Nebulised anti-pseudomonal antibiotics for cystic fibrosis

Background

Persistent infection by Pseudomonas aeruginosa contributes to lung damage, resulting in illness and death in people with cystic fibrosis (CF). Nebulised antibiotics are commonly used to treat this infection.

Objectives

To examine the evidence that nebulised anti-pseudomonal antibiotic treatment in people with CF reduces frequency of exacerbations of infection, and improves lung function, quality of life and survival. To examine adverse effects of nebulised anti-pseudomonal antibiotic treatment.

Search strategy

Trials were identified from the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register. Companies that marketed nebulised anti-pseudomonal antibiotics were contacted for information on unpublished trials.

Most recent search of the Group's Cystic Fibrosis Trials Register: November 2006.

Selection criteria

Trials were selected if, nebulised anti-pseudomonal antibiotics treatment was used for four weeks or more in people with CF, allocation to treatment was randomised or quasi-randomised, and there was a placebo or a no placebo control group or another nebulised antibiotic comparison.

Data collection and analysis

For the first version of this review, two authors independently selected and judged the quality of the trials to be included in the review. One author extracted data from these trials and performed all tasks for updates of the review.

Main results

The search identified 116 citations to 53 trials. Fourteen trials, with 1100 participants, met the inclusion criteria. Thirteen trials with 985 participants compared a nebulised anti-pseudomonal antibiotic with placebo or usual treatment. One of these trials accounted for 53% of the total participants; and seven of these trials used a cross-over design. Tobramycin was studied in eight trials and follow up ranged from 1 to 32 months. Lung function, measured as forced expired volume in one second (FEV₁) was better in the treated group than in control group in nine of these. Resistance to antibiotics increased more in the antibiotic treated group than in placebo group. Tinnitus and voice alteration were more frequent with tobramycin than placebo. One short-term trial of one month, with 115 participants, compared tobramycin and colistin, and showed a trend towards greater improvement in FEV₁ in the tobramycin group.

Authors' conclusions

Nebulised anti-pseudomonal antibiotic treatment improves lung function. However, more evidence, from longer duration trials, is needed to determine if this benefit is maintained as well as to determine the significance of development of antibiotic resistant organisms. There is insufficient evidence for recommendations about type of drug and dose regimens.