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Treating lower and upper airway infections in CF
Christiane Knoop
Institut de Mucoviscidose de l’ULB
Hôpital Universitaire Erasme, Brussels,
Belgium
15th South Eastern European Cystic Fibrosis Conference
CFTR protein
2Rowe et al. N Engl J Med 2005; 352:1992.
CFTR protein
3Rowe et al. N Engl J Med 2005; 352:1992.
Pathogenesis of CF lung disease
4
Abnormal CFTR Protein
Defective Ion Transport2
CFTR gene defect
End StageLung Disease
Cycle ofDestruction
InfectionInflammation
Mucus Obstruction
Delayed mucociliary clearance
Abnormal CFTR protein
Airway surface liquid depletion
Defective ion transport
Scarring
5
CF lung disease
� First cause of morbidity and mortality
in CF adults
� →→→→ 75 % hospital admissions
Penketh Thorax 1987
� FEV1 < 30 % predicted values
� paO2 < 55 mmHg ±±±± paCO2 > 50 mmHg
Survival at 2 yrs < 50 %
Kerem N Engl J Med 1992
Symptoms and signs
• Chronic cough
• Expectorations
• Hemoptysis
• Dyspnea
• Exercise intolerance
• Thoracic pain
• Normal auscultation
→ crackles upper lung
zones → disseminated
• Signs of thoracic
hyperinflation
• Cyanosis
• Clubbing
65th South Eastern European Cystic Fibrosis Conference
Bacterial colonizations
7Cystic Fibrosis Foundation Annual Data Report 2011
Types of colonisations/infections
8
• New infection
• Initial infection successfully
eradicated
• Intermittent colonisation
• Chronic colonisation
• Acute pulmonary exacerbation
5th South Eastern European Cystic Fibrosis Conference
9
Follow-up
1) Clinical assessment
2) Lung function tests
3) Microbiology
5th South Eastern European Cystic Fibrosis Conference
10
Microbiology
• Sputum culture or laryngeal swab at each
out-patient visit (1 x / 4-6 weeks)
• Culture for Pseudomonas and other CF –
associated bacteria
Experienced personnel !
• Antibiotic sensitivity to be established for
various colonies
5th South Eastern European Cystic Fibrosis Conference
Conventional treatment of CF lung disease
11
• Physiotherapy
• Mucolytics (DNAse, hypertonic saline, …)
• Bronchodilators – inhaled corticosteroids
• Antibiotics (inhaled, oral, iv)
• Anti-inflammatory medications (azi,
ibuprofen, …)
• Oxygen – Ventilation
• Preventive measures
Döring et al. J Cystic Fibrosis 2012; 11: 461.
Conventional treatment of CF lung disease
12
• Physiotherapy
• Mucolytics (DNAse, hypertonic saline, …)
• Bronchodilators – inhaled corticosteroids
• Antibiotics (inhaled, oral, iv)
• Anti-inflammatory medications (azi,
ibuprofen, …)
• Oxygen – Ventilation
• Preventive measures
Döring et al. J Cystic Fibrosis 2012; 11: 461.
13
Mucolytics
1) DNAse - Pulmozyme
2) Hypertonic saline
Mucoclear 6% ou 3%
Nebusal 7%
14
DNAse:To whom it should be prescribed ?
In all patients
CF lung disease: mild, moderate, severe
Start during a stable phase or during an acute
exacerbation Am J Respir Crit Care Med 1996
Several months trial
2.5 mg / day
Follow-up of symptoms, lung function, number
of acute exacerbations
No clear criteria for efficacy, no long-lasting
effect
Hypertonic saline
15Elkins et al. N Engl J Med 2006; 354:229.
N = 164
~ 60 euro/month
16
Antibiotics
1) New infection with Pseudomonas
aeruginosa
→→→→ Eradication
2) Chronic colonization/ infection with
Pseudomonas aeruginosa
→→→→ Maintenance therapy
3) Treatment of pulmonary exacerbations
Pseudomonas and other
17
Eradication of new Pseudomonas infection
• Left untreated will progress to chronic infection
• worse lung function
• more exacerbations
• higher mortality
• Prompt eradication treatment necessary
(ideally within 4 wks of sputum)
• No regimen superior to others
• Oral cipro + inhaled coli up to 3 months
• Tobramycin solution for inhalation 28 days
• Follow-up cultures !
Smyth A et al. ECFS Standards of Care: Best practice guidelines. J Cyst Fibr 2014; 13: Suppl 1: S23 – S42.
18
Maintenance treatment
19
Chronic Pseudomonas infection
• Long-term inhaled antibiotics
• Tobramycin solution for inhalation ON/OFF > 6 yrs
to be continued indefinitely (US guidelines), all age
groups (European guidelines)
• TIS and tobramycin dry-powder =
• Inhaled aztreonam is an alternative
• Nebulized or dry-powder colistin widely used
Smyth A et al. ECFS Standards of Care: Best practice guidelines. J Cyst Fibr 2014; 13: Suppl 1: S23 – S42.
20
Other chronic infections
• No recommendations
• In practice
• MSSA flucloxacillin, minocyclin, sxt …
Smyth A et al. ECFS Standards of Care: Best practice guidelines. J Cyst Fibr 2014; 13: Suppl 1: S23 – S42.
New (formulations of) inhaled antibiotics
21
• Tobramycin solution for inhalation (TIS) = TOBI 2,042
euro/month
• Aztréonam (AZLI) = Cayston 3,060 euro/month
• Dry-powder formulations
• TIP = TOBIpodhaler 2,083 euro/month
• CDPI = Colobreathe 1,343 euro/month
• Liposomal formulations
• Amikacine
• International comparator study vs. TIS ongoing
• Antibiotics in development
• Levofloxacine dry-powder
• Vancomycin: nebulized and dry-powder
22
Definition of pulmonary exacerbation
Development of ≥≥≥≥ 3 new symptoms/signs:
• ↑↑↑↑ cough
• ↑↑↑↑ expectorations and/or change of colour
• Fever > 1x/week
• Weight loss > 1 kg ou 5 % of weight + anorexia
• ↑↑↑↑ RR
• New crackles
• ↓↓↓↓ exercise tolerance
• ↓↓↓↓ FEV1 ≥≥≥≥ 10 % of basal values
• ↓↓↓↓ saturation ≥≥≥≥ 10 %
• Changes on X-ray
23
Treatment of pulmonary exacerbation
• Gold standard: β β β β-lactamin + aminoside
• (lack of evidence ! Toxicity, allergy, … )
• if MSSA : + oxacilline
N Engl J Med 1996
• ↑↑↑↑ volume of distribution and AB clearance
• →→→→ higher AB doses and/or shortened
• intervals of administration (PI patients !)
• Duration: 10 - 21 days
• Goal: return to baseline clinical situation/
lung function
17 novembre 2014 24
CF SINUS DISEASE
CFpathogens
25
Preventive measures
1) Avoid contact with infected persons
2) Shots� influenza
3) Improve nutrition
4) Avoid tobacco exposure
(active and passive)Gilljam Resp Med 1991
Campbell J Pediat 1992
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