ORIGINAL ARTICLE: PANCREATOLOGY

Decreased Fecal Calprotectin Levels in Cystic Fibrosis

Patients After Antibiotic Treatment for
Downloaded from http://journals.lww.com/jpgn by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

Respiratory Exacerbation
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 04/02/2023

y yz y§jj y§jj yz

Zeev Schnapp, Corina Hartman, Galit Livnat, Michal Shteinberg, and Yigal Elenberg

ABSTRACT

Objectives: In all patients with cystic fibrosis (CF), gastrointestinal (GI)

What Is Known
tract CF transmembrane conductance regulator dysfunction occurs early in
life. The identical pathophysiological triad of obstruction, infection, and  The majority of patients with cystic fibrosis are pan-
inflammation causes disease of the airways and in the intestinal tract (CF
creatic insufficient, resulting in maldigestion and
enteropathy). Mucus accumulation within GI tract is a niche for abnormal
malabsorption of nutrients, and thus contributing
microbial colonization, leading to dysbiosis. Fecal calprotectin (FC) is a
to gastrointestinal tract dysfunction (cystic fibrosis
neutrophil cytosolic protein released during apoptosis and necrosis and
enteropathy).
reflects inflammatory status. Systemic antibiotic treatment for pulmonary  Fecal calprotectin is used as an indicator for
exacerbations has been shown to improve systemic inflammatory markers
intestinal inflammation.
and serum and sputum calprotectin. Antibiotic treatment aimed at pulmo-  Sputum and serum calprotectin levels decreased
nary complaints may improve GI tract inflammatory status. We hypothe-
during antibiotic treatment of acute pulmonary
sized that high levels of FC present during pulmonary exacerbation are due,
exacerbations.
in part, to multiorgan dysbiosis and thus should diminish with systemic  Baseline levels of fecal calprotectin are higher in
antibiotic treatment.
pancreatic insufficient cystic fibrosis patients.
Methods: This prospective pilot study enrolled 14 patients with CF, with no
current GI symptoms. FC levels and lung function were measured at the
What Is New
beginning and end of systemic antibiotic treatment.
Results: Compared to preantibiotic treatment baseline values, end of  Patients with cystic fibrosis have elevated fecal cal-
treatment FC levels declined significantly after antibiotic treatment,
protectin levels during pulmonary exacerbation even
P ¼ 0.004 and similarly, there was significant improvement in forced
when there are no indications of gastrointestinal
expiratory volume in 1 second, P ¼ 0.002.
symptoms.
Conclusions: High levels of FC during respiratory exacerbation may reflect  Our study shows that elevated levels of fecal calpro-
a systemic exacerbation rather than solely pulmonary. Antibiotic treatment
tectin during pulmonary exacerbation in cystic fibro-
lowered the FC levels possibly by its impact on the intestinal microbiome.
sis patients respond to systemic antibiotic treatment.
Key Words: calprotectin, cystic fibrosis, gastrointestinal inflammation

(JPGN 2019;68: 282–284)

C ystic fibrosis (CF) is the most common life-shortening,

recessive disease in Caucasians, with an average life expec-
tancy of 40 years. The CF transmembrane conductance regulator
(CFTR) protein is expressed on the apical surface of epithelial cells
and functions as a cyclic adenosine monophosphate-dependent
chloride-bicarbonate channel. Absent or defective CFTR leads to
Received August 1, 2018; accepted October 20, 2018.
From the Department of Pediatrics, Lady Davis Carmel Medical Center,
the ythe B. Rappaport Faculty of Medicine, Technion-Israel Institute of
Technology, the zPediatric Gastroenterology Unit, the §Pediatric
Pulmonology Unit and CF Center, and the jjPulmonology Institute,
Lady Davis Carmel Medical Center, Haifa, Israel.
Address correspondence and reprint requests to Zeev Schnapp, MD,
Department of Pediatrics, Lady Davis Carmel Medical Center, Michal 7
st., Haifa, Israel (e-mail: ZeevSc@clalit.org.il).
The authors report no conflicts of interest.
Copyright # 2018 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000002197
viscous luminal secretions in the affected organs, particularly lungs,
intestines, and pancreas (1).
The majority of patients with CF are pancreatic insufficient
(PI), resulting in maldigestion and malabsorption of nutrients and
thus contributing to gastrointestinal (GI) tract dysfunction (CF
enteropathy) (2).
Werlin et al (3) showed that mucosal ulcerations, erythema,
and breaks were observed by capsule endoscopy in 20 of 28 (71%)
patients with CF and PI, adding evidence of the presence of
intestinal inflammation. In their study, 18 of 21 (85%) patients
with PI also had elevated fecal calprotectin (FC) levels.
Calprotectin is a calcium- and zinc-binding protein that
makes up to 60% of cytosolic proteins in neutrophils, which is
released during apoptosis or necrosis. It contributes to inflammatory
process regulation and has antibacterial, antifungal, and antiproli-
ferative properties. In the intestine, calprotectin is mainly derived
from neutrophils and eosinophils (4). FC levels were significantly
higher in underweight patients with CF older than 18 years with PI,
CF-related diabetes mellitus, reduced lung function, and chronic
Pseudomonas aeruginosa airways colonization (5). Sputum and

282 JPGN  Volume 68, Number 2, February 2019

Copyright © ESPGHAN and NASPGHAN. All rights reserved.

