Scottish Adult Cystic Fibrosis Service Ninewells Hospital Dundee Intravenous Antibiotic Therapy Information Leaflet February 2008 Intravenous antibiotic therapy in cystic fibrosis Patients with cystic fibrosis (CF) have recurrent chest infections, the most common infecting organisms being Burkholderia Cepacia complex, Haemophilus Influenzae, Pseudomonas Aeruginosa, Staphylococcus Aureus, and Stenotrophomonas Maltophilia. The prognosis of CF patients has improved in recent years due to intravenous (IV) antibiotic use, which had necessitated long periods of hospitalisation for some patients. Often patients are not acutely unwell and home treatment is preferred to hospitalisation where there is a risk of cross-infection with resistant organisms. Home intravenous antibiotic treatment Patients receiving IV antibiotic therapy for the first time are initially assessed for suitability of home treatment. If suitable, a hospital admission is arranged, where patients are trained in preparation and administration of IV antibiotics by members of the CF team, with emphasis on safety and hygiene aspects. Patients must be formally certified as competent before being discharged to self-administer IV antibiotics at home. Patients requiring frequent IV treatment have their aseptic technique reassessed regularly. Further courses of IV antibiotic treatment are often initiated on an outpatient basis. Patients are given their first dose of each IV antibiotic course in hospital to observe for adverse effects including anaphylaxis.
Selection of IV antibiotic regimen Pseudomonas Aeruginosa Infecting organism? Staphylococcus Aureus Haemophilus Influenzae Severe Mild Severe Mild Sensitive to ceftazidime? Sensitive to ciprofloxacin? IV cefuroxime 1.5g TDS Oral ciprofloxacin 500mg TDS +/- oral co-amoxiclav 625mg TDS documented ceftazidime hypersensitivity? Oral ciprofloxacin 500mg TDS & oral coamoxiclav 625mg TDS IV ceftazidime 2g & tobramycin TDS Sensitive to Tazocin? documented Tazocin hypersensitivity? IV Tazocin 4.5g & tobramycin TDS Sensitive to aztreonam? documented aztreonam hypersensitivity? IV aztreonam 2g & tobramycin TDS Sensitive to meropenem? documented meropenem hypersensitivity? IV meropenem 1g & tobramycin TDS If Burkholderia cepacia or Stenotrophomonas maltophilia is cultured from a patient s sputum, the above flowchart does not apply. Antibiotics will be chosen on the basis of microbial sensitivities and patient allergies. If tobramycin or other aminoglycosides can no longer be used due to bacterial resistance or intolerable side effects, colistin is a suitable alternative. It can be combined with a second antibiotic by following the flow chart above. Colistin must not be used in combination with aminoglycosides due to increased risk of toxicity. Other antibiotics may be prescribed on occasion, depending on microbial sensitivities and patient allergies. All antibiotics are prescribed for a fourteen day course unless specified otherwise..
Administration Wherever possible, IV antibiotics are administered by bolus injection via a peripherally placed mid-line catheter or implanted vascular port (accessed using a gripper needle). Lines are inserted and removed by medical or nursing staff at the CF unit. Routine practice is to use two antibiotics by the following procedure: 1. sodium chloride 0.9% 2-3ml 2. antibiotic 1 3. sodium chloride 0.9% 2-3ml 4. antibiotic 2 5. sodium chloride 0.9% 2-3ml 6. heparinised saline 10u/ml (Hepsal ) 4ml Sodium chloride 0.9% injection is used as a flush to avoid the problems associated with mixing active drugs. Heparinised saline is used to prevent thrombus formation in the administration line. Plastic vials of sodium chloride 0.9% and water for injections should be supplied to minimise the risk of injecting shards of glass. Brands of plastic vials include Mini- Plasco and Steripak.
