Repurposing fusidic acid as an antimicrobial against enterococci with a low probability of resistance development.

Drug repurposing constitutes a strategy to combat antimicrobial resistance, by using agents with known safety, pharmacokinetics, and pharmacodynamics. Previous studies have implemented new fusidic acid (FA) front-loading-dose regimens, allowing higher serum levels than those achievable with ordinary doses. As susceptibility breakpoints are affected by serum level, we evaluated the repurposing of FA as an antimicrobial product against enterococci. FA minimum inhibitory concentrations (MICs) against standard enterococci strains; Enterococcus faecalis ATCC 29212 and Enterococcus faecium ATCC 27270 were 2 and 4 µg/mL, respectively. The MIC against 98 enterococcal clinical isolates was ≤ 8 µg/mL; all would be susceptible if categorized according to recalculated breakpoints (≥ 16 µg/mL), based on the serum level achieved using the front-loading regimen. FA administration in vivo, using the BALB/c mouse infection model, significantly reduced bacterial burden by two to three log10 units in the liver and spleen of mice infected with vancomycin-susceptible and -resistant strains. Exposure of the standard enterococcal strains to increasing, but not fixed, FA concentrations resulted in resistant strains (MIC = 128 µg/mL), with thicker cell walls and slower growth rates. Only one mutation (M651I) was detected in the fusA gene of the resistant strain derived from serial passage of E. faecium ATCC 27270, which was retained in the revertant strain after passage in the FA-free medium. In conclusion, FA can be repurposed as an antimicrobial drug against enterococci with a low probability of mutational resistance development, and can be employed for treatment of infections attributable to vancomycin-resistant enterococci.

A pediatric HIV outbreak in Pakistan.

Background: Following reports of an outbreak of HIV infection among children in Larkana District, Pakistan, an international team investigated the extent and cause of the outbreak between April and June 2019. Aims: To investigate the incidence of HIV among children in Larkana District, Pakistan and describe the distribution of cases by time, place and person. Methods: Self-referred persons were tested for HIV using the national testing protocol. Local epidemiology of HIV was reviewed to generate hypotheses. An infection prevention and control (IPC) team conducted site visits and reviewed IPC practices. Results: Between 25 April and 27 June 2019, a total of 30 191 persons were tested for HIV in Larkana District, and 876 of them tested positive. Of those who tested positive, 719 (82%) were children aged <15 years. Traditional skin piercing procedures and transmission from high-risk populations to children were ruled out during the investigation. Informative interviews with parents or guardians of a convenience sample of 211 children aged <15 years showed that 99% of children had an injection or infusion for medical treatment within the past 12 months. Our investigation identified lack of HIV prevalence data for the general population including tuberculosis patients and those who attended antenatal care services. Conclusions: Investigations indicate that unsafe healthcare practices in formal and informal healthcare settings as the most likely cause of the 2019 outbreak of HIV infection in Larkana, Pakistan. Measures should be taken to improve IPC practices at the facility level, especially in pediatric and antenatal care clinics.

Identification of miR-106b-5p, miR-601, and miR-760 Expression and Their Clinical Values in Non-Small Cell Lung Cancer (NSCLC) Patients' Serum.

AIM: to explore the relative quantitative determination of the serum level of three miRNAs (miR-601, 760, and 106b-5p) and determine their expression pattern in non-small cell lung cancer (NSCLC) patients in comparison to controls. Also, to reveal each miRNA's diagnostic and prognostic impact on NSCLC patients. MATERIALS AND METHODS: Serum miR-106b-5p, 601, and 760 expression profiles were estimated by real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) for 70 NSCLC patients, age-matched with 30 control subjects. The receiver operating characteristic (ROC) curve analysis estimated their diagnostic and prognostic potentials. RESULTS: In comparison to the control, the miR-106b-5p expression pattern was upregulated (1.836 ± 0.254, p = 0.0012) while both miR-601 and miR-760 expression patterns were considerably downregulated (-0.586 ± 0.1906, p < 0.0001) and (-1.633 ± 0.152, p < 0.0001), respectively with predominant down-expression for miR-760 among cases. MiR-760 showed the highest diagnostic potential (AUC = 0.943 and 0.864 respectively), whereas miR-601 has a higher prognostic power (AUC = 0.771 and 0.682, respectively) for differentiating early stages (I/II) NSCLC patients from control subjects. Moreover, miR-760 presented the highest prognostic potential for differentiating NSCLC stages. CONCLUSION: Both serum miR-760 and miR-601 may be used as potential biomarkers of NSCLC in Egyptian patients with a stronger staging and diagnostic potential for miR-760.

