Research Letter
Is there a role for antimicrobial stewardship in bronchiectasis?
Chronic Respiratory Disease 1–2 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1479972315587514 crd.sagepub.com
I Gassiep1,2 and A Chaudhuri1,2 Keywords Antimicrobial stewardship, bronchiectasis, ciprofloxacin, infective exacerbation, management
Bronchiectasis is a common respiratory condition resulting in irreversible bronchial damage. The pathogenesis is thought to follow a ‘‘vicious cycle’’ whereby chronic inflammation and/or infection causes ciliary dysfunction, dilated bronchioles, and decreased sputum clearance. Decreased clearance therefore exacerbates the infection risk.1 A significant majority of these patients exhibit airway colonization with various pathogenic organisms, most notably Pseudomonas aeruginosa (PA). Infective exacerbations with PA are challenging to manage in these patients due to a high rate of recurrences and potential impact of progressive antimicrobial resistance. These two factors interact in yet another vicious cycle, making antibiotic choice of paramount importance during every episode of exacerbation. Although there has been considerable research on antibiotic use in bronchiectasis among cystic fibrosis (CF) patients, little research has been undertaken in non-cystic fibrosis bronchiectasis (NCFB), such that management decisions are largely based on expert opinion and theory rather than clinical evidence. In a retrospective audit carried out in a tertiary teaching hospital in Brisbane, in order to examine antibiotic use in infective exacerbations of NCFB and its concordance with the Australian therapeutic guidelines (ATG),2 there was a stark discordance with guidelines. During the 3-year period of the audit, 134 admissions occurred in 75 patients with NCFB. Previous sputum samples were available for each of the 134 admissions. PA was cultured from 80 previous sputum samples prior to treatment of which seven were ciprofloxacin resistant. The overall rate of isolating a ciprofloxacin-resistant strain of PA was 5%. All 134 episodes were treated with at least one intravenous antibiotic. In total, 32 different treatment regimens were used for treatment of infective exacerbations of NCFB (Figure 1). Interestingly, of the 107 regimens, including an antipseudomonal
agent, only 30 (28%) contained ciprofloxacin. The reason for dual antipseudomonal treatment over the recommended single-agent oral ciprofloxacin therapy (as per the ATG2) was noted only in 9.3% of patients. The aim of this audit was to assess the current management of infective exacerbations of NCFB with particular attention to antipseudomonal therapy. Interestingly, the usage of oral ciprofloxacin was unexpectedly low and replaced instead by the universal use of intravenous antibiotics (often antipseudomonal). In fact, antibiotics with antipseudomonal activity were used in 80% of NCFB admissions in our study but such treatment was not required in 40% of admissions. This raises numerous questions about rational antimicrobial prescription and the role of antimicrobial stewardship (AMS) beyond that of primarily restricting certain ‘‘classes’’ of antibiotics. In fact encouraging their appropriate use (indication, dose, and route) can mitigate other risks such as those associated with intravenous access and a prolonged hospital stay for that reason as well as adverse events such as aminoglycoside toxicity. The British Thoracic Society guidelines are recognized as an international standard in the management of bronchiectasis, having combined multiple databases and 1830 references. Their recommendation for first-line treatment is amoxicillin 500 mg three times a day or clarithromycin 500 mg twice daily (inpatients
1
Department of Infectious Diseases, Greenslopes Private Hospital, Brisbane, Queensland, Australia 2 School of Medicine, University of Queensland, Brisbane, Queensland, Australia Corresponding author: I Gassiep, Department of Infectious Diseases, Greenslopes Private Hospital, Newdegate St Greenslopes, Queensland 4120, Australia. Email: [email protected]
Downloaded from crd.sagepub.com at East Tennessee State University on June 11, 2015
2
Chronic Respiratory Disease
Figure 1. Ten most prescribed antibiotic regimens for infective exacerbation of NCFB. NCFB: non-cystic fibrosis bronchiectasis.
who are penicillin allergic) for 14 days. Patients colonized with PA should be treated with oral ciprofloxacin during an episode of infective exacerbation. Furthermore, only patients unresponsive to this course should be treated with a single intravenous antipseudomonal agent, unless they have proven resistance to one or more antibiotics, including ciprofloxacin.1 The ATG recommends considering dual intravenous therapy for PA infection upon failure of oral therapy.2 Management of infective exacerbations of NCFB poses a significant AMS challenge. The treatment regimens at this hospital vary markedly, highlighting a lack of consensus among specialists regarding which regimen may be most effective and least harmful to the patient. Author declaration This study is unfunded. The authors report no conflicts of interest. The Greenslopes Private Hospital Ethics committee
gave permission for this paper to be submitted for publication.
