Pulmonary Disorders II

Notably, most pulmonary exacerbations are not due to the acquisition of a new microorganism,

and patients with CF commonly have routine cultures collected throughout their care. Using the

patient’s previous susceptibility pattern or restarting a previous successful antibiotic regimen is

common practice.

For patients with history of or suspected infection with Pseudomonas aeruginosa, initial

treatment with two antipseudomonal agents is recommended, despite limited evidence that

Database Syst Rev 2021;6:CD002007).

ii.

Two drugs from different classes are recommended rather than double β-lactams, with most

data supporting a β-lactam in combination with an aminoglycoside, although toxicity risk and

patient-specific factors should be taken into account.

iii.

Aggressive dosing of β-lactam antibiotics is recommended to optimize time above the minimum

inhibitory concentration, primarily based on pharmacokinetic data. Current evidence is

insufficient to recommend routine use of extended infusion or continuous infusion β-lactams

for all patients with CF, but this practice should be considered on a case-by-case basis and is

Care 2009;54:522-37).

iv.

Extended-interval aminoglycoside dosing (e.g., once-daily dosing of tobramycin 10 mg/kg,

targeting a peak concentration of 20–30 mg/L and a trough concentration of less than 1 mg/L)

Cochrane Database Syst Rev 2017;3:CD002009).

Evidence is currently lacking for or against the simultaneous administration of inhaled and

2009;180:802-8; Cochrane Database Syst Rev 2022;8:CD008319.

Duration of therapy

A 10- to 14-day course of antibiotics is common practice, and durations are primarily driven by

clinical response, either symptomatology or FEV1 measurements.

The Standardized Treatment of Pulmonary Exacerbation (STOP) trial reflected this precedent with

a mean duration of intravenous antibiotics in adults of 16.2 days (J Cyst Fibros 2017;16:600-6).

The STOP2 trial excluded ICU patients, but identified that for patients who improved within 7–10

days, 10 days of antibiotics was noninferior to 14 days. Patients without improvement should

complete a 14-day course, but treating past 14 days was noninferior to a 21-day treatment course

Therapy

Clinical benefit(s)

Inhaled tobramycina

Inhaled aztreonama

Oral azithromycina

Oral azithromycinb

aPatients with history of Pseudomonas aeruginosa.

bPatients without history of P. aeruginosa.