Aerosol antibiotic treatment in cystic fibrosis.

The outlook for people with cystic fibrosis has improved steadily since the first descripition of the disease in the late 1930s. A major reason for the improved prognosis has been the availability and effective use of antibiotics to delay the onset, and slow the progress, of the inevitable bronchopulmonary bacterial colonisation and infection that will eventually prove fatal. During the 1970s and 1980s the main emphasis of treatment concerned intravenous antibiotics as techniques of intravenous access had improved. Also, more patients survived to become infected by Pseudcmonas aeruginosa for which only intravenous antibiotics were effective until the recent introduction of the quinolones (for example, ciprofloxacin). However, during this period there appeared sporadic reports of the use of aerosol antibiotics. In 1981, a controlled study comparing twice daily nebulised gentamicin 80 mg and carbenicillin 1 g with placebo demonstrated a slowing of the decline of respiratory function tests between courses of intravenous antibiotic treatment. ' In patients recently colonised by P aeruginosa, nebulised colistin sulphomethate reduced the frequency ofcultures positive for the organism.2 Although some reports of the use of aerosol antibiotics have been anecdotal and uncontrolled, the majority have reported that patients benefited from their use. Controlled studies have confirmed benefit to the patients in the treated groups. 34 During the past five years there has been a steady increase in the use of aerosol antibiotics in a variety of clinical situations. Attitudes to the early treatment and control of pseudomonas infection in patients with cystic fibrosis have changed, with an impatience to eradicate P aeruginosa at an early stage after colonisation, rather than waiting until tissue infection is well established5 (C Vasquez et al, European Cystic Fibrosis Conference, 1991). The discovery of thecystic fibrosis gene and consequent new treatment possibilities have increased the interest in early treatment and the prevention of pulmonary damage. Many clinicians are now prepared to recommend more time consuming treatment regimens for patients who are relatively well in an attempt to maintain the patient in as good a condition as possible so that maximum benefit may be available subsequently. The importance of the method of delivery of the aerosol antibiotics has been emphasised by a number of workers.69 However, it is still common for those with cystic fibrosis to be prescribed nebulised antibiotics using an inappropriate nebuliser and inadequate compressor system often using a mask when a mouthpiece would have been more appropriate. These patients are wasting a great deal of time and deriving little or no benefit from a potentially valuable type of treatment. Many useful data have been published over the past decade on the techniques and equipment for efficient nebulisation of antibiotics but some has appeared in journals not usually read by general paediatricians. The purpose of this article is to review the clinical indications, drugs used, and methods of administration of inhaled antibiotics in cystic fibrosis.