Thursday, January 28, 2010

Iron Chelation, Cystic Fibrosis, COPD and Ventilators

Cystic Fibrosis is a terrible disease that involves a mutation in a gene that encodes for a chloride channel. The result of having a defective Chloride channel is that children with CF do not produce secretions well. Everything is too thick. CF patients sweat is too salty and respiratory mucous is too thick. It also negatively affects seamen production, and can be a reason for over-thick muconium in a neonate. The consequence of all this is that because the respiratory secretions in the lungs are so thick, the cilia in the airway cannot get rid of them well and consequently, bacteria set up shop in the lungs. Bacterial biofims of antibiotic-resistant gram negative bacteria usually get entrenched in the lungs causing recurrent pneumonias and an eventual early death. That is unless the patient can get a lung transplant. But that is just trading one problem for another (rejection) until we learn to genetically modify and grow organs.

After a while a typical CF patient will require more and more daily respiratory treatments to prevent pneumonia. These patients may spend up to 3 hours a day getting various antibiotic nebulization treatments and percussive treatments. Not long ago someone noticed that kids with CF who surfed had many less pneumonia infections and much better pulmonary function testing than CF kids who didn't surf. What researchers found was that the hypertonic saline in ocean water was working to kill some of the biofilms in the CF kids airway. Using hypertonic saline nebulization is now routine for CF.

Very new research has come out that another strategy is very effective at almost totally eliminating biofilms in the lungs of CF patients. Even nasty resistant B-lactimase producers like pseudomonas and burkholderia cepacia are no match. CF patients regularly receive nebulized aminoglycoside antibiotics and Polymixin B. If you add a safe iron chelator deferoxamine to the mix, the antibiotic tobramycin and deferoxamine work senergistically together to eliminate biofilms more that 90%.

Now this just isn't good new for CF patients, because CF patients are not the only ones with impaired ciliary motility and biofilm problems. COPD patients as well as all Ventilated patients could theoretically benefit from routine treatments with these cheap medicines. Vent patients are almost guaranteed 100% to contract what is called "ventilator-associated pneumonia" after being intubated for 7 days or more. And the bacterias that are responsible are usually the same nasty resistant gram negative pseudomonas and acenitobacter species that plague CF patients. The consequence of this is that if a patient is intubated for a week, they will likely be intubated for 2 weeks until they get over their VAP. And then there are a significant number of these patients who get a VAP that can't get off the vent unless they are trached. And then there is a number of trached patients who become permanently ventilator dependent.

I have done some research in the past involved with iron regulation, ferritin, and even worked with Deferoxamine, etc. I remember discussing the bacterio-static potential of deferoxamine with Dr. Watt and others, but I didn't know medicine at that time, so although we realized that limiting iron metabolism would limit bacterial growth, we didn't know how to apply it.

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