studies are required to validate these findings.

Funding: Amsterdam Medical Center Foundation, Nederlandse Organisatie voor Wetenschappelijk Onderzoek/ZonMW, and the European Union Innovative Medicines Initiative 2.
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http://dx.doi.org/10.1016/S2213-2600(21)00237-XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232929PMC
September 2021

An Perspective on What Individual Antimicrobials Add to Mycobacterium avium Complex Therapies.

Antimicrob Agents Chemother 2021 07 16;65(8):e0273020. Epub 2021 Jul 16.

Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands.

For Mycobacterium avium complex pulmonary disease (MAC-PD), current treatment regimens yield low cure rates. To obtain an evidence-based combination therapy, we assessed the activity of six drugs, namely, clarithromycin (CLR), rifampin (RIF), ethambutol (EMB), amikacin (AMK), clofazimine (CLO), and minocycline (MIN), alone and in combination, against Mycobacterium avium and studied the contributions of individual antibiotics to efficacy. The MICs of all antibiotics against M. avium ATCC 700898 were determined by broth microdilution. We performed kinetic time-kill assays of all single drugs and clinically relevant two-, three-, four-, and five-drug combinations against M. avium. Pharmacodynamic interactions of these combinations were assessed using area under the time-kill curve-derived effect size and Bliss independence. Adding a second drug yielded an average increase of the effect size (E) of 18.7% ± 32.9%, although antagonism was seen in some combinations. Adding a third drug showed a smaller increase in effect size (+12.2% ± 11.5%). The RIF-CLO-CLR (E of 102 log CFU/ml · day), RIF-AMK-CLR (E of 101 log CFU/ml · day), and AMK-MIN-EMB (E of 97.8 log CFU/ml · day) regimens proved more active than the recommended RIF-EMB-CLR regimen (E of 89.1 log CFU/ml · day). The addition of a fourth drug had little impact on effect size (+4.54% ± 3.08%). , several two- and three-drug regimens are as effective as the currently recommended regimen for MAC-PD. Adding a fourth drug to any regimen had little additional effect. , the most promising regimen would be RIF-AMK-macrolide or RIF-CLO-macrolide.
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http://dx.doi.org/10.1128/AAC.02730-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284439PMC
July 2021

Assessing COVID-19 pneumonia-Clinical extension and risk with point-of-care ultrasound: A multicenter, prospective, observational study.

J Am Coll Emerg Physicians Open 2021 Jun 1;2(3):e12429. Epub 2021 May 1.

Section Acute Internal Medicine, Department of Internal Medicine Radboud University Medical Center Nijmegen The Netherlands.

Background: Assessing the extent of lung involvement is important for the triage and care of COVID-19 pneumonia. We sought to determine the utility of point-of-care ultrasound (POCUS) for characterizing lung involvement and, thereby, clinical risk determination in COVID-19 pneumonia.

Methods: This multicenter, prospective, observational study included patients with COVID-19 who received 12-zone lung ultrasound and chest computed tomography (CT) scanning in the emergency department (ED). We defined lung disease severity using the lung ultrasound score (LUS) and chest CT severity score (CTSS). We assessed the association between the LUS and poor outcome (ICU admission or 30-day all-cause mortality). We also assessed the association between the LUS and hospital length of stay. We examined the ability of the LUS to differentiate between disease severity groups. Lastly, we estimated the correlation between the LUS and CTSS and the interrater agreement for the LUS. We handled missing data by multiple imputation with chained equations and predictive mean matching.