Global Antimicrobial Resistance and Use Surveillance System on the African continent: Early implementation 2017-2019.

Background: Antimicrobial resistance (AMR) is becoming a critical public health issue globally. The World Health Organization launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) to support the strengthening of the AMR evidence base. Objective: The article describes the evolution of national AMR surveillance systems and AMR data reporting of countries in the African continent between 2017 and 2019, and the constraints, perceived impact and value of the participation in GLASS. Methods: Data on implementation of national surveillance systems and AMR rates were submitted to GLASS between 2017 and 2019 and summarised though descriptive statistics. The information on constraints and perceived impact and value in GLASS participation was collected though a set of questionnaires. Results: Between 2017 and 2019, Egypt, Ethiopia, Madagascar, Malawi, Mali, Mozambique, Nigeria, South Africa, Sudan, Tunisia, Uganda and Zambia submitted data to GLASS. The main constraints listed are linked to scarce laboratory capacity and capability, limited staffing, budget issues, and data management. Moreover, while the data are not yet nationally representative, high resistance rates were reported to commonly-used antibiotics, as the emerging resistance to last treatment options. Conclusion: Despite the limitations, more and more countries in the African continent are working towards reaching a status that will enable them to report AMR data in a complete and systematic manner. Future improvements involve the expansion of routine surveillance capacity for several countries and the implementation of surveys that allow to effectively define the magnitude of AMR in the continent.

The Untargeted Phytochemical Profile of Three Meliaceae Species Related to In Vitro Cytotoxicity and Anti-Virulence Activity against MRSA Isolates.

BACKGROUND: A high mortality rate is associated with about 80% of all infections worldwide, mainly due to antimicrobial resistance. Various antimicrobial and cytotoxic activities have been proposed for Meliaceae species. This study aimed to evaluate the in vitro anti-virulence and cytotoxic effect of the leaf extracts of Aphanamixis polystachya, Toona ciliata and Melia azedarach against five MRSA strains and on three cancer cell lines, followed by biological correlation to their encompassed phytoconstituents. MATERIAL AND METHODS: We explored three plants of this family against a panel of Methicillin-resistant Staphylococcus aureus (MRSA) strains and several cancer cell lines to select the most promising candidates for further in vivo and preclinical studies. The phytochemical composition was evaluated by UHPLC-QTOF-MS untargeted profiling. Cell viability was assessed by SRB assay. Minimum Inhibitory Concentration was carried out by using the agar micro-dilution technique. Inhibition of biofilm formation and preformed biofilm disruption were assessed spectrophotomertically, according to the Sultan and Nabil method (2019). RESULTS: A total of 279 compounds were putatively annotated to include different phytochemical classes, such as flavonoids (108), limonoids/terpenoids (59), phenolic acids (49) and lower-molecular-weight phenolics (39). A. polystachya extract showed the most potent cytotoxic activity against Huh-7, DU-145 and MCF-7 cell lines (IC50 = 3, 3.5 and 13.4 µg mL-1, respectively), followed by M. azedarach, with no effect recorded for T. ciliata extract. Furthermore, both A. polystachya and M. azedarach extracts showed promising anti-virulence and antimicrobial activities, with A. polystachya being particularly active against MRSA. These two latter extracts could inhibit and disrupt the biofilm, formed by MRSA, at sub-lethal concentrations. Interestingly, the extracts inhibited hemolysin-α enzyme, thus protecting rabbit RBCs from lysis. A. polystachya extract reduced the pigmentation and catalase enzyme activity of tested pigmented strains better than M. azedarach at both tested sub-MICs. Consequently, susceptibility of the extract-treated cells to oxidant killing by 200 mM H2O2 increased, leading to faster killing of the cells within 120 min as compared to the extract-non-treated cells, likely due to the lower antioxidant-scavenging activity of cells exhibiting less staphyloxanthin production. CONCLUSION: These findings suggested that both A. polystachya and M. azedarach natural extracts are rich in bioactive compounds, mainly limonoids, phenolics and oxygenated triterpenoids, which can combat MRSA biofilm infections and could be considered as promising sources of therapeutic cytotoxic, antibiofilm and anti-virulence agents.

Exploring the Antivirulence Activity of Pulverulentone A, a Phloroglucinol-Derivative from Callistemon citrinus Leaf Extract, against Multi-Drug Resistant Pseudomonas aeruginosa.

