Norfolk, Suffolk & Cambridgeshire Paediatric CF Network
Clinical Guideline Cystic Fibrosis - Antibiotic Guideline for the Care of Children with Cystic Fibrosis 1
Scope
2
Aim
Children within the Trust.
To standardise in-patient and out-patient care with regards to the management of infective exacerbations of Cystic Fibrosis lung disease. To comply with National Guidance as issued by the Cystic Fibrosis Trust (CF Trust Consensus Document :Antibiotic Treatment for Cystic Fibrosis- 3 rd Edition 20091).
1 Undertaken by Paediatric Cystic Fibrosis Team Paediatric nursing and medical staff
2 Introduction The main objective when treating children with CF is to aggressively manage all types of respiratory infection, thereby improving both morbidity and mortality. Common viral respiratory infections are important as they may result in secondary bacterial chest infections, contributing to the damaging inflammatory process in the CF lung, and are also associated with the early acquisition of Pseudomonas aeruginosa (PA) 2. Sputum, cough swabs, or NPA cultures should be taken at each clinic visit, before and weekly during acute therapy. Treatment should be guided by the sensitivities of the last culture result, and reviewed during treatment. If cultures are unknown, empirical treatment should be started, and reviewed when cultures become available. Pulmonary function tests should be performed in all children capable of the test at each clinic contact, midway through a course of IV antibiotics, and before cessation of IV therapy is considered. Antibiotic therapy is considered when a drop of ≥ 10% FEV1 is observed. Satisfactory response is indicated by the return of lung function tests to their most recent best value, which is most often, but not always, their annual assessment lung function values. Chest x-rays are not routinely performed unless the child fails to respond to therapy, develops haemoptysis, pneumothorax is considered, or ABPA is suspected.
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The majority of chest infections in children with CF should be treated with antibiotic doses appropriate for severe infections. The metabolic clearance rate of some antibiotics is altered in CF, therefore the dose of all antibiotics is higher than usual and should be continued for a minimum of 10 days to 2 weeks. Consideration to a prolonged course of >2 weeks should be given to those patients who fail to show either an improvement clinically and/or an improvement in their lung function tests. Patients who fail to respond to an oral antibiotic course should be considered for IV therapy.
3 Respiratory exacerbation All families are aware that they may contact the CF Team if they are concerned about their child. Advice may be given by the Specialist Nurse, Specialist Registrar, or Consultant. These children often need to be seen either on the ward, in A&E or at the next clinic (NB. not next available clinic). Chest exacerbation is often indicated by: increase in sputum production; changes in colour and/or consistency increase in cough breathlessness haemoptysis chest pain poor appetite or weight loss malaise, fatigue and lethargy. Poor exercise tolerance. fever >38°C NB Chest infections in children with CF are rarely accompanied by fever so an alternative cause should be sought a >10% drop in lung function abnormal chest auscultation BUT a clear chest does not exclude an infective exacerbation new or increased palpable chest secretions Sputum or cough swab must be sent to microbiology for culture. An NPA can be performed on infants. Samples MUST identify the patient as suffering from CF. A CXR is only occasionally useful but if abnormal (consolidation, pneumothorax) it requires immediate action. A CXR should always be performed if the patient complains of chest pain, to exclude a pneumothorax. Antibiotics should be prescribed for all patients with an infective exacerbation. Initially oral antibiotics can be prescribed with IVs being reserved for either the very ill or the non-responders.
4
Prophylactic antibiotics (A) Staphylococcus aureus (SA) is a significant pathogen in CF and may be present in respiratory cultures without causing symptoms. Despite this it may initiate an immunological response, and cause significant lung damage.