Results: We included 114 patients treated between March 19, 2020, and May 4, 2020. An LUS ≥12 was associated with a poor outcome within 30 days (hazard ratio [HR], 5.59; 95% confidence interval [CI], 1.26-24.80; = 0.02). Admission duration was shorter in patients with an LUS <12 (adjusted HR, 2.24; 95% CI, 1.47-3.40; < 0.001). Mean LUS differed between disease severity groups: no admission, 6.3 (standard deviation [SD], 4.4); hospital/ward, 13.1 (SD, 6.4); and ICU, 18.0 (SD, 5.0). The LUS was able to discriminate between ED discharge and hospital admission excellently, with an area under the curve of 0.83 (95% CI, 0.75-0.91). Interrater agreement for the LUS was strong: κ = 0.88 (95% CI, 0.77-0.95). Correlation between the LUS and CTSS was strong: κ = 0.60 (95% CI, 0.48-0.71).

Conclusions: We showed that baseline lung ultrasound - is associated with poor outcomes, admission duration, and disease severity. The LUS also correlates well with CTSS. Point-of-care lung ultrasound may aid the risk stratification and triage of patients with COVID-19 at the ED.
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http://dx.doi.org/10.1002/emp2.12429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087918PMC
June 2021

Amikacin Liposome Inhalation Suspension for Refractory Mycobacterium avium Complex Lung Disease: Sustainability and Durability of Culture Conversion and Safety of Long-term Exposure.

Chest 2021 Sep 19;160(3):831-842. Epub 2021 Apr 19.

Division of Infectious Disease, Oregon Health and Science University School of Medicine, Portland, OR.

Background: In the CONVERT study, treatment with amikacin liposome inhalation suspension (ALIS) added to guideline-based therapy (GBT) met the primary end point of increased culture conversion by month 6 in patients with treatment-refractory Mycobacterium avium complex lung disease (ALIS plus GBT, 29% [65/224] vs GBT alone, 8.9% [10/112]; P < .0001).

Research Question: In patients who achieved culture conversion by month 6 in the CONVERT study, was conversion sustained (negative sputum culture results for 12 months with treatment) and durable (negative sputum culture results for 3 months after treatment) and were there any additional safety signals associated with a full treatment course of 12 months after conversion?

Study Design And Methods: Adults were randomized 2:1 to receive ALIS plus GBT or GBT alone. Patients achieving culture conversion by month 6 continued therapy for 12 months followed by off-treatment observation.

Results: More patients randomized to ALIS plus GBT (intention-to-treat population) achieved conversion that was both sustained and durable 3 months after treatment vs patients randomized to GBT alone (ALIS plus GBT, 16.1% [36/224] vs GBT alone, 0% [0/112]; P < .0001). Of the patients who achieved culture conversion by month 6, 55.4% of converters (36/65) in the ALIS plus GBT treated arm vs no converters (0/10) in the GBT alone arm achieved sustained and durable conversion (P = .0017). Relapse rates through 3 months after treatment were 9.2% (6/65) in the ALIS plus GBT arm and 30.0% (3/10) in the GBT alone arm. Common adverse events among ALIS plus GBT-treated patients (dysphonia, cough, dyspnea, hemoptysis) occurred mainly within the first 8 months of treatment.

Interpretation: In a refractory population, conversion was sustained and durable in more patients treated with ALIS plus GBT for 12 months after conversion than in those treated with GBT alone. No new safety signals were associated with 12 months of treatment after conversion.

Trial Registry: ClinicalTrials.gov; No.: NCT02344004; URL: www.clinicaltrials.gov.
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http://dx.doi.org/10.1016/j.chest.2021.03.070DOI Listing
September 2021

Risk factors for in-hospital mortality in laboratory-confirmed COVID-19 patients in the Netherlands: A competing risk survival analysis.

PLoS One 2021 26;16(3):e0249231. Epub 2021 Mar 26.

Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands.

Background: To date, survival data on risk factors for COVID-19 mortality in western Europe is limited, and none of the published survival studies have used a competing risk approach. This study aims to identify risk factors for in-hospital mortality in COVID-19 patients in the Netherlands, considering recovery as a competing risk.

