Report of the UK Cystic Fibrosis Trust Antibiotic Working Group

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39. Regelmann WE, Elliott GR, Warwick WJ, Clawson CC. Reduction of sputum Pseudomonas aeruginosa density byantibiotics improves lung function in cystic fibrosis more than do bronchodilators and chest physiotherapy alone.Am Rev Respir Dis 1990;141:914–21.40. Wolter JM, Bowler SD, McCormack JG. Are antipseudomonal antibiotics really beneficial in acute respiratoryexacerbations of cystic fibrosis? Aust N Z J Med 1999;29:15–21.41. Smith AL, Fiel SB, Mayer-Hamblett N, Ramsey B, Burns JL. Susceptibility testing of Pseudomonas aeruginosaisolates and clinical response to parenteral antibiotic administration: lack of association in cystic fibrosis. Chest2003;123:1495–502.42. Sanchez P, Linares JF, Ruiz-Diez B, Campanario E, Navas A, Baquero F et al. Fitness of in vitro selectedPseudomonas aeruginosa nalB and nfxB multidrug resistant mutants. J Antimicrob Chemother 2002;50:657–64.43. Fonseca AP, Extremina C, Fonseca AF, Sousa JC. Effect of subinhibitory concentration of piperacillin/tazobactamon Pseudomonas aeruginosa. J Med Microbiol 2004;53:903-10.44. Wagner T, Soong G, Sokol S, Saiman L, Prince A. Effects of azithromycin on clinical isolates of Pseudomonasaeruginosa from cystic fibrosis patients. Chest 2005;128:912–9.45. Perry JD, Laine L, Hughes S, Nicholson A, Galloway A, Gould FK. Recovery of antimicrobial-resistantPseudomonas aeruginosa from sputa of cystic fibrosis patients by culture on selective media. J Antimicrob Chemother2008;61:1057–61.46. Kahlmeter G, Brown DF, Goldstein FW, MacGowan AP, Mouton JW, Osterlund A et al. European harmonizationof MIC breakpoints for antimicrobial susceptibility testing of bacteria. J Antimicrob Chemother 2003;52:145–8.47. Moriarty TF, McElnay JC, Elborn JS, Tunney MM. Sputum antibiotic concentrations: implications for treatmentof cystic fibrosis lung infection. Pediatr Pulmonol 2007;42:1008–17.48. Burns JL, Van Dalfsen JM, Shawar RM, Otto KL, Garber RL, Quan JM et al. Effect of chronic intermittentadministration of inhaled tobramycin on respiratory microbial flora in patients with cystic fibrosis. J Infect Dis1999;179:1190–6.49. Aaron SD. Antibiotic synergy testing should not be routine for patients with cystic fibrosis who are infected withmultiresistant bacterial organisms. Paediatr Respir Rev 2007;8:256–61.Cystic Fibrosis Trust 2.9March 2009
3.1 Introduction3. IDENTIFICATION OF LOWER AIRWAY INFECTIONIdentification of lower respiratory infection in individuals with CF represents a challenge. Youngchildren may not expectorate sputum, even when they have a wet cough. Many patients with CF havelittle lung damage and so do not have sputum to expectorate. However, in order to avoid progressivelung damage and bronchiectasis, it is essential to identify and treat lower respiratory infection at anearly stage. It is a paradox in CF that as treatment of pulmonary infection improves, diagnosis of suchinfection becomes more difficult. There are a number of situations where diagnosis of pulmonaryinfection is important, for different reasons.• The asymptomatic patient without chronic airway infection. Identification of Pseudomonasaeruginosa from the respiratory culture of asymptomatic patients facilitates prompt treatment,which results in eradication in a significant number. 1;2 Not treating P.aeruginosa results inchronic airway infection. 1;3-6• The symptomatic patient without chronic airway infection. The identification of airwayinfection in the symptomatic patient facilitates appropriate treatment. 7• The patient with chronic airway infection. In these patients, regular culture of respiratorysamples facilitates:• Monitoring individuals for change in sensitivity patterns 8;9• Identification of new strains/pathogens in an individual 10–12• Identification of emergence of epidemic strains in a clinic population 8;13;143.2 Methods to identify airway infectionIn the patient who is not productive of sputum, the following microbiology specimens can becollected. The advantages and disadvantages of each are summarized in table 1.