Oral anti-pseudomonal antibiotics for cystic fibrosis

Background

Pseudomonas aeruginosa is the most common bacterial pathogen causing infection in the lungs of people with CF and appropriate antibiotic therapy is vital. Antibiotics for exacerbations are usually given intravenously, and for long-term treatment, via a nebuliser. Oral anti-pseudomonal antibiotics with the same efficacy and safety as intravenous or nebulised antibiotics would benefit the quality of life of people with CF due to ease of treatment and avoidance of hospitalisation.

Objectives

To determine the benefit or harm of oral anti-pseudomonal antibiotic therapy for people with CF, colonised with Pseudomonas aeruginosa, in the:
1. treatment of an exacerbation of respiratory tract infection; and
2. long-term treatment in chronic infection.

Search strategy

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.

We contacted pharmaceutical companies for information on relevant trials and checked reference lists of identified trials.

Most recent search: April 2008.

Selection criteria

Randomised or quasi-randomised controlled trials comparing any dose of oral anti-pseudomonal antibiotics, with other combinations of inhaled, oral or intravenous antibiotics, or with placebo or usual treatment for exacerbations and long-term treatment.

Data collection and analysis

Two authors independently selected the trials, extracted data and assessed quality. We contacted trialists to obtain missing information.

Main results

We included four trials examining exacerbations (197 participants) and two trials examining long-term therapy (85 participants). We regarded the most important outcomes as quality of life and lung function. In our analysis, we were unable to identify any statistically significant difference between oral anti-pseudomonal antibiotics and other treatments for these outcome measures for either exacerbations or long-term treatment. One of the included trials reported significantly better lung function when treating an exacerbation with ciprofloxacin when compared with intravenous treatment; however, our analysis did not confirm this finding. We found no evidence of difference between oral anti-pseudomonal antibiotics and other treatments regarding adverse events or development of antibiotic resistance, but trials were not adequately powered to detect this.

Authors' conclusions

We found no conclusive evidence that an oral anti-pseudomonal antibiotic regimen is more or less effective than an alternative treatment for either exacerbations or long-term treatment of chronic infection with P. aeruginosa. Until results of adequately-powered future trials are available, treatment needs to be selected on a pragmatic basis, based upon known effectiveness against local strains and upon individual preference.