Methods: In this observational multicenter cohort study we included adults with PCR-confirmed SARS-CoV-2 infection that were admitted to one of five hospitals in the Netherlands (March to May 2020). We performed a competing risk survival analysis, presenting cause-specific hazard ratios (HRCS) for the effect of preselected factors on the absolute risk of death and recovery.

Results: 1,006 patients were included (63.9% male; median age 69 years, IQR: 58-77). Patients were hospitalized for a median duration of 6 days (IQR: 3-13); 243 (24.6%) of them died, 689 (69.9%) recovered, and 74 (7.4%) were censored. Patients with higher age (HRCS 1.10, 95% CI 1.08-1.12), immunocompromised state (HRCS 1.46, 95% CI 1.08-1.98), who used anticoagulants or antiplatelet medication (HRCS 1.38, 95% CI 1.01-1.88), with higher modified early warning score (MEWS) (HRCS 1.09, 95% CI 1.01-1.18), and higher blood LDH at time of admission (HRCS 6.68, 95% CI 1.95-22.8) had increased risk of death, whereas fever (HRCS 0.70, 95% CI 0.52-0.95) decreased risk of death. We found no increased mortality risk in male patients, high BMI or diabetes.

Conclusion: Our competing risk survival analysis confirms specific risk factors for COVID-19 mortality in a the Netherlands, which can be used for prediction research, more intense in-hospital monitoring or prioritizing particular patients for new treatments or vaccination.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249231PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997038PMC
April 2021

Clinical characteristics and outcomes of 952 hospitalized COVID-19 patients in The Netherlands: A retrospective cohort study.

PLoS One 2021 18;16(3):e0248713. Epub 2021 Mar 18.

Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.

Objective: To describe clinical characteristics, disease course and outcomes in a large and well-documented cohort of hospitalized COVID-19 patients in the Netherlands.

Methods: We conducted a multicentre retrospective cohort study in The Netherlands including 952 of 1183 consecutively hospitalized patients that were admitted to participating hospitals between March 2nd, 2020, and May 22nd, 2020. Clinical characteristics and laboratory parameters upon admission and during hospitalization were collected until July 1st.

Results: The median age was 69 years (IQR 58-77 years) and 605 (63.6%) were male. Cardiovascular disease was present in 558 (58.6%) patients. The median time of onset of symptoms prior to hospitalization was 7 days (IQR 5-10). A non ICU admission policy was applicable in 312 (32.8%) patients and in 165 (56.3%) of the severely ill patients admitted to the ward. At admission and during hospitalization, severely ill patients had higher values of CRP, LDH, ferritin and D-dimer with higher neutrophil counts and lower lymphocyte counts. Overall in-hospital mortality was 25.1% and 183 (19.1%) patients were admitted to ICU, of whom 56 (30.6%) died. Patients aged ≥70 years had high mortality, both at the ward (52.4%) and ICU (47.4%). The median length of ICU stay was 8 days longer in patients aged ≥70 years compared to patients aged ≤60 years.

Conclusion: Hospitalized COVID-19 patients aged ≥70 years had high mortality and longer ICU stay compared to patients aged ≤60 years. These findings in combination with the patient burden of an ICU admission and possible long term complications after discharge should encourage us to further investigate the benefit of ICU admission in elderly and fragile COVID-19-patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248713PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7971488PMC
April 2021

Dysregulated Innate and Adaptive Immune Responses Discriminate Disease Severity in COVID-19.

J Infect Dis 2021 04;223(8):1322-1333

Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands.