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The use of prophylactic anti-staphylococcal antibiotics has been shown to reduce clinical symptoms, and the need for additional antibiotics in the first two years of life3. All children should be started on a narrow spectrum prophylactic antibiotic (flucloxacillin) against SA at diagnosis, and should remain on it until at least 5 years of age. If after this time there is no evidence to support continued anti-staphylococcal prophylaxis (i.e. ≤ 3 isolates of SA in the preceding year) then consideration to its discontinuation should be givenError: Reference source not found 4. Haemophilus influenzae (HI) Although there is very little evidence to support its role in the pathogenesis of CF lung disease, children chronically infected with HI (≥ 2 isolates of HI in one year) will require appropriate prophylaxis (co-amoxiclav) Error: Reference source not found. Oral cephalosporins should not be used as prophylaxis against either SA or HI as their use has been associated with increased acquisition of Pseudomonas aeruginosaError: Reference source not found . Pseudomonas aeruginosa (PA) Patients chronically infected with PA (≥ 2 isolates of PA in one year) should receive twice daily nebulised colistin for the foreseeable future. This may be alternated with nebulised tobramycin on an alternate month basis. Additionally, consideration should be given to using long term azithromycin in patients chronically infected with PA. It has been shown to have anti-inflammatory effects and to interfere with biofilm formation in such CF patients5 6.
5
Management of upper respiratory viral infections
(D)
The frequency of URTI’s for which additional antibiotics may be required varies between 1 and 10 per year amongst children with CF, despite the use of prophylactic antibiotics7. There is little evidence to suggest that an antibiotic active against Haemophilus influenzae (HI) at the time of viral infections prevents secondary bacterial infection BUT the report of additional bacterial infection in 20% of non-CF individuals with viral URTI who respond to antibiotics active against HI lends support to the practiceError: Reference source not found. Bacterial exacerbation is frequently triggered by viral infections; therefore the policy seems sensible and supported by available research8 9. With all URTI’s the twice daily prophylactic antibiotic (flucloxacillin) dose should be doubled. If there is no improvement within 48 hours, the prophylactic antibiotic should be stopped and oral co-amoxiclav commenced to broaden antimicrobial cover. If the child is not on oral prophylaxis, an antibiotic that will cover both SA and HI should be prescribed. Co-amoxiclav would be the first choice although clarithromycin is an acceptable alternative. Oral cephalosporins should be avoided, because of concerns about increased PA isolation 10 .
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A sputum or cough swab should be sent before the increase or change in antibiotics and action taken if necessary, depending on the result. If the patient’s symptoms do not improve with an appropriate course of antibiotics, then consideration should be given to commencing IV antibiotics, even if the patient appears clinically well.
6
Staphylococcus aureus (SA) & MRSA SA is a significant pathogen in CF and is associated with an immunological response suggesting tissue infection11. It is reasonable to attempt to eradicate SA from respiratory cultures even if the child appears well. CF infants treated with long term anti-staphylococcal agents have less cough, fewer respiratory exacerbations, and fewer positive cultures for SA compared with infants not on prophylaxis for the first two years of lifeError: Reference source not found . If SA grows while the child is receiving a prophylactic antibiotic consider:
Compliance Increasing the Flucloxacillin to 25mg/kg (max. 1g) four times daily
(BNF for Children 2011-2012) for 2 weeks Adding another oral anti-staphylococcal antibiotic for 2 weeks
e.g. Clarithromycin/Azithromycin/ Fusidic acid/ Rifampicin (D) MRSA
(D)
If SA persists then consider: (D) Extending the course of oral antibiotics to 6 weeks in total Commencing intravenous therapy (either 2 agents) or one IV agent in combination with an oral agent for a minimum of 2 weeks. MRSA is increasingly common but still remains rare within the CF context despite the use of SA prophylaxis. MRSA colonisation is without serious consequences in the majority of patients12 but eradication should be attempted in order to preserve the patient’s suitability for transplantation in the future. MRSA positive patients should be isolated in CF clinic and on the ward, to prevent spread to other patients including those without CF. The Trust guidelines on infection control should be adhered to. Eradication: (C) The regimen should include standard topical treatment (refer to standard Trust Guidelines on TOPICAL TREATMENT FOR MRSA) and either combination oral therapy with rifampicin and fusidic acid, or twice daily nebulised vancomycinError: Reference source not found Error: Reference source not found , or a combination of all three, for 5 daysError: Reference source not found. This course can be repeated if the MRSA fails to respond, before intravenous therapy is considered. In CF patients over 12 years, an oral tetracycline may
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be used as an alternative to rifampicin or fusidic acid, if the organism is susceptible. Resistant or serious cases may require intravenous vancomycin, teicoplanin or linezolid13. Linezolid can be given by either oral or IV routes. Oral linezolid is as efficacious as IV and is therefore preferred. It requires microbiology approval before prescribing. Courses of >28 days have been associated with many side effects including skin rash, blood dyscrasias and optic atrophy. Patients at risk of thrombocytopenia (splenomegaly) should have a weekly full blood count whilst taking linezolid. Oral or intravenous therapy can be supplemented with nebulised vancomycin if clinically indicated14 Error: Reference source not found. The decision to treat MRSA colonisation is a clinical one based on signs, symptoms and investigations and should be in accordance with the hospital infection control policy. Children should remain segregated within the CF clinic for 1 year providing MRSA is not recultured during that time. The decision to screen other family members for colonisation by MRSA is a clinical one.
