Cystic Fibrosis- management of Burkholderia. cepacia complex infections

Transcription

1 Guideline Cystic Fibrosis- management of Burkholderia cepacia complex infections Key messages Burkholderia cepacia infections are associated with significant adverse outcomes in Cystic Fibrosis patients Spread of infection can be limited by strict infection control measures. Early and aggressive combination antibiotic therapy may prevent chronic infection. 1 Scope. Trust wide 2 Aim To optimise the management of Burkholderia cepacia infections in paediatric patients with Cystic Fibrosis (CF) 3 Introduction Burkholderia cepacia complex (Bcc) are a group of at least 17 closely related species of gram negative environmental bacteria, mainly found in soil and water [1]. They do not cause infections in healthy people, but have been shown to be of increasing importance to patients with CF in recent years. They are highly virulent and easily transmissible between CF patients through social and environmental contact. Clinical outcome from Bcc infection is variable. There is a spectrum of symptoms of infection varying from asymptomatic carriage, transient infection or rapid deterioration with septicaemia and necrotising pneumonia. The latter is called cepacia syndrome and is often fatal. Infection does tend to be chronic and is associated with accelerated decline in lung function and shortened life expectancy. B. cenocepacia has the greatest potential for virulence in CF patients. B. cenocepacia, B. multivorans and B dolosa are the most common isolates Page 1 of 6

2 from CF sputum. There is a decreased survival of patients with B cenocepacia post lung transplant [1]. 4 Responsibilities All staff: Adhere to standard infection control recommendations when caring for patients with CF. Clinicians: Liaise with microbiologists and decide on appropriate management on a case-by-case basis. Secretarial staff/outpatient department: Ensure that patients with confirmed Bcc are booked into separate clinics, or at the end of normal clinics. 5 Definitions Burkholderia cepacia complex: A group of closely related species of bacteria belonging to the group Burkholderia. Cepacia syndrome: Rapid and life threatening outcome of Bcc infection, usually with a fulminant clinical picture and very poor prognosis 6 Management of patients who are infected with Bcc 6.1 Laboratory identification Accurate identification of Bcc from sputum specimens is of the utmost importance. However Bcc species are prone to misidentification. All new isolates suspected as Bcc should be sent to the reference laboratory (Health Protection Agency, Colindale) for further specialised analysis and subtyping and the final results discussed with the microbiologists. Virulence and crossinfection potential differ among strains. [1] 6.2 Patient counselling Following a confirmed report of the first growth of Bcc, a senior clinician should discuss with parents in detail the implications. All parents, and if possible the child, should be aware of their Bcc status. Around 3% of CF patients in the UK and USA are infected with Bcc. [2]. 6.3 Antibiotic treatment Intravenous antibiotics are given to CF patients to treat infective exacerbations. These are associated with an increase in respiratory symptoms with deterioration in clinical, biochemical and radiological markers of disease [1]. It is sometimes unclear which organism is responsible for the exacerbation as CF patients are infected with more than one organism. It is common practice to choose antibiotics likely to be effective in the most dominant bacterial species in that patient. Page 2 of 6

3 Despite recognition of the clinical importance of Bcc infection for over 25 years there have been no randomised controlled trials to evaluate optimum treatment of exacerbations [1]. Most organisms within the Bcc complex exhibit high levels of resistance to antibiotics and treatment options may be limited. Antibiotic therapy should be directed by in vitro sensitivities where available. Bcc are innately resistant to colomycin and other aminoglycosides and often resistant to beta lactams. In vitro treatment of Bcc typically requires at least 3 antibiotics. The most consistently active agents appear to be ceftazidime, piperacillintazobactam, meropenem, imipenem, ciprofloxacin, cotrimoxazole, and tetracyclines [4]. Although Bcc are typically resistant to aminoglycosides, high peak concentrations of tobramycin (eg when given nebulised) inhibit the majority of strains. Routine use of synergy testing to guide therapy is currently not recommended. A recent RCT for the addition of aztreonam for inhaled solution for 24 weeks in CF patients with Bcc showed no significant improvement in lung function [11] Management of first isolate Some isolates of Bcc can be successfully eradicated with early aggressive therapy before chronic infection becomes established. In view of the potentially serious implications of chronic infection, eradication should be attempted in all first isolates of Bcc. Although definitive evidence is lacking, the consensus approach is to treat with three intravenous antibiotics (eg: tobramycin plus meropenem plus ceftazidime) for up to 3 weeks, followed by three months of nebulised tobramycin (TOBI,Bramitob )[4]. There have been a few reports which suggest that eradication can be enhanced by giving aerosolised amiloride and tobramycin in combination, as amiloride may act synergistically with tobramycin. This is not yet standard practice but might be considered after a consultant decision on a case-by-case basis [8] Management of Exacerbations In chronically infected patients, oral antibiotics (Ciprofloxacin/ trimethoprim/doxycycline) can be considered for the treatment of mild exacerbations at the discretion of the consultant. Combination therapy of two or three antibiotics should be given for more significant respiratory Exacerbations [2, 3, 6]. Some patients will be chronically infected with Psueudomonas aeruginosa as well as Bcc and initial empiric therapy for exacerbations might have to be tailored to cover both organisms Cepacia syndrome This is associated with poor prognosis and a high mortality. Optimum treatment strategy is not well defined. Treatment with co-trimoxazole has Page 3 of 6