The clinical spectrum of COVID-19 varies and the differences in host response characterizing this variation have not been fully elucidated. COVID-19 disease severity correlates with an excessive proinflammatory immune response and profound lymphopenia. Inflammatory responses according to disease severity were explored by plasma cytokine measurements and proteomics analysis in 147 COVID-19 patients. Furthermore, peripheral blood mononuclear cell cytokine production assays and whole blood flow cytometry were performed. Results confirm a hyperinflammatory innate immune state, while highlighting hepatocyte growth factor and stem cell factor as potential biomarkers for disease severity. Clustering analysis revealed no specific inflammatory endotypes in COVID-19 patients. Functional assays revealed abrogated adaptive cytokine production (interferon-γ, interleukin-17, and interleukin-22) and prominent T-cell exhaustion in critically ill patients, whereas innate immune responses were intact or hyperresponsive. Collectively, this extensive analysis provides a comprehensive insight into the pathobiology of severe to critical COVID-19 and highlights potential biomarkers of disease severity.
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http://dx.doi.org/10.1093/infdis/jiab065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928798PMC
April 2021

Immune defects in patients with pulmonary disease without cystic fibrosis.

ERJ Open Res 2020 Oct 10;6(4). Epub 2020 Nov 10.

Radboud University Medical Centre, University Centre of Chronic Diseases Dekkerswald, Dept of Pulmonary Diseases, Nijmegen, The Netherlands.

The prevalence of infections in non-cystic fibrosis (CF) patients has increased in recent years. In this study, we investigate whether immune defects explain the apparent susceptibility to this opportunistic infection in non-CF patients. We performed stimulations of peripheral blood mononuclear cells and whole blood from 13 patients with pulmonary disease and 13 healthy controls to investigate their cytokine production after 24 h and 7 days. Patients were predominantly women (54%) with a mean age of 59 years; 62% had nodular bronchiectatic disease. Many patients had predisposing pulmonary diseases, such as COPD (46%), and asthma (23%). Patients with COPD showed an impaired interleukin (IL)-6 response to and a reduced IL-17 response to , together with a -specific enhanced IL-22 production. Patients without COPD showed higher levels of interleukin-1 receptor antagonist (IL-1Ra), an anti-inflammatory molecule. Within the non-COPD patients, those with bronchiectasis showed defective interferon (IFN)-γ production in response to . In conclusion, susceptibility to is likely determined by a combination of immunological defects and predisposing pulmonary disease. The main defect in the innate immune response was a shift of the ratio of IL-1β to IL-1Ra, which decreased the bioactivity of this pathway in the adaptive immune response. In the adaptive immune response there was defective IL-17 and IFN-γ production. Patients with COPD and bronchiectasis showed different cytokine defects. It is therefore crucial to interpret the immunological results within the clinical background of the patients tested.
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http://dx.doi.org/10.1183/23120541.00590-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682720PMC
October 2020

Subtle immunodeficiencies in nodular-bronchiectatic complex lung disease.

ERJ Open Res 2020 Oct 19;6(4). Epub 2020 Oct 19.

Radboudumc Center for Infectious Diseases, Dept of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.

https://bit.ly/33AALwx.
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http://dx.doi.org/10.1183/23120541.00548-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7569207PMC
October 2020

The tough process of unmasking the slow-growing mycobacterium: case report of infection.

Access Microbiol 2020 31;2(1):acmi000074. Epub 2019 Oct 31.

Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands.

belongs to the complex (MTBC). It can cause pulmonary and extrapulmonary tuberculosis in humans. Compared to , which is the most prevalent subspecies of the MTBC, infection has a different etiology. Moreover, establishing the diagnosis with conventional bacteriology can be difficult. We will illustrate this with a case of an extrapulmonary tuberculosis of the hip caused by in an immunocompetent patient in The Netherlands.
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http://dx.doi.org/10.1099/acmi.0.000074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525059PMC
October 2019

Epidemiology of nontuberculous mycobacterial pulmonary disease in Europe and Japan by Delphi estimation.

Respir Med 2020 11 21;173:106164. Epub 2020 Sep 21.

Radboud Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands. Electronic address:

Background: Nontuberculous mycobacterial pulmonary disease (NTM-PD) is an emerging opportunistic infection, but basic epidemiological data are lacking in most regions. We have investigated epidemiology and diagnostic and treatment practices in five EU countries (United Kingdom, Spain, Italy, France, Germany; EU5) and Japan.

