Treatment of an Early/Mild Respiratory Exacerbation of Cystic Fibrosis
|Publication: 17/11/2017 --|
|Last review: 01/01/1900|
|Next review: 17/11/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Treatment of an Early / Mild Respiratory Exacerbation of Cystic Fibrosis
These guidelines can be followed if any of the following in box 1 are present:
If the child/person with CF is well other than the symptoms above, and consideration is given to alternative non-infectious causes, then antibiotics could be appropriately commenced at home as per this guidance. If any of the following features are present, then urgent medical review either at the CF Centre, or in primary or secondary care is recommended:
Where possible, it would be useful for cough swabs and/or sputum samples, and nasopharyngeal aspirates (NPA) if viral aetiology is suspected, to be obtained before starting antibiotics.
Management of patients with CF includes routine cultures of respiratory secretions to identify infecting organisms and guide antibiotic selection. Because patients with CF frequently carry the same bacteria for prolonged periods of time, past culture results can be used to guide antibiotic choices when a patient’s condition warrants intensifying treatment. The current recommendation is to perform cultures as a minimum every three months so that relatively current information is available to guide treatment when a pulmonary exacerbation occurs (2). In Leeds, surveillance screening through cough swabs or sputum occurs at least every 8 weeks.
Where no culture result is available, antibiotic choice must be made empirically. S. aureus is the earliest isolate from the lungs, usually followed by non-typeable Haemophilus influenzae (not covered by vaccines) and Pseudomonas. S. pneumoniae is occasionally isolated but is relatively rare.
Cough swabs taken at home by parents/carers are not as useful as hospital obtained cough swabs. Self-obtained sputum samples may be more helpful.
If there is no positive microbiology on surveillance screening in a patient with persistent cough, performing induced sputum should be discussed with the CF team prior to starting IV antibiotics.
Bronchoscopy may be useful in children who cannot provide induced sputum, where there is no known microbiological cause for respiratory deterioration. Where appropriate it may be possible to combine this with other procedures that may aid the care of the patient or help diagnosis e.g. CT scan/pH study.
A negative sputum culture does not exclude bacterial infection.
For a mild respiratory exacerbation, in an otherwise well person with CF, with none of the severity features listed above, a pre-determined specific oral antibiotic that is on the EMIS/GP medication list should be commenced, for a total of two weeks. It is usual practice to allow a new cough 48 hours to settle before starting the antibiotic. This will usually cover both H. influenzae and S. aureus (e.g. co-amoxiclav). If the patient is known to be chronically infected with Pseudomonas aeruginosa, then oral ciprofloxacin will often be used. Parents/adults with CF may have a two week supply of this specified antibiotic stored at home, to start if required as described in this guideline [C].
During working hours parents/adults with CF should contact their CF service and speak with a CF doctor or CF nurse specialist. If no severity features are present, then the CF doctor/CF nurse specialist can recommend that this guideline is followed and the specific prescribed antibiotic for this indication can be used.
If out of hours, and the person with CF is not otherwise unwell (see severity assessment) parents/adults with CF may start the specified prescribed antibiotic as long as they contact the CF team the next working day. If in any doubt, they should contact the CF team via the paediatric or adult CF ward for advice (as appropriate).
It is becoming increasingly recognised that coughs should be treated early to prevent later bronchiectasis, but also that many coughs are viral. If the cough clears within a few days of commencing antibiotics, and there is no recent positive microbiology, then the course may be truncated to five to seven days at the clinician’s discretion. Not all patients with viral infections may need oral antibiotics. Many symptoms will resolve without complications.
Counselling of parents/patients
Patients and parents should be counselled that all antibiotic treatment courses have potential risks as well as benefits, and all courses of additional antibiotics for new cough should be discussed with the CF team as above. Parents and patients should be advised of the severe features listed above so that they can seek urgent medical review should these develop. They should be advised to seek advice if the cough persists beyond two weeks. Patients or parents should be advised to report any suspected side effects of treatment promptly. All patients should be advised to increase physiotherapy.
Parent of a child or Adult with CF rings the CF Unit describing a new cough, increase in cough frequency or change in amount/type of sputum or other symptoms described in box 1
|Clinical condition:||New cough|
|Target patient group:||Adults and children with cystic fibrosis (CF)|
|Target professional group(s):|
- http://www.uptodate.com/contents/cystic-fibrosis-antibiotic-therapy-for-lung-disease accessed June 2015
- CF Trust. Antibiotic Treatment for cystic fibrosis. Third edition. May 2009
- Regelmann WE; Schechter MS; Wagener JS. Pulmonary exacerbations in cystic fibrosis: young children with characteristic signs and symptoms. Pediatric Pulmonology, July 2013, vol./is. 48/7(649-57),
- Blackburn R, Henderson L,Lillie M. Empirical treatment of influenza-associated pneumonia in primary care: a descriptive study of the antimicrobial susceptibility of lower respiratory tract bacteria (England, Wales and Northern Ireland, January 2007 to March 2010) Thorax Online First, published on February 25, 2011 as 10.1136/thx.2010.134643
- Verhoefa J, Gillissen A. Resistant Haemophilus influenzae in community-acquired respiratory tract infections: a role for cefixime.International Journal of Antimicrobial Agents. Volume 21, Issue 6, June 2003, Pages 501–509
- Mortenson J. Himes S Comparative In Vitro Activity of Cefixime against Haemophilus influenzae Isolates, Including Ampicillin-Resistant, Non-3-Lactamase-Producing Isolates, from Pediatric Patients Antimicrobial agents and chemotherapy, July 1990, p. 1456-1458
- Frederiksen B1, Lanng S, Koch C, Høiby N. Improved survival in the Danish center-treated cystic fibrosis patients: results of aggressive treatment. Pediatr Pulmonol 1996;21:153–8.
- Everett C. Clinical history in gastroesophageal cough Respiratory Medicine Volume 101, Issue 2, February 2007, Pages 345–348
- Smith J. Cough frequency and patterns of cough in cystic fibrosis JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Supplement No. 46 Volume 99 2006
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
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