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Antibiotic adjuvant therapy for pulmonary infection in cystic fibrosis1
Paediatric Respiratory Reviews 13 (2012) 160–161
Contents lists available at SciVerse ScienceDirect
Paediatric Respiratory Reviews
Cochrane Corner
Antibiotic adjuvant therapy for pulmonary infection in cystic fibrosis1 Matthew N. Hurley *, Andrew P. Prayle Department of Child Health, School of Clinical Sciences, University of Nottingham, Nottingham UK on behalf of the Cochrane Cystic Fibrosis and Genetic Disorders Group
Antibiotic resistance increasingly poses a challenge to the successful treatment of many infections and this is particularly the case for the treatment of lung infections with Pseudomonas aeruginosa (see Figure 1) in cystic fibrosis, a bacterium with inherent antibiotic tolerance that may acquire antibiotic resistance rapidly. While early infections may be eradicated if treated early,2–4 the establishment of chronic infection which cannot be cleared with current antibiotic therapies, is inevitable. As there has been limited progress in the development of new antibiotics to which conventional antibiotic-resistant strains may be sensitive, new approaches that may act to re-sensitise bacteria to coadministered antibiotics without selecting for resistance are needed. We examined randomised and quasi-randomised controlled trials of the use of antibiotic adjuvants for the treatment of acute pulmonary exacerbations or the treatment of chronic infection. Pulmonary exacerbations, lung function and quality of life were our primary outcomes. We identified eighteen studies, the methodological quality of which was largely poor. The results of five studies recently completed or ongoing are awaited. Three studies were eligible for inclusion individually examining the effect of b-carotene, zinc or garlic supplementation. For each of these interventions there was no statistically significant effect in any of the primary outcomes of the review and so we cannot recommend their use. There is a need for further development of these strategies and for them to be evaluated in well-designed
double-blind randomised controlled trials of sufficient power and duration to detect an effect.
References
3. Douglas TA, Brennan S, Gard S, Berry L, Gangell C, Stick SM, et al. Acquisition and eradication of P. aeruginosa in young children with cystic fibrosis. The European respiratory journal official journal of the European Society for Clinical Respiratory Physiology 2009;33:305–11. 4. Langton Hewer SC, Smyth AR. Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2009. Art. No.: CD004197. http://dx.doi.org/10.1002/ 14651858.CD004197.pub3.
1. Hurley MN, Forrester DL, Smyth AR. Antibiotic adjuvant therapy for pulmonary infection in cystic fibrosis. Cochrane Database of Systematic Reviews 2010. Art. No.: CD008037. http://dx.doi.org/10.1002/14651858.CD008037.pub2. 2. Ratjen F, Munck A, Kho P, Angyalosi G. Treatment of early Pseudomonas aeruginosa infection in patients with cystic fibrosis: the ELITE trial. Thorax 2010;65:286–91. Epub 2009/12/10.
* Corresponding author. E-mail address: [email protected] (M.N. Hurley). 1526-0542/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.prrv.2012.04.005
Figure 1. Pseudomonas aeruginosa swarming.
M.N. Hurley, A.P. Prayle / Paediatric Respiratory Reviews 13 (2012) 160–161
161
Percutaneous lines for delivering intravenous antibiotics in people with cystic fibrosis5 In the UK, half of patients registered on the UK CF Registry received intravenous antibiotics in 2010.6 Obtaining intravenous access to deliver these antibiotics makes many patients anxious. We looked at the evidence for superiority of long lines over peripheral cannulae, and compared different types of long line. We didn’t look at totally implantable devices, as they are considered in another Cochrane review.7 We found two randomised controlled trials which looked at long lines in patients with CF; both were from the same single centre in the UK, and both were of paediatric patients only. Williams8 compared a cannula with a long line (a 15 cm Dow Corning with an internal diameter of 0.3 mm), and Lacy9 compared two brands of long lines. Neither study was blinded Long iv line Study or Subgroup Williams 1988 (1)
Mean 8.8
Short iv line
(which would be particularly challenging to do with this type of trial), but otherwise there were no signs of a high risk of bias. Williams showed that long lines have greater lifespan than cannulae (8.4 days versus 4.0 days), and that patients preferred long lines (see Figure 2). The second trial found essentially no evidence for a difference between a Hydrocath and Vygon EC. Although they are frequently used, the evidence base for using long lines is limited, especially in adult patients (where there are no randomised trials). Long lines last longer than cannulae and are preferred by paediatric patients, but there is little evidence to help when choosing between long lines.