Study Design: and methods: Annual prevalence in each country was established using a 2-round Delphi method in combination with a regional prevalence-estimation model that incorporated data obtained from a blinded physician screening survey (3154 physicians) and a real-world NTM-PD treating-physician/patient-chart observational study (619 physicians - 1429 patient charts).

Results: The annual prevalence of NTM-PD was estimated at 6.2/100,000 in the EU5 and 24.9/100,000 in Japan. Overall prevalence between the EU5 was comparable, while differences in regional prevalence were found to be pronounced in France and The United Kingdom. Regional differences were also found in Japan, with the majority of cases in Chubu and Kanto regions.

Conclusion: This new methodology for obtaining often missing regional-level epidemiological data reveals dramatic variations in NTM-PD annual prevalence and helps pinpoint areas that may merit special preventative and treatment focus.
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http://dx.doi.org/10.1016/j.rmed.2020.106164DOI Listing
November 2020

Management of Drug Toxicity in Mycobacterium avium Complex Pulmonary Disease: An Expert Panel Survey.

Clin Infect Dis 2021 07;73(1):e256-e259

Division of Pulmonary and Critical Care Medicine, Seoul National University College of Medicine, Seoul, South Korea.

Adverse events are frequent in nontuberculous mycobacteria pulmonary disease treatment, but evidence to support their management is scarce. An expert panel survey on management of adverse events shows consistent opinions on management of hepatoxicity, ocular toxicity, ototoxicity, tinnitus, and gastrointestinal upset. These opinions can provide assistance in individual patient management decisions.
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http://dx.doi.org/10.1093/cid/ciaa1361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8491833PMC
July 2021

Cone-Beam CT Image Guidance With and Without Electromagnetic Navigation Bronchoscopy for Biopsy of Peripheral Pulmonary Lesions.

J Bronchology Interv Pulmonol 2021 Jan;28(1):60-69

Departments of Pulmonology.

Background: Bronchoscopic diagnosis of small peripheral lung lesions suspected of lung cancer remains a challenge. A successful endobronchial diagnosis comprises navigation, confirmation, and tissue acquisition. In all steps, 3-dimensional information is essential. Cone-beam computed tomography (CBCT) imaging can provide computed tomography information and 3-dimensional augmented fluoroscopy imaging. We assessed whether CBCT imaging can improve navigation and diagnosis of peripheral lesions by 2 clinical workflows with a cross-over design: (1) a primary CBCT and radial endobronchial ultrasound mini probe imaging-based approach and (2) a primary electromagnetic navigation (EMN) and radial endobronchial ultrasound mini probe imaging-based approach.

Methods: All patients with a peripheral lung lesion biopsy indication were eligible for study inclusion and randomly assigned to study arms. Commercially available equipment was used. The main study goals were to assess CBCT-confirmed navigation success and diagnostic accuracy. Surgery or unambiguous clinical follow-up served as the gold standard.

Results: Eighty-seven patients with 107 lesions were included. Lesion mean longest axis size in the CBCT arm was 16.6 mm (n=47) and 14.2 mm in the EMN arm (n=40). The primary CBCT approach and primary EMN approach had 76.3% and 52.2% navigation success, respectively. Addition of EMN to the CBCT approach increased navigation success to 89.9%. Addition of CBCT imaging to the EMN approach significantly increased navigation success to 87.5% per lesion. The overall diagnostic accuracy per patient was significantly lower than the navigation success, being 72.4%.

Conclusion: CBCT imaging is a valuable addition to navigation bronchoscopy. Although overall navigation success was high, the diagnostic accuracy remains to be improved. Future research should focus on improving the tissue acquisition methodology.
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http://dx.doi.org/10.1097/LBR.0000000000000697DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7742216PMC
January 2021

Thioridazine Is an Efflux Pump Inhibitor in Mycobacterium avium Complex but of Limited Clinical Relevance.