(1) Background: Bacterial resistance to antibiotics is a global life-threatening issue. Antivirulence therapy is a promising approach to combat bacterial infections as it disarms the bacteria from their virulence factors with reduced selective pressure and a lower chance of resistance. (2) Methods: Callistemon citrinus leaf extract and its major constituent, Pulverulentone A, were tested for their ability to inhibit biofilm, exopolysaccharides, pyocyanin and proteases produced by MDR P. aeruginosa. In addition, a Galleria mellonella larvae model was employed to evaluate the in vivo cytotoxicity of Pulverulentone A and its ability to combat Pseudomonas infection. Docking study was further performed to investigate Pulverulentone A druggability against main quorum sensing (QS) targets expressed by P. aeruginosa; (3) Results: Both C. citrinus extract and the isolated compound could inhibit biofilm formation, extracellular polymeric substances (EPS) and pigment production by the tested isolates. Unexpectedly, no significant inhibition was observed on proteases production. The in silico docking analysis revealed good interactions of Pulverulentone A with all QS targets examined (LasR, MyfR/PqsR, QscR). Pulverulentone A was safe up to 400 µg·mL-1 in Galleria caterpillars. Moreover, pre-treatment of P. aeruginosa with Pulverulentone A slightly enhanced the survival of the infected larvae. (4) Conclusions: The present study proves Pulverulentone A safety with significant in vitro and in silico antivirulence potential against P. aeruginosa.

Correlation Between Tumor Infiltration CD8+ T-cells And PD-L1 Expression In Laryngeal Cancer And Their Prognostic Significance: Prospective Non-interventional Trial.

INTRODUCTION: Tumor microenvironment plays crucial role in cancer evolution. There is a dynamic and continuous relation between immune cells and cancer cells' resistance. Tumor infiltration CD8-lymphocytes and programmed death ligand-1 have proved important prognostic role in different malignancies. We aimed at evaluating this role in laryngeal cancer. PATIENTS AND METHODS: We prospectively analyzed laryngeal cancer patients' specimens, to identify the CD8-lymphocytes and the PD-L1 expression. A total score formed of the sum of percentage and intensity of PD-L1. A final rate was considered as negative or low when combined percentage and intensity scores 0 to 4, and high when scores 5-7. CD8-lymphocyte infiltration was divided into strong (= 10/100 of epithelial cells or =20/100 stromal cell infiltration) or weak (<10/100 epithelial cells or <20/100 stromal cell infiltration). RESULTS: Forty patients were included; twelve had stage 1 or 2 and 28 with advanced stages. PD-L1 expressionwas positive in 92.5%. Neither the PD-L1 nor CD8- lymphocytes had overall survival impact, however high PD-L1 correlated with better survival in advanced stage subgroup (p = 0.036), high CD8-lymphocytes infiltration had better survival but did not reach significance. Therewas significant correlation between the CD8-lymphocyte infiltration; whether epithelial or stromal, and tumor PD-L1 expression; p-value of 0.001 and < 0.0001 respectively. Subgroup of patients with low CD8+ infiltration and low PD-L1 had the worst survival. CONCLUSION: There is a correlation between CD8- l lymphocytes infiltration and PD-L1 expression inlaryngeal cancer and high PD-L1 expression is associated with better OS in advanced stages. Key words: PD-L1, CD8, laryngeal cancer, tumor microenvironment.

Pimenta Oil as A Potential Treatment for Acinetobacter Baumannii Wound Infection: In Vitro and In Vivo Bioassays in Relation to Its Chemical Composition.

Bacterial biofilm contributes to antibiotic resistance. Developing antibiofilm agents, more favored from natural origin, is a potential method for treatment of highly virulent multidrug resistant (MDR) bacterial strains; The potential of Pimenta dioica and Pimenta racemosa essential oils (E.Os) antibacterial and antibiofilm activities in relation to their chemical composition, in addition to their ability to treat Acinetobacter baumannii wound infection in mice model were investigated; P. dioica leaf E.O at 0.05 µg·mL-1 efficiently inhibited and eradicated biofilm formed by A. baumannii by 85% and 34%, respectively. Both P. diocia and P. racemosa leaf E.Os showed a bactericidal action against A. baumanii within 6h at 2.08 µg·mL-1. In addition, a significant reduction of A. baumannii microbial load in mice wound infection model was found. Furthermore, gas chromatography mass spectrometry analysis revealed qualitative and quantitative differences among P. racemosa and P. dioica leaf and berry E.Os. Monoterpene hydrocarbons, oxygenated monoterpenes, and phenolics were the major detected classes. ß-Myrcene, limonene, 1,8-cineole, and eugenol were the most abundant volatiles. While, sesquiterpenes were found as minor components in Pimenta berries E.O; Our finding suggests the potential antimicrobial activity of Pimenta leaf E.O against MDR A. baumannii wound infections and their underlying mechanism and to be further tested clinically as treatment for MDR A. baumannii infections.