 JPGN  Volume 68, Number 2, February 2019
serum calprotectin levels decreased during antibiotic treatment of
acute pulmonary exacerbations (6,7).
The aim of this study was to assess CF patients’ GI inflam-
matory burden as expressed by FC levels before and after systemic
antibiotic treatment for respiratory exacerbation.
Downloaded from http://journals.lww.com/jpgn by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
METHODS
Study Population
This prospective study was conducted between January 1,
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 04/02/2023
2017 and December 31, 2017. The study enrolled 14 patients older
than 1 year with CF who were admitted to Carmel Medical Center’s
Pediatric Department for systemic antibiotic treatment for an acute
respiratory exacerbation. Patients with GI symptoms were
excluded. The study protocol was approved by the institutional
review board and written consent was obtained from all the adult
patients and guardians of children and adolescents.
Collection of Stool Samples, Procedures,
and Definitions
Stool sample were collected from each of the 14 patients
during their hospitalization within the first 24 hours of admission
and at day 10 to 14 of treatment. Quantification of FC was
performed by DiaSorin Liaison and FC levels were expressed in
mg/g (normal FC level is <50 mg/g).
Spirometry was performed in the pulmonary physiology
laboratory. Values of forced expiratory volume in 1 second
(FEV1.0) were expressed as percentage of predicted normal values
when adjusted for age, gender, sex, height, and weight.
Statistical Analysis
Statistical analyses were performed using IBM statistics
(SPSS) version 22. Wilcoxon sign rank test was used to test
correlation between FC and other variables. A P value of <0.05
was considered to be significant.
RESULTS
Subjects’ Characteristics
The baseline characteristics of the study subjects are sum-
marized in Table 1.
Fecal Calprotectin and Spirometric Tests
Pretreatment FC levels declined significantly between the
onset of antibiotic therapy and the second measurement at day 10 to
14 of treatment. Similarly, there was a significant improvement in
FEV1.0 between therapy onset and day 10 to 14 of therapy
(Table 2).
TABLE 1. Patient and sample characteristics for cystic fibrosis patients
Median age (y) at time of sample collection, median (range) 25.5 (6–44)
Sex (m/f) 6/8
Ethnic origin
Jewish 4
Arabic (Muslim/Christian) 10 (9/1)
Age of diagnosis, mo, median (range) 9 (0–72)
Pancreatic insufficiency, n (%) 14 (100)
www.jpgn.org
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
Decreased FC Levels in CF Patients After Antibiotic Treatment
TABLE 2. Fecal calprotectin, forced expiratory volume in 1 second,
and body mass index parameters
Start of treatment End of treatment P
FC mean mg/g (range) 421.14 (21–3550) 102.50 (6–627) 0.004
FEV1.0% predicted 59.6 (22–98) 67.1 (24.3–109) 0.002
mean (range)
FC ¼ fecal calprotectin, FEV1.0 ¼ forced expiratory volume in 1 second.
DISCUSSION
CF is a multisystem disease with an increased incidence of
GI tract inflammation. The typical triad of mucus stasis, infection,
and inflammation occurs in both intestine and respiratory tract.
CFTR gene is highly expressed in the GI tract and other than the
basic genetic defect, chronic use of antibiotics and pancreatic
enzymes, altered bowel motility, and gut microbiome have also
been associated with intestinal inflammation (3,8).
As shown by Parisi et al (5) baseline levels of FC are higher
in PI CF patients without respiratory exacerbation. Our study
showed that use of systemic antibiotics for treating respiratory
exacerbation was associated with decreased FC levels as compared
to pretreatment values.
Despite the unknown baseline FC levels, we observed
decline in FC suggests that treating inflammation in one system
(respiratory) may induce changes within another (GI). CF pulmo-
nary exacerbation may represent part of a systemic inflammatory
exacerbation which includes the GI tract, even with no GI com-
plaints, possibly representing ‘‘silent’’ GI inflammation. Antibiotic
treatment may alter the microbiome in both organs reducing the
inflammatory burden.
Calprotectin can be measured in several body fluids (eg,
sputum and blood), and its level in stool may be partially due to
swallowed respiratory secretions. We, however, like Adriaanse et al
(8), think sputum levels do not grossly change FC levels, most
logically because sputum calprotectin protein is being partially
degraded in the GI tract.
The observed decrease in FC levels after 10 to 14 days of
antibiotic treatment may result from various possible mechanisms:
First, CF gut dysmotility can be influenced by the prokinetic
properties of certain antimicrobial agents (such as erythromycin)
and thus antibiotic treatment of these patients helped promote GI
motility thus lowering the inflammatory burden.
Second, small intestinal bacterial overgrowth, a disease state