7
Haemophilus influenzae (HI)
(D)
H. influenzae is the most common bacterial pathogen isolated from respiratory cultures in young children with CF on long term antistaphylococcal prophylaxis, and should be treated regardless of symptoms 15. First choice is co-amoxiclav for 2 weeks which can be combined with clarithromycin if necessary. The course may also be extended to 4 weeks if required. In children >12years who are unable to tolerate co-amoxiclav, doxycycline would be a suitable alternative. A 2 week course of IV antibiotics should be commenced if cultures remain positive, the patient remains symptomatic, or there is a clinical deteriorationError: Reference source not found. Patients who fail to respond to a 4 week course of oral antibiotics should receive a 2 week course of intravenous antibiotic therapy.
8 Pseudomonas aeruginosa (PA)
(A)
There is strong evidence that early identification and treatment of PA and the prevention of chronic PA infection reduces clinical symptoms, improves general health, slows the rate of respiratory decline and significantly improves survival16 17. The treatment regime for first isolation of PA and response to positive surveillance cultures is described on the next 3 pages:
1st isolation: 3 weeks oral ciprofloxacin OR if the patient is unwell, 2 weeks dual therapy intravenous antibiotics PLUS 3 months twice daily nebulised colistin. If the patient fails to eradicate the PA with oral therapy, remains well and is > 6years, then consider treatment with 1 month of twice daily inhaled tobramycin However, if they remain symptomatic, have deteriorated or are < 6years, then failure to eradicate the PA should result in a 2 week
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course of dual therapy IV antibiotics. Similarly, failure to eradicate with inhaled tobramycin should result in IV antibiotics for 2 weeks 18 19. 2nd isolation: as above PLUS lifelong twice daily nebulised antibiotics (1ST choice, colistin) unless there has been a long interval between isolates in which case further eradication may be attempted. These patients will require intermittent systemic (IV or oral) antibiotic therapy depending on clinical status but 3-monthly elective IVs should be consideredError: Reference source not found. Long term oral azithromycin should be considered in all patients chronically infected with PA. Please refer to “Cystic fibrosis- indications for the use of long term azithromycin” for guidance. Patients chronically infected with PA who are unstable may benefit from alternate month colistin and tobramycin nebulisers. ALL PATIENTS WILL HAVE MONTHLY SPUTUM/COUGH SWAB/NPA TAKEN FOLLOWING 1ST ISOLATION OF PA FOR THE FIRST 3 MONTHS, AND SUBSEQUENTLY AT ALL CLINIC VISITS OR WHEN CLINICALLY INDICATED. Choice of intravenous antibiotic: Anti-pseudomonal therapy is determined by sputum culture sensitivities (use the results from a recent sputum culture whilst awaiting the new sputum culture results). All patients must receive two IV agents to reduce the risk of resistance20. Ideally these agents should be of two different drug classes eg. a Beta-lactam combined with an aminoglycoside, however with mounting concerns regarding repeated courses of aminoglycosides over a lifetime, this may not always be possible. In a fully sensitive organism, intravenous ceftazidime and tobramycin would be the usual first choice. There are issues regarding the predictive value of sensitivity testing in CF pseudomonas isolates. As such, occasionally when we are treating a resistant pseudomonas aeruginosa, antibiotics that the organism is “resistant” to are chosen to treat it and response is determined clinically. Aminoglycosides can be given once daily. Tobramycin is preferred. Gentamicin is NOT advised because of mounting evidence of oto- and nephro-toxicity when used in repeated courses over a patient’s life span 21. Patients who are receiving regular courses of intravenous aminoglycosides should have their renal function and hearing assessed annually by GFR, plasma magnesium and pure tone audiometry. Ideally patients should receive only two courses of aminoglycosides per annum.
