Initial and Chronic Methicillin Resistant Staphylococcus Aureus (MRSA) Infection in Cystic Fibrosis (CF)
Initial and Chronic Methicillin Resistant Staphylococcus Aureus (MRSA) Infection in Cystic Fibrosis (CF)
This study aims to examine features of MRSA that are associated with chronic MRSA infection
 and bacterial persistence despite IV antibiotic therapy. Subjects are asked to expectorate
 sputum and complete CF symptom diaries both at beginning and end of IV therapy.
This is an observational, translational study examined bacterial morphology and function pre-
 vs. post antibiotic therapy in patients with CF who experience a pulmonary exacerbation that
 requires IV antibiotics.

 All clinical care is dictated by the treating physician(s).

 Inclusion criteria:

 1. Male or female with a confirmed diagnosis of CF (by sweat test and/or identification of
 2 CF disease causing mutations).

 2. Chronic infection with MRSA defined as having had MRSA positive respiratory cultures for
 > 1 year with > 50% of cultures being MRSA positive.

 3. Being able to expectorate sputum on a consistent basis, i.e. also at the end of IV
 therapy 3A: starting April 2017 people with CF who cannot expectorate sputum can also
 participate if they will do two orapharyngeal swab cultures.

 4. Having a pulmonary exacerbation defined for this protocol as the decision of the
 treating physician to start IV therapy in hospital or at home. Typically this occurs
 when there has been a >5% drop in FEV1 % predicted compared to the patient's baseline
 and increased respiratory symptoms.

 1. NOTE: Patients who had oral or inhaled antibiotics with or without MRSA activity
 but failed i.e. are changed to IV antibiotics are allowed to participate.

 Exclusion criteria:

 1. Presence / infection with B. cepacia genomovar III (B. cenocepacia)

 2. Subjects who have undergone lung or liver transplant in the past (NOTE: patients listed
 for transplant are eligible)

 3. Concomitant participation and/or use of an investigational drug within 30 days of this
 study. Concomitant observational studies are allowed with TRI-STAR

 Sputum collection:

 The subject will be asked to expectorate a sputum into a sterile specimen cup solely for this
 study. This may be a second sample after giving one for the clinical laboratory at start of
 therapy. The subject will be asked for a repeat sputum sample for the study at end of
 therapy.

 Time point definition: A) Start of therapy sample: up to 3 days prior and up to 36 hours
 after the first dose of anti-MRSA antibiotic. B) End of therapy: no earlier than 36 hours
 prior to the last dose and up to one week after completion.

 Collection of clinical information: Clinical information to be collected include:
 Demographics, age, CF genotype, anthropometrics; FEV1 FVC, FEF 25-75 in liter and % predicted
 per site specific reference values; all medications (routine and those started within 2 weeks
 and at time of admission/IV therapy).

 CF daily Symptom score: Subject will be asked to complete the CF Symptom diary for the first
 and last 3 days of IV therapy. For subjects admitted to the hospital this will be
 administered by the RC for those at home the RC will call / e-mail them as reminder or do it
 with them per phone.

 Spirometry at conclusion of therapy: Most patients have a follow-up clinic visit or are still
 in the hospital at time of completion of IV therapy and spirometry is part of routine
 clinical assessment. NOTE: Patients who would not have a clinic visit at end of therapy may
 be asked to return for spirometry and sputum sample solely for this study. If the subject
 agrees to this, reimbursement for travel will be allowed.

 Laboratory Assays:

 In vitro assays done on either banked isolates in Aim 1 or sputum samples / MRSA isolates
 from sputum include tests on bacterial fitness as growth under different conditions;
 antibiotic susceptibility assays; metabolic and virulence activity and genes, and mutator
 rates for sputum isolates. More details are provided in the grant application.
Inclusion Criteria:

 1. Male or female with a confirmed diagnosis of CF (clinical features and positive sweat
 test and/or identification of 2 CF disease causing mutations).

 2. At least 4 years of age or older.

 3. Chronic infection with MRSA defined as having had MRSA positive respiratory cultures
 for > 1 year with ≥ 50% of cultures being MRSA positive e.g. 2/4 of the most recent
 cultures grew MRSA.

 4. Being able to expectorate sputum on a consistent basis, i.e. also at the end of IV
 therapy.

 5. Having a pulmonary exacerbation defined for this protocol as the decision of the
 treating physician to start IV therapy in hospital or at home. Typically this occurs
 when there has been a >5% drop in FEV1 % predicted compared to the patient's baseline
 and increased respiratory symptoms.

 NOTE: Patients who had oral or inhaled antibiotics with or without MRSA activity but failed
 this outpatient therapy i.e. are changed to IV anti-MRSA antibiotics are allowed to
 participate.(Example: was on oral doxycycline and on admission changed to ceftaroline =
 eligible. On oral doxycycline that is continued on admission = not eligible).

 -  Patient enrollment should be prioritized to those receiving IV vancomycin or
 ceftaroline, with secondary consideration of patients who receive oral anti-MRSA
 therapy (TMP-SMX or a tetracycline derivative) that was initiated on hospital
 admission.

 -  Patients on linezolid will not be included as this medication is given orally and IV
 and may confound analyses.

 Exclusion Criteria:

 1. Presence / infection with B. cepacia genomovar III (=B. cenocepacia). Subjects who
 have undergone lung or liver transplant in the past (NOTE: patients listed for
 transplant are eligible)

 2. Concomitant participation and/or use of an investigational drug within 30 days of this
 study.

 3. Concomitant observational studies are allowed with TRI-STAR, if approved by the other
 study investigator or their proxy.