Mean Difference
SD Total Mean
SD Total
IV, Fixed, 95% CI
1.7
2.4
3.10 [1.28, 4.92]
10
5.7
10
Mean Difference IV, Fixed, 95% CI
-4
-2
0
2
4
Favours short iv line Favours long iv line (1) Williams et al used a visual analogue scale (0 = awful, 10 = excellent)
Figure 2. Patient satisfaction.
References 5. Prayle AP, Hurley MN, Smyth AR. Percutaneous lines for delivering intravenous antibiotics in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2010. Art. No.: CD008243. http://dx.doi.org/10.1002/14651858.CD008243.pub2. 6. CF Trust. UK CF Registry Annual Data Report 2010. CF Trust, 2010. 7. A-Rahman AKM, Spencer D. Totally implantable vascular access devices for cystic fibrosis. Cochrane Database of Systematic Reviews 2003. Art. No.: CD004111. http://dx.doi.org/10.1002/14651858.CD004111.
8. Williams J, Smith HL, Woods CG, Weller PH. Silastic catheters for antibiotics in cystic fibrosis. Arch Dis Child 1988;63:658–9. Epub 1988/06/01. 9. Lacy DE, Spencer DA, Venkataraman M, Ruiz G, Weller PH. Comparison of two percutaneous intravenous ‘‘midline’’ catheters in cystic fibrosis. J Intraven Nurs 1996;19:28–31. Epub 1996/01/01.
In collaboration with the Cochrane CF and Genetic Disorders Group’ http://cfgd.cochrane.org/.
Contents lists available at SciVerse ScienceDirect
Paediatric Respiratory Reviews
Cochrane Corner
Antibiotic adjuvant therapy for pulmonary infection in cystic fibrosis1 Matthew N. Hurley *, Andrew P. Prayle Department of Child Health, School of Clinical Sciences, University of Nottingham, Nottingham UK on behalf of the Cochrane Cystic Fibrosis and Genetic Disorders Group
Antibiotic resistance increasingly poses a challenge to the successful treatment of many infections and this is particularly the case for the treatment of lung infections with Pseudomonas aeruginosa (see Figure 1) in cystic fibrosis, a bacterium with inherent antibiotic tolerance that may acquire antibiotic resistance rapidly. While early infections may be eradicated if treated early,2–4 the establishment of chronic infection which cannot be cleared with current antibiotic therapies, is inevitable. As there has been limited progress in the development of new antibiotics to which conventional antibiotic-resistant strains may be sensitive, new approaches that may act to re-sensitise bacteria to coadministered antibiotics without selecting for resistance are needed. We examined randomised and quasi-randomised controlled trials of the use of antibiotic adjuvants for the treatment of acute pulmonary exacerbations or the treatment of chronic infection. Pulmonary exacerbations, lung function and quality of life were our primary outcomes. We identified eighteen studies, the methodological quality of which was largely poor. The results of five studies recently completed or ongoing are awaited. Three studies were eligible for inclusion individually examining the effect of b-carotene, zinc or garlic supplementation. For each of these interventions there was no statistically significant effect in any of the primary outcomes of the review and so we cannot recommend their use. There is a need for further development of these strategies and for them to be evaluated in well-designed
double-blind randomised controlled trials of sufficient power and duration to detect an effect.