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Algorithms:
TREATMENT OF EARLY P. AERUGINOSA INFECTION First growth of Pseudomonas aeruginosa?
Yes
3/52 of oral Ciprofloxacin PLUS 3/12 of nebulised Colistin Repeat cultures x 3 (at least 1 month apart)
Further growth?
No
Stop nebulised antibiotics Continue surveillance cultures
Yes
Well?
Yes
Consider 1/12 nebulised tobramycin
No Repeat cultures x 2 (1 month apart)
2/52 Course of IV therapy PLUS Nebulised Colistin x 3/12 Repeat cultures x 3 (at least 1 month apart).
Further growth?
Yes
Further growth? No Yes
Systemic antibiotics as required Continuous nebulised antibiotics Consider long term oral azithromycin
Stop nebulised antibiotics Continue surveillance cultures
TREATMENT OF URTI OR POSITIVE CULTURES Norfolk, Suffolk & Cambridgeshire Paediatric CF Network
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URTI or positive culture?
Yes
On prophylactic antibiotics?
No
Commence 2/52 oral co-amoxiclav
Yes
URTI Double prophylaxis x 48 hours. If no response, change to co-amoxiclav x 48 hours. SA
Increase flucloxacillin to 100mg/kg/day OR commence co-amoxiclav
HI
Stop flucloxacillin. Commence co-amoxiclav x 2/52
PA (NOT 1ST isolation) Asymptomatic: continue with nebs only Symptomatic: 2/52 oral ciprofloxacin if NO course in previous 3/12. If resistant, consider azithromycin instead. Consider IVs as first response in children that are very ill.
Please note that if the patient remains symptomatic or has a positive culture after an appropriate course of antibiotics, then admission should be considered. Endless courses of oral antibiotics should not be given.
9 Unusual organisms If detected at shared-care hospital, please contact Addenbrooke’s for advice.
Stenotrophomonas maltophilia (D): usually clears spontaneously and is not always pathogenic although the evidence is confusing 22 23. Strict isolation policies are not necessary as there is no evidence of patient-to-
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patient transmission24. Treatment should be restricted to those patients chronically infected AND with evidence of clinical deterioration in the absence of other causes. Treatment choices include: 2-4 weeks of oral co-trimoxazole, oral trimethoprim, oral chloramphenicol, or minocycline (if >12 years).
Burkholderia cepacia (C) (please refer to Cystic fibrosis: Guideline for the treatment of Burkholderia cepacia): extended sensitivities must be requested and sample sent to Colindale for genotyping. Patients infected with an epidemic strain can present with Cepacia Syndrome. This is a rapid and progressive pneumonic illness which is untreatable and fatal. Patients infected with other strains often behave no differently from those infected with PA 25. The distribution of isolates is disproportionate with almost 90% belonging to B. multivorans or genomovar II. All patients infected with B. cepacia are to be isolated in both out-patient and in-patient settings. They are isolated for the duration of their admission if other CF patients are in-patients at the same time. Therapy (intravenous and oral) is guided by antibiotic sensitivity patterns and synergy testing or checking MIC’s may be worthwhile. Oral agents useful against B. cepacia include trimethoprim, co-trimoxazole, minocycline (if >12 years). and doxycycline (if >12 years). and these may be considered for mild exacerbations or oral prophylaxis. Patients may also benefit from nebulised ceftazidime which can be rotated with nebulised tobramycin . Due to resistance patterns, patients should not receive nebulised colistin if B. cepacia is the sole isolate from their sputum. Patients should not have B. cepacia cultured from their sputum for at least 1 year before relaxation of the segregation policy occurs.