Effects of nitroglycerin versus labetalol on peripheral perfusion during deliberate hypotension for sinus endoscopic surgery: a randomized, controlled, double-blinded trial.

BACKGROUND: Deliberate hypotension is used to provide a bloodless field during functional endoscopic sinus surgery; however, the impact of controlled hypotension during anesthesia on peripheral tissue perfusion has not been extensively evaluated. The aim of this study was to compare the impact of nitroglycerin- versus labetalol-induced hypotension on peripheral perfusion. METHODS: The present randomized, double-blinded, controlled trial included adult patients undergoing endoscopic sinus surgery. Patients were allocated to one of two groups according to the drug received for induction of deliberate hypotension: nitroglycerin (n = 20) or labetalol (n = 20). Mean arterial pressure was maintained at 55-65 mmHg in both groups. Both study groups were compared according to pulse oximeter-derived peripheral perfusion index (primary outcome), serum lactate level, mean arterial pressure, heart rate, surgical field score, and intraoperative blood loss. RESULTS: Forty patients were included in the final analysis. The nitroglycerin group exhibited a higher peripheral perfusion index at nearly all records (p < 0.0001) and lower postoperative serum lactate levels (1.3 ± 0.2 mmol/L vs. 1.7 ± 0.4 mmol/L; p = 0.001) than the labetalol group. The peripheral perfusion index was higher in the nitroglycerin group than at baseline at most intraoperative readings. The median surgical field score was modestly lower in the labetalol group than in the nitroglycerin group in the first 20 min (2 [interquartile range (IQR) 2-2.5] versus 1.5 [IQR 1-2]; p = 0.001). Both groups demonstrated comparable and acceptable surgical field scores in all subsequent readings. CONCLUSION: Nitroglycerin-induced deliberate hypotension was accompanied by higher peripheral perfusion index and lower serum lactate levels than labetalol-induced deliberate hypotension during sinus endoscopic surgery. TRIAL REGISTRATION: The study was registered at clinicaltrials registry system with trial number: NCT03809065. Registered at 19 January 2019. This study adheres to CONSORT guidelines.

Optimization of ß-cyclodextrin consolidated micellar dispersion for promoting the transcorneal permeation of a practically insoluble drug.

Development of efficient ocular drug delivery system for antifungal drugs becomes a must nowadays to face and eradicate the widely spread ophthalmic fungal infections. Itraconazole, a triazole antifungal, is struggling to penetrate the cornea and subsequently, its efficacy is limited. The aim of this study was to enhance itraconazole corneal penetration through utilizing the minimum surfactant amount in presence of ß-cyclodextrin which acted as a dissolution and permeation enhancer. ß-Cyclodextrin consolidated micellar dispersions (CCMD) were prepared after an initial screening to select the composition of surfactant(s). The preparation was done according to a modified melt dispersion technique. The prepared CCMD were characterized through the analysis of their particle size, zeta potential and solubilization efficiency. The optimum formula was chosen based on a factorial response surface analysis and it was composed of 17:1 w/w surfactant/drug, 30:1 w/w cyclodextrin/drug ratios and 0.02% polyethylene oxide. This formula was subjected to in vitro characterization including release, imaging by transmission electron microscope, mucoadhesion, stability, in addition to the determination of the minimum inhibitory concentration. Moreover, the ex vivo/in vivo permeation, safety and efficacy profiles were determined. The optimized CCMD formula was found to be significantly safe, stable, mucoadhesive and efficient to permeate the drug through rabbits' corneas. Consequently, the optimized CCMD formulation can be a promising, safe and efficient platform for the transcorneal delivery of lipophilic drugs including most antifungals.

Remediation of a mixture of analgesics in a stirred-tank photobioreactor using microalgal-bacterial consortium coupled with attempt to valorise the harvested biomass.