in which the bacterial burden in the small intestine exceeds 106
colony-forming units/1 mL in intestinal sampled fluid (9) may
contribute to dysmotility. Studies in germ-free rats demonstrated
faster small bowel transit compared to those with typical microbial
flora. Intestinal transit through the small bowel was increased or
decreased by colonization of the bowel with specific bacterial
species (10). Escherichia coli, which is overabundant in young
children with CF, has been shown to impede intestinal motility (11).
In addition to the unique niche formed by static mucus in the
CF intestine, other factors contribute to microbial dysbiosis in CF
such as the need for periodic courses of antibiotics in addition to
chronic antibacterial therapy to combat airway infection. Even
when administered by inhalation, significant amounts of antibiotics
will be ingested and thus also affect the GI tract flora (12).
Herein we conclude that dysbiosis, dysmotility, and small
intestinal bacterial overgrowth are interconnected and may be
modified by antimicrobial agents. In this study, patients were
treated with systemic courses of different antibiotics for 10 to 14
days. Although the type of antibiotic varied between patients, they
283
 Schnapp et al
were mostly broad spectrum antimicrobial agents. Such treatments
most likely contribute to differences in gut flora.
The study has several limitations including the small number
of patients, use of different antibiotic regimens, and lack of baseline
FC levels. Microbiome analysis, which might have provided further
support for our ‘‘changed flora’’ hypothesis, was not performed.
Downloaded from http://journals.lww.com/jpgn by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
CONCLUSIONS
Measuring FC in CF patients before and after receiving
systemic antibiotics suggests that GI inflammation is part of a
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 04/02/2023
broader systemic response in a pulmonary CF exacerbation and may
allow for a greater understanding of the mechanism of this phe-
nomenon and of treatment options.
Diminished FC levels at the end of systemic antibiotic
treatment for respiratory exacerbation suggests that such interven-
tions apply not only to the respiratory system as the main target but
also influences inflammation in the GI tract, possibly through its
impact on the intestinal microbiome.
Further prospective studies with larger numbers of patients,
and using additional tools for evaluation of GI tract inflammatory
status should be considered. Furthermore, microbiome composition
studies may also deepen our understanding of the pathophysiologi-
cal mechanisms of GI tract dysfunction in patients with CF.
REFERENCES
1. Lee JM, Leach ST, Katz T, et al. Update of faecal markers of inflam-
mation in children with cystic fibrosis. Mediators Inflamm 2012;2012:
948367.
284
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
JPGN  Volume 68, Number 2, February 2019
2. Farrell PMP, Rosenstein BJB, White TTB, et al. Guidelines for diag-
nosis of cystic fibrosis in newborns through older adults: cystic fibrosis
foundation consensus report. J Pediatr 2008;153:S4–14.
3. Werlin SL, Benuri-Silbiger I, Kerem E, et al. Evidence of intestinal
inflammation in patients with cystic fibrosis. J Pediatr Gastroenterol
Nutr 2010;51:304–8.
4. Bjerke K, Halstensen TS, Jahnsen F, et al. Distribution of macrophages
and granulocytes expressing L1 protein (calprotectin) in human Peyer’s
patches compared with normal ileal lamina propria and mesenteric
lymph nodes. Gut 1993;34:1357–63.
5. Parisi GF, Papale M, Rotolo N, et al. Severe disease in cystic fibrosis and
fecal calprotectin levels. Immunobiology 2017;222:582–6.
6. Gray RD, Imrie M, Boyd AC, et al. Sputum and serum calprotectin are
useful biomarkers during CF exacerbation. J Cyst Fibros 2010;9:193–8.
7. Ratjen F, Saiman L, Mayer-Hamblett N, et al. Effect of azithromycin on
systemic markers of inflammation in patients with cystic fibrosis un-
infected with Pseudomonas aeruginosa. Chest 2012;142:1259–66.
8. Adriaanse MPM, Van Der Sande LJTM, Van Den Neucker AM, et al.
Evidence for a cystic fibrosis enteropathy. PLoS One 2015;10:1–15.
9. Stotzer PO, Brandberg A, Kilander AF. Diagnosis of small intestinal
bacterial overgrowth in clinical praxis: a comparison of the culture of
small bowel aspirate, duodenal biopsies and gastric aspirate. Hepato-
gastroenterology 1998;45:1018–22.
10. Husebye E, Hellstrom PM, Sundler F, et al. Influence of microbial
species on small intestinal myoelectric activity and transit in germ-free
rats. Am J Physiol Gastrointest Liver Physiol 2001;280:G368–80.
11. De Lisle RC, Roach E, Jansson K. Effects of laxative and N-acetylcys-
teine on mucus accumulation, bacterial load, transit, and inflammation
in the cystic fibrosis mouse small intestine. Am J Physiol Gastrointest
Liver Physiol 2007;293:G577–84.
12. De Lisle RC, Borowitz D. The cystic fibrosis intestine. Cold Spring
Harb Perspect Med 2013;3:1–17.
www.jpgn.org