Non-tuberculous mycobacterium (NTM) (D): NTM must be screened for yearly at annual review, or if otherwise clinically indicated. Screening for NTM can only be performed on sputum or BAL. NTM that commonly infect the CF lung include M. avium complex (MAC), M. abscessus, M. kansasii, M. xenopi, and M. malmoense. Frequently commensals in CF sputum with no impact on CF pulmonary health or nutritional status, they only occasionally require treatmentError: Reference source not found. Anecdotally, there appears to be increased mortality and morbidity with M. abscessus infection and careful consideration to therapy undertaken needs to be given eg: steroids may be contraindicated; extensive immunological testing may be required. The CF Trust has issued guidance with regards infection control measures to be undertaken with regards M. abscessus. Staff do not need to wear masks but universal precautions should be observed. Patients should be isolated both within the out and in patient settings. The decision to treat NTM infection is based on clinical and radiological findings. The current ATS 2007 consensus guidelines, although not specific to CF, are extremely helpful in guiding therapy26. Evaluation of NTM lung disease should include
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Multiple positive sputum samples should be isolated before therapy is undertaken, and bronchoscopy +/- biopsy considered27. High resolution CT scan with contrast. Exclusion of an alternative diagnosis. If clinical and radiological criteria are met, then treatment should be commenced for a minimum of 12-18 months. These bacteria are notoriously difficult to treat and eradication may not be possible. Treatment is obviously dictated by the specific species of NTM and resistance patterns Error: Reference source not found.
M. abscessus28 M.abscessus is universally resistant to standard anti-tuberculous agents and no antibiotic regimen based on in vitro susecptibities has been shown to produce long term sputum conversion in patients with this organism. First line therapy is based on a 3 week induction phase followed by a prolonged continuation phase (12-18 months) as detailed below: Induction phase (3 weeks): Intravenous Amikacin AND Intravenous Imipenem AND Oral Linezolid AND Oral Azithromycin (daily) Continuation phase (12-18 months minimum): Nebulised Amikacin PO Azithromycin (three times weekly) PLUS another agent to which the organism is sensitive (consider Ciprofloxacin or Minocycline (in children >12yr) if sensitivities restrictive) Tigecycline (if >12yr) or linezolid can be considered if allergy to any of the first line drugs arises. It can be prescribed with ondansetron if nausea occurs. Doxycycline (if >12 yr) or Co-trimoxazole can be substituted if minocycline is poorly tolerated. Second line therapy for M. abscessus Patients on first line maintenance therapy will be regarded as “failing” treatment or relapsing if they have the following: Increasing sputum & breathlessness Fevers Sweats Rising CRP No response to treatment with non-mycobacterial antibiotics Persistent smear positive sputum (AFB positive)
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In this instance, the induction phase should be repeated with the addition of intravenous Tigecycline AND intravenous Cefoxitin The continuation phase would include: Nebulised Amikacin Nebulised Meropenem Oral Azithromycin Oral Minocycline Consideration to interferon should be given. Surveillance Full blood count, CRP, renal profile and liver function tests must be checked prior to commencing therapy with the latter two repeated every 12 weeks unless otherwise indicated If LFT’s rise to 5x the upper limit of normal at any stage, all oral drugs should be stopped, with re-introduction one at a time following normalisation of these tests. A second nebulised agent may be introduced in this occurrence. Mycobacterium Avium Complex (MAC) Treatment is continued until the patient is culture negative for 1 year. First
line Oral Azithromycin Oral Rifampicin Oral Ethambutol
Second line Add nebulised OR intravenous amikacin Third Line Consider linezolid
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FIGURE 1
ATYPICAL MYCOBACTERIA ISOLATED (SERIALLY POSITIVE CULTURES)
BASELINE HRCT
SUGGESTIVE OF MYCOBACTERIAL DISEASE?