An artificial microalgal-bacterial consortium was used to remediate a mixture of analgesics (ketoprofen, paracetamol and aspirin) in a stirred-tank photobioreactor. A hydraulic retention time (HRT) of 3days supported poor treatment because of the formation of p-aminophenol (paracetamol toxic metabolite). Increasing the HRT to 4days enhanced the bioremediation efficiency. After applying an acclimatization regime, 95% removal of the analgesics mixture, p-aminophenol and COD reduction were achieved. However, shortening the HRT again to 3days neither improved the COD reduction nor ketoprofen removal. Applying continuous illumination achieved the best analgesics removal results. The harvested biomass contained 50% protein, which included almost all essential amino acids. The detected fatty acid profile suggested the harvested biomass to be a good biodiesel-producing candidate. The water-extractable fraction possessed the highest phenolic content and antioxidant capacity. These findings suggest the whole process to be an integrated eco-friendly and cost-efficient strategy for remediating pharmaceutical wastewater.

Biodegradation of ketoprofen using a microalgal-bacterial consortium.

OBJECTIVE: To test the toxicity of ketoprofen (a commonly-used NSAIDs) using two microalgal strains and Artemia sp. following the isolation of bacterial and microalgal strains and testing their ability to biodegrade and tolerate ketoprofen. RESULTS: Chlorella sp. was the most resistant to ketoprofen. A defined bacterial consortium (K2) degraded 5 mM ketoprofen as a sole carbon source both in the dark or continuous illumination. Ketoprofen did not undergo photodegradation. In the dark, biodegradation was faster with a lag phase of 10 h, 41% COD removal and 82 % reduction in toxicity. The consortium degraded up to 16 mM ketoprofen. The consortium was composed of four bacterial isolates that were identified. MS/MS analysis suggested a ketoprofen biodegradation pathway that has not been previously reported. Combining Chlorella sp. and the K2 consortium, ketoprofen was degraded within 7 days under a diurnal cycle of 12 h light/12 h dark. CONCLUSION: The feasibility of using a microalgal-bacterial system to treat pharmaceutical wastewater is promising for the reduction of the process cost and providing a safer technology for pharmaceutical wastewater treatment.

Circulating Serum miRNAs as Diagnostic Markers for Colorectal Cancer.

AIM: The study was designed to assess the possibility of using circulating miRNAs (serum miRNAs) as diagnostic biomarkers in colorectal cancer (CRC) and to identify their possibility as candidates for targeted therapy. METHODS: The study involved two sample sets: 1- a training set which included 90 patients with colorectal related disease (30 with CRC, 18 with inflammatory bowel disease (IBD), 18 with colonic polyps (CP) and 24 with different colonic symptoms but without any colonoscopic abnormality who were enrolled as control group) and 2- a validation set which included 100 CRC patients. Serum miRNAs were extracted from all subjects to assess the expression profiles for the following miRNAs (miR-17, miR-18a, miR-19a, miR-19b, miR-20a, miR-21, miR-146a, miR-223, miR-24, miR-454, miR-183, miR-135a, miR- 135b and miR- 92a) using the custom miScript miRNA PCR-based sybergreen array. The area under the receiver operating characteristic curve (AUC) was used to evaluate the diagnostic performance of the studied miRNAs for colorectal cancer diagnosis. RESULTS: Data analysis of miRNA from the training set showed that; compared to control group, only miR-19b was significantly up-regulated in patients with IBD group (fold change = 5.24, p = 0.016), whereas in patients with colonic polyps, miR-18a was significantly up-regulated (fold change = 3.49, p-value = 0.018). On the other hand, miR-17, miR-19a, miR-20a and miR-223 were significantly up-regulated (fold change = 2.35, 3.07, 2.38 and 10.35; respectively and p-value = 0.02, 0.015, 0.017 and 0.016; respectively in CRC patients. However, the validation set showed that only miR-223 was significantly up-regulated in CRC patients (fold change = 4.06, p-value = 0.04). CONCLUSION: Aberrant miRNA expressions are highly involved in the cascade of colorectal carcinogenesis. We have found that (miR-17, miR-19a, miR-20a and miR-223) could be used as diagnostic biomarkers for CRC. On the other hand, miR-19b and miR-18a could be used as diagnostic biomarkers for CP and IBD respectively.

Relation of Osteoprotegerin, Visfatin and Ghrelin to Metabolic Syndrome in Type 2 Diabetic Patients.

