Report of the UK Cystic Fibrosis Trust Antibiotic Working Group

Table 7.2 Published data on eradication strategies used against MRSA in patients withCystic FibrosisReference Regimen Duration OutcomeMaiz et al 55Solis et al 52Garskeet al 54Aerosolised vancomycin 250 mg in 4 ml sterile water nebulised twicedaily* for 10 minutes*Preceded by nebulised terbutaline 500 μgAerosolised vancomycin 4 mg/kg/dose diluted in 0.9% sodium chloride4 times daily**Preceded by nebulised SalbutamolTracheostomy: 2% vancomycin cream twice daily; changetubeNasal carriage: 2% mupirocin cream 4 times dailyOR 2% vancomycin cream 4 times dailyOropharyngeal carriage: 2% vancomycin pasteOR 2% vancomycin gelOR 5 mg vancomycin lozenges 4 times dailyGastrointestinal carriage: 40 mg/kg/day vancomycin oral suspensionin 4 divided dosesSkin carriage:4% chlorhexidine bath alternate days (dilute1/100)Rifampicin 600 mg once daily orally plus sodium fusidate 250–500 mgtwice daily orally17 months Successful eradication in7 of 12 patients for meanof 12 months5 days Successful eradication in7 of 12 patients for meanof 12 months6 months Successful eradication in5 of 7 patients for mean ofsix monthsMacfarlaneet al 53 Step 1: Topical therapy plusFusidic Acid 50 mg/kg/dayRifampicin 20–40 mg/kg/dayStep 2:RepeatStep 3: IV Teicoplanin (section 8.3)5 days5 days10–14 days7.3. Respiratory infection with Stenotrophomonas maltophilia7.3.1 IntroductionIsolation of S.maltophilia from sputa of patients with CF has increased markedly since the early1980s 56 [2-] and some Specialist CF Centres now report a prevalence of over 20%. 57;58 [3] Theprecise reasons for these increases are unclear but there is an association between the emergence ofS.maltophilia in patients with CF and exposure to anti-pseudomonal antibiotics. 59–62 [3] There issome evidence that the organism is acquired from a variety of environmental sources found bothwithin the hospital and the community, particularly moist sites, such as taps, showerheads, plugholesand water itself. 63 [3] Equipment used to deliver aerosolised antibiotics may also be a potential sourceof S.maltophilia. 64;65 [3] There is no evidence of patient-to-patient transmission 66–68 [3] and strictisolation protocols, such as those applied to patients colonised with B.cepacia and highly transmissibleP.aeruginosa, are not necessary.The clinical significance of S.maltophilia colonisation in CF remains an area of uncertainty. Therehave been no reports of acute deterioration in people with CF following acquisition of S.maltophilia.One retrospective review suggests that patients chronically colonised with S.maltophilia experiencelong-term deterioration in lung function, similar to that in P.aeruginosa-colonised patients 69 [3]although the majority of studies have not shown this relationship. 70–73 [3] There are anecdotal reportsthat gradual deterioration only occurs in those patients colonised with >106 cfu of S.maltophilia perml of sputum. 74 [3] However two large cohort studies using data from the Cystic Fibrosis FoundationRegistry have found that, although those positive for S.maltophilia had more advanced disease,acquisition of the organism had no significant impact on short term (three years) survival 75 nor didCystic Fibrosis Trust 7.3March 2009