• Cough swab• Cough plate• Oropharyngeal culture (throat)• Laryngeal or naso-pharyngeal aspirate• Exhaled breath condensate• Induced sputum following hypertonic saline• Bronchoalveolar lavage• Serology (functional P.aeruginosa antibodies)In the patient who does produce sputum, a sputum sample is likely to be the best clinical specimen,for practical purposes.Cystic Fibrosis Trust 3.0March 2009
Page 3 and 4: 4. ORAL ANTIBIOTICS IN CYSTIC FIBRO
Page 5 and 6: 7. OTHER INFECTIONS7.1 Management o
Page 7 and 8: GRADING SCHEME FOR LEVELS OF EVIDEN
Page 9 and 10: SUMMARY•All young children with c
Page 11: In 1989 the Copenhagen centre recom
Page 15 and 16: These bacteria can be harmless comm
Page 17 and 18: 2.7 Clinical relevance of in vitro
Page 19: 17. Macia MD, Blanquer D, Togores B
Page 23 and 24: Table 2: Laboratory techniques and
Page 25 and 26: 20. Hoppe JE, Theurer MU, Stern M.
Page 27 and 28: 4.2.4 Recommendations for treatment
Page 29 and 30: 4.5 Use of oral antibiotics at time
Page 31 and 32: groups in terms of the chronic use
Page 33 and 34: 5.1 Introduction5. NEBULISED ANTIBI
Page 36 and 37: 5.5 Nebulised antibiotics to preven
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Page 40 and 41: • If a facemask is used the face
Page 42 and 43: 5.16 Nebuliser/compressor systems f
Page 44 and 45: 19. Ratjen F, Walter H, Haug M, Mei
Page 46 and 47: 69. Pitchford KC, Corey M, Highsmit
Page 48 and 49: outcome between active and placebo
Page 50 and 51: Drug Route Age/weight DoseFrequency
Page 52 and 53: much sooner. A minimum of 10-14 day
Page 54 and 55: 6.8 References1. Armstrong DS, Grim
Page 56 and 57: 7. OTHER INFECTIONS7.1 Management o
Page 58 and 59: 7.2 Respiratory infection with meti
Page 60 and 61: Table 7.2 Published data on eradica
Page 62 and 63: 7.4.2 Recommendations• Given the
Page 64 and 65: although not all authors have found
Page 66 and 67: Table 7.3 Drugs for treatment of My
Page 68 and 69: 7.9.2 Diagnosis of ABPAThe Cystic F
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• It is important to assess the c
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12. Blackburn L, Brownlee K, Conway
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57. Ballestero S, Virseda I, Escoba
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107. Deerojanawong J, Sawyer SM, Fi
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155. Stevens DA, Moss RB, Kurup VP,
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8. PHARMACOPOEIAOriginally based on
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8.3 Treatment of more severe exacer
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Co-amoxiclav orallyAge Dose Frequen
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Cefotaxime intravenouslyAge Dose Fr
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8.7 Treatment of Pseudomonas aerugi
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8.8.3 Other ß-lactam antibioticsTh
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Amikacin intravenouslyAge Dose Freq
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8.10 Chronic oral anti-pseudomonal
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TemocillinAge Dose Frequency>12year
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Liposomal Amphotericin (“Ambisome
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9. ANTIBIOTIC-RELATED ALLERGIES AND
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I N F O R M A T I O NCystic Fibrosi
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Report of the UK Cystic Fibrosis Trust Antibiotic Working Group

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