YES
CONSIDER ANTIMYCOBACTERIAL THERAPY (FIGURE 2)
NO
OBSERVE OVER 12 MONTH PERIOD SERIAL +VE AFB CULTURES REPEAT HRCT SHOWS PROGRESSION
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FIGURE 2
ANTI-MYCOBACTERIAL THERAPY
M.ABSCESSUS
FIRST LINE Induction phase (3 weeks) IV Amikacin AND IV Imipenem AND PO Linezolid AND PO Azithromycin (daily) Continuation phase (12-18 months minimum) Nebulised Amikacin PO Azithromycin (thrice weekly) PLUS another agent to which the organism is sensitive (consider Ciprofloxacin or Minocycline (in children >12yr) if sensitivities restrictive)
MAC
FIRST LINE PO Clarithromycin PO Rifampicin PO Ethambutol Treat until culture negative for 1 year. Second line Add nebulised OR intravenous amikacin Third Line Consider linezolid
SECOND LINE IV Cefoxitin AND/OR IV Tigecycline in addition to first line agents Consider interferon Consider surgery
Achromobacter (Alcaligenes) xylosoxidans (D): can appear spontaneously with routes of acquisition unclear. Evidence regarding its
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clinical significance is confusing. Treatment should be restricted to those patients chronically infected AND with evidence of clinical deterioration in the absence of other causes. Therapy is guided by sensitivities.
10 Influenza (D)
CF patients should receive the influenza vaccine annually and a request for this should be made to their GP (DOH recommendation). NICE guidelines 2003 recommend oseltamivir (Tamiflu) for at-risk children >1yr who present to their GP within 48 hours of the onset of an influenza-like illness. This obviously includes all children with CF, including those that have received the influenza vaccine.
11 Intravenous antibiotics (A)
Indications:
- eradication of first isolate of PA - failure to respond to oral therapy - seriously unwell at time of presentation (>10% drop in lung function, weight loss, desaturation) - planned 3/12 IVs Choice of IVs: depends on most recent positive sputum result and should always include two antibiotics as a minimum29. Those patients not chronically infected with PA, should receive IVs that will cover the most common pathogens including SA, HI, Strep. pneumoniae and Moraxarella catarrhalis, in addition to possible first isolate of PA.
First line: ceftazidime, tobramycin & high dose oral flucloxacillin
Second line: dictated by sensitivities. Anti-pseudomonal monotherapy is not acceptable.
Dosage: In general, high doses are required because of high renal clearance and to ensure high levels of tissue and sputum penetration (see drug formulary section). The serious infection doses are used, and are rounded up not down. CF is a serious condition and the aim of therapy is to push antibiotic doses to the upper therapeutic range. When results of sputum culture are available, confirm that all organisms are covered by the chosen regime. However, if the child is improving clinically on antibiotics to which the organisms exhibit in vitro resistance, do not automatically change them (but discuss with consultant).
Length of course: A minimum of 2 weeks is given. Rarely this is shortened to 10 days.
