Use of Aerosolized Antibiotics in Patients With Cystic Fibrosis: Comparability of Nebulizers and Compressors
Comparability of Nebulizers and Compressors: Due to the technical differences between devices and the physical and chemical differences between drugs, it cannot be assumed that equivalent efficacy will result from interchanging nebulizers and compressors or using alternative antibiotics.
The Complexity of Sputum-Antibiotic Interaction in CF Patients: To date, studies with tobramycin represent the most complete understanding of sputum-antibiotic interactions in CF patients. Similar studies need to be performed with other antibiotics such as colistin, β-lactam agents, and newer compounds. Therefore, recommendations are limited to preservative-free tobramycin.
Recommendations for the Delivery and Dosing of Preservative-Free 300-MG Dose of Tobramycin
1. Preservative-free 300-mg dose of tobramycin should be delivered using a PARI LC PLUS nebulizer plus a De Vilbiss PulmoAide compressor (consensus grade I).
Comment: At present the largest study of efficacy has been done with the PARI LC PLUS nebulizer and a De Vilbiss PulmoAide compressor. Changing nebulizer cup or compressor type may affect lung deposition, clinical efficacy, and toxicity. Other breath-enhanced systems may have better in vitro delivery characteristics, but they have not been tested clinically (to our knowledge). Increasing lung deposition may also increase systemic absorption, potentially increasing toxic effects.
2. Based on similar sputum concentrations and proven clinical efficacy, a preservative-free 300-mg dose of tobramycin can be given to all patients > 6 years (consensus grade I). contraceptive pills
Comment: Lower doses of tobramycin in previous studies resulted in an inconsistent clinical response. To our knowledge, there are no data available in children < 6 years of age. Infants and younger children may nose breathe, cry, or scream which can interfere with airway deposition. Younger children have low tidal volumes and may hold the aerosol mask away from their faces. Further studies are necessary to evaluate efficacy, safety, and delivery device requirements for children < 6 years old.
3. Studies support the use of preservative-free 300-mg dose of tobramycin aerosolized twice a day for cycles of 1 month receiving drug, followed by 1 month not receiving drug (consensus grade I).
Comment: To our knowledge, there are no data supporting longer off periods, shorter cycles, or continuous aerosol treatment.
4. Admixing other medications with a preservative-free 300-mg dose of tobramycin cannot be recommended at this time (consensus grade III).
5. Based on the order of aerosolized medications used in the phase III clinical trial, the recommended order of aerosolized medications is (when prescribed) inhaled bronchodilators, DNase, and chest physiotherapy followed by aerosolized preservative-free 300-mg dose of tobramycin. When prescribed, inhaled corticosteroids or cromolyn/nedocromil sodium should follow inhaled tobramycin (consensus grade III).