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Pediatr Pulmonol. 2020 Apr;55(4):1061-1073. doi: 10.1002/ppul.24699. Epub 2020 Feb 21.

Viral strategies predisposing to respiratory bacterial superinfections.

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Pulmonary and Allergy Disease Unit, Department of Pediatrics, G. Gaslini University Hospital, Genoa, Italy.
Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, Florida.


Acute respiratory infections are amongst the leading causes of childhood morbidity and mortality globally. Viruses are the predominant cause of such infections, but mixed etiologies with bacteria has for decades raised the question of the interplay between them in causality and determination of the outcome of such infections. In this review, we examine recent microbiological, biochemical, and immunological advances that contribute to elucidating the mechanisms by which infections by specific viruses enable bacterial infections in the airway, and exacerbate them. We analyze specific domains in which viruses play such facilitating role including enhancement of bacterial adhesion by unmasking cryptic receptors and upregulation of adhesion proteins, disruption of tight junction integrity favoring paracellular transmigration of bacteria and loss of epithelial barrier integrity, increased availability of nutrient, such as mucins and iron, alteration of innate and adaptive immune responses, and disabling defense against bacteria, and lastly, changes in airway microbiome that render the lung more vulnerable to pathogens. Separate exhaustive analysis of each domain focuses on individuals with cystic fibrosis (CF), in whom viruses may play a key role in paving the way for the primary injury that leads to permanence of bacterial pathogens, viruses may then serve as triggers for "CF exacerbations"; these constituting the signature and ultimately the outcome determinants of these patients.


adhesion molecules; cystic fibrosis (CF); epithelial cells; immune response; microbiota; mucin; nutrients


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