Aminoglycosides: Evidence to support once-daily aminoglycosides includes reduced toxicity30, reduced PA resistance to aminoglycosides, and improved bacterial killing compared with conventional three-times daily
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dosing. In addition, it is cost-effective as less money is spent on nursing time, and equipment. Importantly for the child, fewer surveillance blood tests are required as only trough serum levels need to be monitored. Tobramycin is the aminoglycoside of choice. Please refer to previous notes with regards choice of aminoglycoside. The once daily aminoglycoside regimen suggested is: Tobramycin Amikacin
10-12 mg/kg once daily over 30 minutes 30mg/kg once daily over 30 minutes
The aminoglycoside should be administered in the morning or early afternoon. Trough serum tobramycin level should be measured 23 hours after administration of the first dose (i.e. shortly before 2nd dose), 48 hours after any adjustment and weekly thereafter. Aim for tobramycin trough of 12 years: 100mg twice daily
Available as: - 50mg & 100mg tablets
Available as: - 150mg & 300mg capsules - 100mg/5ml syrup
Take standing or sitting upright with plenty of water (see doxycycline) Neonate: 510mg/kg twice daily 1 month – 1 year: 510mg/kg twice daily 1 -18 years: 10mg/kg (max. 600mg twice daily
NTM
Decision
Monitor visual acuity – test before treatment and warn patients to report any visual changes Used in caution in children less than 5 years old For S.aureus Give 1 hour BEFORE meals or on an empty stomach. Liquid tastes awful. Last line for MRSA or S. aureus where patients have not responded to conventional agents e.g. high dose flucloxacillin, rifampicin, fusidic acid. Monitor full blood count weekly – haematopoietic disorders have been reported Visual function should be monitored regularly if treatment is required for longer than 28 days. Warn patients to report any visual changes
Second line therapy for M.abscessus Can be useful for S. maltophilia
Second line for S.aureus. Usually give with fusidic acid. Consultant decision.
For first line Norfolk, Suffolk & Cambridgeshire Paediatric CF Network
One month
2 weeks Consultant decision and microbiolo gy approval required
Patient MUST be > 12 years (due to discolouratio n of growning teeth & bone)
Consultant decision
Give half to one hour before food.
2-4 weeks
Caution in CF liver disease May colour urine and discolour soft contact lenses
Use in caution in CF liver disease
Please note: rifampicin interacts with many drugs – please check the cBNF
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Sodium Fusidate/ Fusidic Acid
As Sodium Fusidate: available as: -250mg tablets As Fusidic Acid: available as: -250mg/5ml suspension
13.2
treatment of MAC: 1 month-18 years: 10mg/kg once daily (max. 450mg if 50kg) As Sodium Fusidate: 12-18 years: 500mg every 8 hours; double in severe infections
Useful for MRSA in combination with rifampicin.
2-4 weeks
Caution in CF liver disease.
As Fusidic Acid: Neonate: 15mg/kg three times daily 1 month-1 year: 15mg/kg three times daily 1-5 years: 250mg three times daily 5-12 years: 500mg three times daily 12-18 years: 750mg three times daily
Intravenous drugs for respiratory exacerbation. See section for antibiotic prescribing policies. Decision depends on: Current and past organisms and their antibiotic sensitivities. Past history of individual. Known 'allergies' or intolerance. Note i. Two anti-pseudomonal antibiotics from different classes are ALWAYS given – consultant decision for exceptions. ii. Flucloxacillin is usually given by mouth as it ruins long lines and is well absorbed orally. iii. Preferred blind starting combination is ceftazidime plus tobramycin (or gentamicin if there are problems with getting tobramycin levels done locally) plus oral flucloxacillin/co-amoxiclav. (Evidence that tobramycin is superior to gentamicin in terms of MICs, and resistance by PA). iv. Course length is always a minimum of two weeks. Occasionally courses are extended to 3 weeks.
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v. vi. vii. Amikacin
Aztreonam
Ceftazidime
Care with first doses as unexpected, severe hypersensitivity really can occur. Round doses up or down for ease of administration, especially for home IVs. Antibiotics can impair liver and renal function. Care with underlying impairment. Available as: -100mg/2ml & 500mg/2ml vials
Available as: - 500mg, 1g & 2g vials
Available as: - 500mg, 1g & 2g vials
30mg/kg ONCE a day (max. 2g once a day)
Neonate under 7 days: 30mg/kg every 12 hours Neonate 7-28 days: 30mg/kg every 6-8 hours 1 month- 2 years: 30mg/kg every 6-8 hours 2-12 years: 50mg/kg every 6-8 hours (max. 2g every 6 hours) 12-18 years: 2g every 6-8 hours 1 month-18 years: 50mg/kg three times daily (Max 9 grams daily). Can use twice
Infuse over 30 minutes. Levels at 23 hours after 1st dose (ie before 2nd dose) must be