4 been associated with reduced mortality. Combining intravenous and nebulised antibiotics as well as addition of corticosteroids have been shown to be of some benefit [2]. Treatment will be decided on a case-by-case basis by the consultant concerned. 6.4 Infection control There is strong evidence that people with CF can acquire Bcc by direct patient-to-patient spread in hospital or during social contact outside the hospital. A policy of strict segregation should be followed for both inpatients and outpatients as this approach has been shown to reduce cross-infection. There should be evidence of at least 3 negative sputum cultures over a period of at least 1 year before a person with CF can be considered free from Bcc [2] Outpatient clinics There should be separate outpatient clinics for patients chronically infected with Bcc and those who are Bcc negative. The Bcc clinics should be held on different days or at a later time to avoid mixing of patients. hygienic measures, as per local infection control policy should be strictly followed for these patients [2] Inpatients Bcc patients should be nursed on different wards to non Bcc patients if possible. If not possible then they should be barrier nursed in cubicles and stringent infection control policies applied [2] Outside the hospital Social contact between CF patents outside the hospital has some potential to spread infection and should be avoided wherever possible. The risk of transmission is higher with close contact of extended duration (eg: travelling together in a car, communal sports or exercise classes)[2]. 7 Monitoring compliance with and the effectiveness of this policy All Bcc isolates will be discussed by the CF multi-professional team in the weekly CF clinic meeting held on Thursdays. Page 4 of 6

5 8 References 1] Horsley A, Jones AM. Antibiotic Treatment for Burkholderia Cepacia complex in people with Cystic Fibrosis experiencing a pulmonary exacerbation (review). The Cochrane Collaboration ] Burkholderia cepacia Complex. Suggestions for Prevention and Infection Control. Report of the UK Cystic Fibrosis Infection Control Group. Second Edition. September ]Antibiotic treatment for Cystic Fibrosis. Third edition. Report of the UK Cystic Fibrosis Trust Antibiotic Group. May ] Aaron SD Ferris W, Henry DA, Speert DP, MacDonald NE. Multiple combination bactericidal antibiotic testing for patients with Cystic fibrosis infected with Burkhloderia cepacia. Am J Respir Crit Care Med2000: 161: ]Cystic Fibrosis in Children and Adults. The Leeds Method of Management, ]Etherington C, Peckham DG, Conway SP, Denton M. Burkholderia cepacia complex infection in adults with cystic fibrosis - is early eradication possible? J Cyst Fibros 2003;2: ]Middleton PG, Kidd TJ, Williams B. Combination aerosol therapy to treat Burkholderia cepacia complex. Eur Respir J 2005;26: ]Ball R, Brownlee KG, Duff AJ, Denton M, Conway SP, Lee TW. Can Burkholderia cepacia complex be eradicated with nebulised Amiloride and TOBI? J Cyst Fibrosis 2010 ;9(1): ]Kazachkov M, Lager J, LiPuma J, Barker PM. Survival following Burkholderia cepacia sepsis in a patient with cystic fibrosis treated with corticosteroids. Pediatr Pulmonol 2001;32: ]Weidmann A, Webb AK, Dodd ME, Jones AM. Successful treatment of cepacia syndrome with combination nebulised and intravenous antibiotic therapy. J Cyst Fibros 2008;7: ] Tullis D E, Burns J L, Retsch-Bogart GZ et al. Inhaled aztreonam for chronic burkholderia infection in cystic fibrosis: A Placebo controlled trial. J Cystic Fibrosis 2013; 12: Associated documents Antibiotic Guideline for the care of children with cystic fibrosis Page 5 of 6

6 Equality and diversity statement This document complies with the Cambridge University Hospitals NHS Foundation Trust service equality and diversity statement. Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document. Page 6 of 6