Commonly prescribed IV antibiotics for adult CF patients Drug Preparation Diluent Usual adult CF dose tes cefuroxime Zinacef 1.5g WFI 15ml 1.5g TDS used for Staph Aureus and H Influenzae infections principal adverse effect is hypersensitivity, manifest as rashes, fever, arthralgia and anaphylaxis colitis), headache transient hepatitis, cholestatic jaundice and alterations in LFTs have been reported other (rare) side effects include blood dyscrasias and haemorrhage due to interference with clotting factors tobramycin N/A 120-180mg TDS active against Pseudomonas Aeruginosa: synergistic action in combination with betalactam antibiotics most adverse effects are dose-related, most importantly nephrotoxicity and ototoxicity must be injected slowly, over 5 minutes avoid in patients with previous aminoglycoside-induced ototoxicity caution in renal impairment plasma concentration monitoring avoids both excessive and subtherapeutic dosage, thus preventing toxicity and ensuring efficacy. Trough plasma levels are taken immediately pre-dose and peak levels 1 hour post-dose. Monitoring is carried out by the CF team for the entire treatment course other (rare) side effects include nausea, vomiting, antibiotic-associated colitis, hypomagnesaemia
Drug Preparation Diluent Usual adult CF dose tes ceftazidime Fortum 1g/2g/3g WFI 10ml 2g or 3g TDS third generation cephalosporin with good activity against pseudomonas principal adverse effect is hypersensitivity, manifest as rashes, fever, arthralgia and anaphylaxis piperacillin with tazobactam colitis) CNS adverse effects include headache, dizziness, paraesthesia transient hepatitis, cholestatic jaundice, alterations in LFTs and elevation of urea and creatinine have been reported neurological sequalae including tremor, myoclonia, convulsions and encephalopathy have occurred in patients with renal impairment in whom the dose has not been appropriately reduced other (rare) side effects include blood dyscrasias and haemorrhage due to interference with clotting factors Tazocin 4.5g WFI 20ml 4.5g TDS antipseudomonal penicillin with beta-lactamase inhibitor principal adverse effect is hypersensitivity, manifest as rashes, fever, arthralgia and anaphylaxis colitis), headache transient hepatitis, cholestatic jaundice, alterations in LFTs and elevation of urea and creatinine have been reported other (rare) side effects include blood dyscrasias and haemorrhage due to interference with clotting factors
Drug Preparation Diluent Usual adult CF dose tes aztreonam Azactam 1g/2g WFI 10ml 2g TDS beta lactam antibiotic with activity against gram-negative bacteria including Pseudomonas Aeruginosa incidence of anaphylaxis is lower than with other penicillins and cephalosporins colitis) transient hepatitis, cholestatic jaundice, alterations in LFTs and elevation of urea and creatinine have been reported other adverse effects include rashes, blood dyscrasias, weakness, confusion, dizziness, muscle aches and fever meropenem Meronem 1g WFI 20ml 1g or 2g TDS broad spectrum beta lactam antibiotic with activity against Pseudomonas Aeruginosa colitis) rarely, hypersensitivity reactions may occur including angioedema and anaphylaxis alterations in LFTs and blood dyscrasias have been reported other side effects include rashes, headache and paraesthesiae
Drug Preparation Diluent Usual adult CF dose tes colistin Colomycin 1MU/2MU 0.9%NaCl 10ml 2MU TDS polymixin antibiotic with activity against Pseudomonas Aeruginosa can cause neurotoxicity including parasthesia, vertigo, and rarely, vasomotor instability, slurred speech and confusion rarely, hypersensitivity reactions may occur caution in renal failure, dose reduction required must be injected slowly over at least 5 minutes must not be used in combination with aminoglycosides due to increased risk of toxicity WFI = water for injections te that all of the above antibiotics can cause phlebitis / thrombophlebitis when given intravenously Please refer to the manufacturer s Summary of Product Characteristics / Data Sheet for full prescribing details te that all antibiotics should be administered slowly over at least 3 minutes unless otherwise stated. Adult Cystic fibrosis team contacts CF office: Tel: 01382 496457 CF consultants: Dr H Rodgers: 01382 496552 Dr John Winter: 01382 496457 CF nurse specialists: Mags Pogson Lawrie MacDougall: 01382 496552 CF pharmacist: Arlene Shaw: 01382 660111 bleep 5059