Antimicrob Agents Chemother 2020 06 23;64(7). Epub 2020 Jun 23.

Radboud Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands

Treatment of complex pulmonary disease (MAC-PD) is challenging partly due to high efflux pump expression. Thioridazine might block these efflux pumps. We explore the efficacy of thioridazine against isolates using MICs, time-kill combination assays, macrophage infection assays, and efflux assays. Thioridazine is bactericidal against , inhibits intracellular growth at 2× MIC, and blocks ethidium bromide efflux. However, its toxicity and low plasma concentrations make it unlikely to add efficacy to MAC-PD therapy.
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http://dx.doi.org/10.1128/AAC.00181-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318027PMC
June 2020

Inhaled tigecycline is effective against Mycobacterium abscessus in vitro and in vivo.

J Antimicrob Chemother 2020 07;75(7):1889-1894

Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Mycobacterium abscessus causes chronic pulmonary infections. Owing to its resistance to most classes of antibiotics, treatment is complex and cure rates are only 45%. Tigecycline is active against M. abscessus, but severe toxicity and the need for IV administration limit its use.

Objectives: To assess the potential of inhaled tigecycline as a treatment for M. abscessus pulmonary disease, by measuring its efficacy in a mouse model of chronic M. abscessus pulmonary disease, establishing the intracellular activity of tigecycline against M. abscessus in human macrophages and measuring the activity of tigecycline in the sputum of cystic fibrosis patients.

Methods: We infected GM-CSF knockout mice with M. abscessus by intrapulmonary aerosol. Infected mice were treated with tigecycline in 0.25, 1.25 and 2.5 mg doses, by inhalation, or untreated, for 28 days. Tigecycline was added to human peripheral blood-derived macrophages infected with M. abscessus to assess its intracellular activity. We performed a time-kill kinetics experiment of tigecycline against M. abscessus with and without sputum of cystic fibrosis patients.

Results: Inhaled tigecycline proved highly effective against M. abscessus in GM-CSF knockout mice. The effect was dose dependent. Tigecycline showed potent activity against M. abscessus in macrophages and retained most of its activity in the presence of sputum of cystic fibrosis patients.

Conclusions: Inhaled tigecycline may represent a viable treatment option for M. abscessus pulmonary disease, where treatment outcomes are currently very poor. A stable and safe formulation is required to proceed to further pharmacodynamic studies and ultimately clinical trials.
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http://dx.doi.org/10.1093/jac/dkaa110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7778363PMC
July 2020

Is there a role for tedizolid in the treatment of non-tuberculous mycobacterial disease?

J Antimicrob Chemother 2020 03;75(3):609-617

Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Pulmonary infections caused by non-tuberculous mycobacteria (NTM) are hard to treat and have low cure rates despite intensive multidrug therapy.

Objectives: To assess the feasibility of tedizolid, a new oxazolidinone, for the treatment of Mycobacterium avium and Mycobacterium abscessus.

Methods: We determined MICs of tedizolid for 113 isolates of NTM. Synergy with key antimycobacterial drugs was assessed using the chequerboard method and calculation of the FIC index (FICI). We performed time-kill kinetics assays of tedizolid alone and combined with amikacin for M. abscessus and with ethambutol for M. avium. Human macrophages were infected with M. abscessus and M. avium and subsequently treated with tedizolid; intracellular and extracellular cfu were quantified over time.

Results: NTM isolates generally had a lower MIC of tedizolid than of linezolid. FICIs were lowest between tedizolid and amikacin for M. abscessus (FICI = 0.75) and between tedizolid and ethambutol for M. avium (FICI = 0.72). Clarithromycin and tedizolid showed initial synergy, which was abrogated by erm(41)-induced macrolide resistance (FICI = 0.53). Tedizolid had a weak bacteriostatic effect on M. abscessus and combination with amikacin slightly prolonged its effect. Tedizolid had concentration-dependent activity against M. avium and its efficacy was enhanced by ethambutol. Both combinations had a concentration-dependent synergistic effect. Tedizolid could inhibit the intracellular bacterial population of both M. avium and M. abscessus.