BACKGROUND: It is now realized that insulin resistance plays a principal role in initiating the pathologic manifestations of the metabolic syndrome (MetS). OBJECTIVES: The aim of this study was to assess the possible role of osteoprotegerin, visfatin and ghrelin in the pathogenesis of MetS among type 2 diabetes mellitus (T2DM). DESIGN AND METHODS: Serum blood samples were obtained from 116 subjects (39 T2DM; 48 T2DM with MetS; 29 healthy controls). Glycemic status and lipid profile were assessed by enzymatic method. Osteoprotegerin, visfatin, ghrelin and insulin were measured by ELISA method. RESULTS: Osteoprotegerin and visfatin were significantly higher, while ghrelin was significantly lower in diabetic patients compared to healthy control group (p<0.05). Moreover, Osteoprotegerin and visfatin showed significant higher levels in T2DM patients with MetS than those without MetS (p<0.05). The best cut-off values for the investigated markers were determined by ROC curve. Osteoprotegerin (1.06 ng/mL), visfatin (32.27 ng/mL) and ghrelin (33.65 pg/mL) presented sensitivity of 76%, 92% and 39.1%; respectively and specificity of 41%, 69.2% and 62.9%; respectively, in predicting MetS among T2DM. Among the investigated parameters, Visfatin was the one which predicts MetS among diabetic patients [AUC=0.88, p<0.05]. CONCLUSION: Osteoprotegerin, visfatin and ghrelin might be implicated in the pathogenesis of diabetes. Moreover, osteoprotegerin and visfatin may have additional potential role in the development of the metabolic syndrome. Visfatin was superior among studied parameters in predicting MetS among T2DM.

The response of rat submandibular salivary gland to plant protein diet; Biological and histochemical study.

OBJECTIVE: This investigation aimed at studying the effect of plant protein diets on the salivary glands. It compares 3 protein's types on the submandibular gland structure and function. The submandibular gland was chosen because it contains all the elements of the salivary glands. The different protein types were chosen to answer if the plant protein or legume plant protein can be replaced for the animal proteins. METHODS: Thirty young albino rats were divided into 3 dietary groups: group I was fed 10% skim milk and acts as a control, group II was fed corn that is a cereal plant protein, while group III was fed 10% soybean, which is a legume plant protein. The animals were sacrificed after 2 months from the beginning of the experiment and the submandibular salivary glands were prepared for the biochemical analysis and histological, as well as, histochemical studies. RESULTS: The biochemical analysis revealed that total protein in soybean fed group was nearly the same as that of the control, while being significantly decreased in the corn fed group. The histological appearance of the submandibular salivary gland of both study groups showed shrinkage in the acini and ducts. The histochemical results showed an intense precipitation for total protein in the soybean group, while the corn fed group showed a mild precipitation. The reaction for DNA and RNA was intense in the control group as compared with both study groups. CONCLUSION: From this study, it was apparent that the plant protein had adverse effects on the submandibular salivary gland and impairs its function. Thus, plant protein including the soybean cannot replace animal protein which is ideal for the normal growth and function of the gland.

Cilomilast: orally active selective phosphodiesterase-4 inhibitor for treatment of chronic obstructive pulmonary disease.

OBJECTIVE: To review available literature evaluating the pharmacology, pharmacokinetics, clinical efficacy, and adverse effects of cilomilast, a selective phosphodiesterase-4 (PDE4) inhibitor. DATA SOURCES: Literature was accessed through MEDLINE (1966-May 2006), Current Contents Clinical Medicine (1998-May 2006), and The Cochrane Library Database (1st quarter 2006) using the terms cilomilast, Ariflo, and SB 207 499. Reference lists from retrieved articles and information from the manufacturer were manually reviewed. STUDY SELECTION AND DATA EXTRACTION: All clinical trials evaluating cilomilast and published in English were included in this review. In addition, articles evaluating the pharmacology, pharmacokinetics, and safety of cilomilast in humans were reviewed. DATA SYNTHESIS: Cilomilast is a second-generation PDE4 inhibitor with antiinflammatory effects that target bronchoconstriction, mucus hypersecretion, and airway remodeling associated with chronic obstructive pulmonary disease (COPD). Selective PDE4 inhibition is proposed to maximize the antiinflammatory effects of PDE inhibition while minimizing the adverse effects of nonselective agents. To date, 4 clinical trials have evaluated the efficacy of cilomilast and demonstrated improvement in lung function (forced expiratory volume in 1 second) and quality of life and reduction in the occurrence of COPD exacerbations compared with placebo. Cilomilast is generally well tolerated, with adverse effects being overall mild and self-limiting. CONCLUSIONS: COPD is a progressive disease, and available treatment options provide limited efficacy. Given its unique mechanism of action and improved adverse effect profile compared with previous agents, cilomilast may have a promising role for the management of COPD.