References
3. Douglas TA, Brennan S, Gard S, Berry L, Gangell C, Stick SM, et al. Acquisition and eradication of P. aeruginosa in young children with cystic fibrosis. The European respiratory journal official journal of the European Society for Clinical Respiratory Physiology 2009;33:305–11. 4. Langton Hewer SC, Smyth AR. Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2009. Art. No.: CD004197. http://dx.doi.org/10.1002/ 14651858.CD004197.pub3.
1. Hurley MN, Forrester DL, Smyth AR. Antibiotic adjuvant therapy for pulmonary infection in cystic fibrosis. Cochrane Database of Systematic Reviews 2010. Art. No.: CD008037. http://dx.doi.org/10.1002/14651858.CD008037.pub2. 2. Ratjen F, Munck A, Kho P, Angyalosi G. Treatment of early Pseudomonas aeruginosa infection in patients with cystic fibrosis: the ELITE trial. Thorax 2010;65:286–91. Epub 2009/12/10.
* Corresponding author. E-mail address: [email protected] (M.N. Hurley). 1526-0542/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.prrv.2012.04.005
Figure 1. Pseudomonas aeruginosa swarming.
M.N. Hurley, A.P. Prayle / Paediatric Respiratory Reviews 13 (2012) 160–161
161
Percutaneous lines for delivering intravenous antibiotics in people with cystic fibrosis5 In the UK, half of patients registered on the UK CF Registry received intravenous antibiotics in 2010.6 Obtaining intravenous access to deliver these antibiotics makes many patients anxious. We looked at the evidence for superiority of long lines over peripheral cannulae, and compared different types of long line. We didn’t look at totally implantable devices, as they are considered in another Cochrane review.7 We found two randomised controlled trials which looked at long lines in patients with CF; both were from the same single centre in the UK, and both were of paediatric patients only. Williams8 compared a cannula with a long line (a 15 cm Dow Corning with an internal diameter of 0.3 mm), and Lacy9 compared two brands of long lines. Neither study was blinded Long iv line Study or Subgroup Williams 1988 (1)
Mean 8.8
Short iv line
(which would be particularly challenging to do with this type of trial), but otherwise there were no signs of a high risk of bias. Williams showed that long lines have greater lifespan than cannulae (8.4 days versus 4.0 days), and that patients preferred long lines (see Figure 2). The second trial found essentially no evidence for a difference between a Hydrocath and Vygon EC. Although they are frequently used, the evidence base for using long lines is limited, especially in adult patients (where there are no randomised trials). Long lines last longer than cannulae and are preferred by paediatric patients, but there is little evidence to help when choosing between long lines.
Mean Difference
SD Total Mean
SD Total
IV, Fixed, 95% CI
1.7
2.4
3.10 [1.28, 4.92]
10
5.7
10
Mean Difference IV, Fixed, 95% CI
-4
-2
0
2
4
Favours short iv line Favours long iv line (1) Williams et al used a visual analogue scale (0 = awful, 10 = excellent)
Figure 2. Patient satisfaction.
References 5. Prayle AP, Hurley MN, Smyth AR. Percutaneous lines for delivering intravenous antibiotics in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2010. Art. No.: CD008243. http://dx.doi.org/10.1002/14651858.CD008243.pub2. 6. CF Trust. UK CF Registry Annual Data Report 2010. CF Trust, 2010. 7. A-Rahman AKM, Spencer D. Totally implantable vascular access devices for cystic fibrosis. Cochrane Database of Systematic Reviews 2003. Art. No.: CD004111. http://dx.doi.org/10.1002/14651858.CD004111.
8. Williams J, Smith HL, Woods CG, Weller PH. Silastic catheters for antibiotics in cystic fibrosis. Arch Dis Child 1988;63:658–9. Epub 1988/06/01. 9. Lacy DE, Spencer DA, Venkataraman M, Ruiz G, Weller PH. Comparison of two percutaneous intravenous ‘‘midline’’ catheters in cystic fibrosis. J Intraven Nurs 1996;19:28–31. Epub 1996/01/01.
In collaboration with the Cochrane CF and Genetic Disorders Group’ http://cfgd.cochrane.org/.