Conclusions: Tedizolid should be further investigated in pharmacodynamic studies and clinical trials for M. avium complex pulmonary disease. It is less active against M. abscessus, but still promising.
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http://dx.doi.org/10.1093/jac/dkz511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7021090PMC
March 2020

Surveillance of adverse events in the treatment of drug-resistant tuberculosis: first global report.

Eur Respir J 2019 12 19;54(6). Epub 2019 Dec 19.

MDR-TB Department, Abu anga Teaching Hospital, Khartoum, Sudan.

The World Health Organization (WHO) recommends that countries implement pharmacovigilance and collect information on active drug safety monitoring (aDSM) and management of adverse events.The aim of this prospective study was to evaluate the frequency and severity of adverse events to anti-tuberculosis (TB) drugs in a cohort of consecutive TB patients treated with new ( bedaquiline, delamanid) and repurposed ( clofazimine, linezolid) drugs, based on the WHO aDSM project. Adverse events were collected prospectively after attribution to a specific drug together with demographic, bacteriological, radiological and clinical information at diagnosis and during therapy. This interim analysis included patients who completed or were still on treatment at time of data collection.Globally, 45 centres from 26 countries/regions reported 658 patients (68.7% male, 4.4% HIV co-infected) treated as follows: 87.7% with bedaquiline, 18.4% with delamanid (6.1% with both), 81.5% with linezolid and 32.4% with clofazimine. Overall, 504 adverse event episodes were reported: 447 (88.7%) were classified as minor (grade 1-2) and 57 (11.3%) as serious (grade 3-5). The majority of the 57 serious adverse events reported by 55 patients (51 out of 57, 89.5%) ultimately resolved. Among patients reporting serious adverse events, some drugs held responsible were discontinued: bedaquiline in 0.35% (two out of 577), delamanid in 0.8% (one out of 121), linezolid in 1.9% (10 out of 536) and clofazimine in 1.4% (three out of 213) of patients. Serious adverse events were reported in 6.9% (nine out of 131) of patients treated with amikacin, 0.4% (one out of 221) with ethionamide/prothionamide, 2.8% (15 out of 536) with linezolid and 1.8% (eight out of 498) with cycloserine/terizidone.The aDSM study provided valuable information, but implementation needs scaling-up to support patient-centred care.
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http://dx.doi.org/10.1183/13993003.01522-2019DOI Listing
December 2019

The differential effect of clarithromycin and azithromycin on induction of macrolide resistance in .

Future Microbiol 2019 06 4;14:749-755. Epub 2019 Jul 4.

Department of Medical Microbiology & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Gelderland, The Netherlands.

Antibiotic resistance in renders treatment poorly effective. Despite -gene-mediated macrolide resistance, treatment with azithromycin or clarithromycin is recommended. It is contested whether macrolides differ in ) induction. We determine whether this is the case. CIP104536 was used. Minimum inhibitory concentrations of clarithromycin and azithromycin were determined. Time-kill kinetics of exposed to azithromycin or clarithromycin were performed and RNA was isolated at predetermined intervals for quantification. Minimum inhibitory concentrations increased >30-fold. Time-kill kinetics showed a temporary bacteriostatic effect, abrogated by induced resistance. expression was increased following exposure to either macrolide for 7 days. Both macrolides induce resistance similarly, and this should not be an argument in choosing either macrolide for therapy.
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http://dx.doi.org/10.2217/fmb-2018-0310DOI Listing
June 2019

Auranofin Activity Exposes Thioredoxin Reductase as a Viable Drug Target in .

Antimicrob Agents Chemother 2019 09 23;63(9). Epub 2019 Aug 23.

