Nebulised antibiotics for adults with cystic fibrosis
Authors: A. K. Webb, M. E. Dodd
Journal: Thorax (1997)

During adolescence most patients with cystic and pulmonary function was maintained.Aerosolised therapy was cost effective because of fibrosis become chronically colonised with Pseudomonas aeruginosa.Acquisition of this the reduced hospital costs.Ceftazidime was compared with a com-organism is associated with a worse prognosis. 1 The emphasis of care is to delay the pro-bination of gentamicin with carbenicillin in a crossover study in which saline was used as the gression of pulmonary sepsis which is responsible for almost the total mortality of placebo. 6Each arm of the crossover period lasted for four months.Both active drug re-patients with cystic fibrosis.Repeated sputum culture of P aeruginosa confirms chronic in-gimens were equally effective in increasing body weight and improving lung function compared fection and it is then impossible to eradicate.Regular courses of intravenous antibiotics have with placebo.These results suggest that only one nebulised antibiotic is required for efficacy.improved survival by reducing sputum load and maintaining pulmonary function, but they A recent short term study recruited 71 patients into a controlled trial of placebo versus interfere with the activities of daily living.The prescription of nebulised antibiotics for dom-high dose nebulised tobramycin, 600 mg/day. 7 The high dose of tobramycin was used to in-iciliary use by patients with cystic fibrosis is increasing.However, experienced physicians crease the bactericidal dose of antibiotic in the sputum against tobramycin sensitive P aeru-working in cystic fibrosis centres have shown considerable variability in their prescribing ginosa.There was a significant improvement in pulmonary function and a reduction of P practices. 2 aeruginosa in the sputum.Bacterial resistance patterns were similar during the active and placebo part of the study.No ototoxicity or nephrotoxicity was observed.These results sug- Clinical indicationsgest that high dose nebulised tobramycin is      clinically effective, safe, and does not promote   P AERUGINOSA bacterial resistance.The introduction of nebulised colistin at the Nebulised tobramycin, 80 mg twice daily, time of initial colonisation with P aeruginosa was evaluated in a long term open study (mean may reduce and delay chronic colonisation, 3 4 duration 20 months) in 14 patients with a defined as three consecutive positive sputum mean age of 13.3 years. 8 Clinical parameters cultures within six months.In an uncontrolled improved and hospital admissions decreased.trial nebulised colistin given to seven children There was a reduction in one or more inwith cystic fibrosis reduced the frequency of flammatory markers (antibody serum titres positive cultures from 46% to 6%. 3 In a conto P aeruginosa, elastase, exotoxin A, alkaline trolled prospective study a combination of phosphatase) in eight patients.No tobramycin nebulised colistin and oral ciprofloxacin sigwas detected in 50 of 70 blood samples.Innificantly prevented or delayed chronic intermittent tobramycin resistance developed in fection with P aeruginosa for 18 months. 4 These five patients (but only in 6.2% of strains) and results suggest a role for nebulised antibiotics persisted in only one patient at the end of the when the organism is first isolated from spustudy.These results suggest that long term tum.No trials have been published on the use nebulised aminoglycosides are safe, clinically of nebulised antibiotics at the time of diagnosis effective and, by reducing the bacterial antigen of cystic fibrosis before P aeruginosa has been load, may diminish the systemic host immune cultured from the sputum.response.A review of five randomised controlled trials showed benefit for nebulised antipseudomonal antibiotic therapy with no demonstrable ad-     verse effects. 9There is no evidence to suggest     that nebulised antibiotics used as an adjunctto a course of intravenous antibiotics augment Regular aerosolised antibiotics have been used clinical improvement. 10Nebulised antibiotics for patients chronically infected with P aerushould not be used as an alternative to intraginosa to reduce the rate of deterioration.An Adult Cystic Fibrosisvenous antibiotics for an infective exacerbation.Unit, Wythenshawe early controlled trial compared twice daily ad-Hospital, Manchester ministration of 80 mg nebulised gentamicin M23 9LT, UK combined with 1 g carbenicillin against Assessment and administration A K Webb M E Dodd placebo. 5In the group that received the active  Patients should be carefully assessed before drugs for six months there was a reduction in