CF Flashcards
clinical presentation
increased cough
increased sputum production
SOB
chest pain
loss of appetite
weight loss
decreased FEV1
decreased FVC
Common pathogens of CF
pseudomonas aeruginosa**
strenotrophomonas maltophilia
MRSA**
acchomocter xylosoxidans
burkhoderia cepacia complex**
nontuberculosis mycobacteria
initial antimicrobial selection
typical pathogens for age
recent culture data
recent outpatient antiimicribial use
previous abx that result in clinical improvement
allergies
advere effects
mucoid
slimy or viscous consistency of bacterial colony
caused by the adaptation that assist the bacteria with resisting antibiotic
seen w persistent pseudomonas infections
aggressive therapy in CF
antibiotic selection for pulmonary exacerbation
no clear consensus what should be prescribed
target most common organism in respiratory tract
quarterly sputum collection for empiric therapy
pulmonary exacerbations =
respiratory symptoms + decline in lung function
two antibiotics
decreased resistance
higher cost
toxicity risk
one antibiotic
increased resistance
reduced cost
reduced toxicity
most centers us a two antibiotic regimen for CF exacerbations to target what
Pseudomonas
what is the outcome of using two different mechanism of action
synergistic activity in vitro
ex: AMG+ beta lactam
when is acute inpatient management indicated
severe exacerbations
resistance to oral antibiotics
failure to resolve exacerbations
antibiotic selection for acute inpatient is based on
sensitivities
microbial culture
renal function
previous clinical response
routes for acute pulmonary exacerbations
oral
IV
aerosolized
first treatment options for Pseudomonas
- tobramycin, amikacin
-cirprofloxacin
second treatment options for Pseudomonas
-piperacillin/tazobactam
-ceftazidime, cefepime
-carbapenem, meropenem, imipenem
treatment option for stenotrophonas maltophilia
-sulfamethoxazole/trimethoprim
-levofloxacin
-ceftazidime
-piperacillin/tazobactam
treatment option for MRSA
vancomycin ***
linezolid **
sulfamethoxazole/trimethoprim
ceftaroline
clindamycin
if MSSA treatment
may use beta lactase except ceftazidime (poor coverage)
treatment option for stenotrophomonas maltopilia
-sulfamethoxazole/trimethoprim
-levofloxacin
-ceftazidime
-piperacillin/tazobactam
treatment option for burkholderia cepacia complex
-sulfamethoxazole/trimethoprim
-doxycycline
-ceftazidime
-meropenem
How long are CF drugs administered and what are the drugs commonly used for pseudomonas
longer period of time
beta lactams
-cepfepime
-ceftazidime
-imipenem
-meropenem
-piperacillin/tazobactam
-
PK of CF
larger volume of distribution
faster clearance
larger antibiotic doses and shorter dosing intervals
therapeutic drug monitoring and necessary dosage and regimen adjustments are critical
dosing strategies of AMG
high doses, extended interval doses
monitoring: random only
less doses and TDM
lower is of toxicity
higher doses=higher peaks
extended intervals=lower troughs= lower troughs =lower toxicity
TOPIC study Conclusion
IV tobramycin had equal Efficacy given one vs three times a day for CF
once a day is less nephrotoxic
what is the guideline Recommendations dosing for AMG for cf pulmonary exacerbation
once a day dosing
what is the long time consequence of AMG in CF?
INCREASED RISK FOR VESTIBULAR LOSS (HEARING LOSS)
Is it sufficient to recommend an optimal duration of antibiotic treatment of an acute exacerbation of pulmonary disease?
No, but most centers treat 10-14 days
monitoring during pulmonary exacerbations
FEV1 to normal baseline, if possible
symptoms improvement
c-reactive protein
procalcitonin
AMG monitoring
peak, trough, or random
renal function panel twice weekly
CBC with differential weekly ‘vestibular testing (annually or those with frequent toobramycin
beta lactam monitoring
CDC with differential weekly
renal function panel weekly
liver functiobtest and bilirubin baseline and when therapy > 14 days (pip.taz, ceftriaxone, imipenem, meropenam
vancomycin monitoring
Target AUC: 400-600 mcg*hr/L
random level and trough before dose when patient reaches steady state
renal function panel twice weekly
Fluroquinolones monitoring
avoid use with QT prolongation
linezoid monitoring
CBC with differential weekly
liver function tests
serotonin syndrom
other considerations for CF pulmonary exacerbation
bronchodilator
mucoytic
enzyme mucolytic inhaled
inhaled antibiotic
chronic management of CF
inhaled antibiotic
Tobramycin
Tobramycin dose
300 mg INH BID x 28 days on , alternated with aztreonam
ADR of tobramycin
discolored sputum, altered voice, hearing loss
when is tobramycin recommended ?
> =6 yo with mild to severe lung disease w peresistent pseudomonas in sputum culture
when is aztreonam recommended ?
> =6 yo with mild to severe lung disease w peresistent pseudomonas in sputum culture
aztreonam dose
75 mg INH TID x 28 on, alternated with tobramycin
ADR of aztreonam
coughing weezing
anti-inflammatory therapy of CF
AZithromycin
when is azithromycin recommended in CF
> =6 yo w persistent p. aeruginosa infection
utilized for antimicrobial (may decrease p. aeruginosa) and anti-inflammatory (decrease neutrophils) properties
what do patients need to be screened for to prevent resistance before taking azithromycin
non tuberculosis mycobacteria
what does the guideline stronly recommend for the prevention and eradication of initial p.aeruginosa
the use of inhaled tobramycin 300 mg BID for 28 days
when is prophylactic antimicrobial therapy used in CF
generally reserved for persistent p. aeruginosa infections and is recommended last during chronic pulmonary clearance therapy