Radboud Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands

Nontuberculous mycobacteria (NTM) are highly drug-resistant, opportunistic pathogens that can cause pulmonary disease. The outcomes of the currently recommended treatment regimens are poor, especially for New or repurposed drugs are direly needed. Auranofin, a gold-based antirheumatic agent, was investigated for Here, we test auranofin against NTM and We tested the susceptibility of 63 NTM isolates to auranofin using broth microdilution. Next, we assessed synergy between auranofin and antimycobacterial drugs using the checkerboard method and calculated the fractional inhibition concentration index (FICI). Using time-kill kinetics assays (TK), we assessed pharmacodynamics of auranofin alone and in combination with drug combinations showing the lowest FICIs for CIP 104536. A response surface analysis was used to assess synergistic interactions over time in TKs. Primary isolated macrophages were infected with and treated with auranofin. Finally, using KEGG Orthology, we looked for orthologues to auranofins drug target in had the lowest auranofin MIC (2 μg/ml) among the tested NTM. The lowest average FICIs were observed between auranofin and amikacin (0.45) and linezolid (0.50). Auranofin exhibited concentration-dependent killing of , with >1-log killing at concentrations of >2× MIC. Only amikacin was synergistic with auranofin according to Bliss independence. Auranofin could not lower the intracellular bacterial load in macrophages. Auranofin itself may not be feasible for treatment, but these data point toward a promising, unutilized drug target.
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http://dx.doi.org/10.1128/AAC.00449-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6709478PMC
September 2019

Minocycline treatment for pulmonary Mycobacterium avium complex disease based on pharmacokinetics/pharmacodynamics and Bayesian framework mathematical models.

J Antimicrob Chemother 2019 07;74(7):1952-1961

Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA.

Objectives: Our aim was to identify the pharmacokinetic/pharmacodynamic parameters of minocycline in the hollow-fibre system (HFS) model of pulmonary Mycobacterium avium complex (MAC) and to identify the optimal clinical dose.

Methods: Minocycline MICs for 55 MAC clinical isolates from the Netherlands were determined. We also co-incubated primary isolated macrophages infected with MAC with minocycline. Next, we performed a 28 day HFS-MAC model dose-response study in which we mimicked pulmonary concentration-time profiles achieved in patients. The HFS-MAC model was sampled at intervals to determine the minocycline pharmacokinetics and MAC burden. We identified the AUC0-24/MIC ratios associated with 1.0 log10 cfu/mL kill below day 0 (stasis), defined as a bactericidal effect. We then performed 10000 Monte Carlo experiments to identify the optimal dose for a bactericidal effect in patients.

Results: The MIC for 50% and 90% of cumulative clinical isolates was 8 and 64 mg/L, respectively. Minocycline decreased MAC bacterial burden below stasis in primary isolated macrophages. In the HFS-MAC model, minocycline achieved a microbial kill of 3.6 log10 cfu/mL below stasis. The AUC0-24/MIC exposure associated with a bactericidal effect was 59. Monte Carlo experiments identified a minocycline susceptibility MIC breakpoint of 16 mg/L. At this proposed breakpoint, the clinical dose of 200 mg/day achieved the bactericidal effect exposure target in ∼50% of patients, while 400 mg/day achieved this in 73.6% of patients, in Monte Carlo experiments.

Conclusions: Minocycline at a dose of 400 mg/day is expected to be bactericidal. We propose a clinical trial for validation.
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http://dx.doi.org/10.1093/jac/dkz143DOI Listing
July 2019

Outcomes of hypertonic saline inhalation as a treatment modality in nontuberculous mycobacterial pulmonary disease.

Eur Respir J 2019 07 11;54(1). Epub 2019 Jul 11.

Dept of Pulmonary Diseases, Radboud Center for Infectious diseases, Radboud University Medical Center, Nijmegen, The Netherlands

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http://dx.doi.org/10.1183/13993003.02143-2018DOI Listing
July 2019
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