Authors’ contribution Dr Ian Gassiep performed data collection and analysis. Drs Gassiep and Chaudhuri had equal input regarding intellectual planning and writing of the article.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Pasteur MC, Bilton D, Hill AT, et al. British thoracic society guideline for non-CF bronchiectasis. Thorax 2010; 65: i1–i58. 2. Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited, 2010.
Downloaded from crd.sagepub.com at East Tennessee State University on June 11, 2015
Is there a role for antimicrobial stewardship in bronchiectasis?
Chronic Respiratory Disease 1–2 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1479972315587514 crd.sagepub.com
I Gassiep1,2 and A Chaudhuri1,2 Keywords Antimicrobial stewardship, bronchiectasis, ciprofloxacin, infective exacerbation, management
Bronchiectasis is a common respiratory condition resulting in irreversible bronchial damage. The pathogenesis is thought to follow a ‘‘vicious cycle’’ whereby chronic inflammation and/or infection causes ciliary dysfunction, dilated bronchioles, and decreased sputum clearance. Decreased clearance therefore exacerbates the infection risk.1 A significant majority of these patients exhibit airway colonization with various pathogenic organisms, most notably Pseudomonas aeruginosa (PA). Infective exacerbations with PA are challenging to manage in these patients due to a high rate of recurrences and potential impact of progressive antimicrobial resistance. These two factors interact in yet another vicious cycle, making antibiotic choice of paramount importance during every episode of exacerbation. Although there has been considerable research on antibiotic use in bronchiectasis among cystic fibrosis (CF) patients, little research has been undertaken in non-cystic fibrosis bronchiectasis (NCFB), such that management decisions are largely based on expert opinion and theory rather than clinical evidence. In a retrospective audit carried out in a tertiary teaching hospital in Brisbane, in order to examine antibiotic use in infective exacerbations of NCFB and its concordance with the Australian therapeutic guidelines (ATG),2 there was a stark discordance with guidelines. During the 3-year period of the audit, 134 admissions occurred in 75 patients with NCFB. Previous sputum samples were available for each of the 134 admissions. PA was cultured from 80 previous sputum samples prior to treatment of which seven were ciprofloxacin resistant. The overall rate of isolating a ciprofloxacin-resistant strain of PA was 5%. All 134 episodes were treated with at least one intravenous antibiotic. In total, 32 different treatment regimens were used for treatment of infective exacerbations of NCFB (Figure 1). Interestingly, of the 107 regimens, including an antipseudomonal
agent, only 30 (28%) contained ciprofloxacin. The reason for dual antipseudomonal treatment over the recommended single-agent oral ciprofloxacin therapy (as per the ATG2) was noted only in 9.3% of patients. The aim of this audit was to assess the current management of infective exacerbations of NCFB with particular attention to antipseudomonal therapy. Interestingly, the usage of oral ciprofloxacin was unexpectedly low and replaced instead by the universal use of intravenous antibiotics (often antipseudomonal). In fact, antibiotics with antipseudomonal activity were used in 80% of NCFB admissions in our study but such treatment was not required in 40% of admissions. This raises numerous questions about rational antimicrobial prescription and the role of antimicrobial stewardship (AMS) beyond that of primarily restricting certain ‘‘classes’’ of antibiotics. In fact encouraging their appropriate use (indication, dose, and route) can mitigate other risks such as those associated with intravenous access and a prolonged hospital stay for that reason as well as adverse events such as aminoglycoside toxicity. The British Thoracic Society guidelines are recognized as an international standard in the management of bronchiectasis, having combined multiple databases and 1830 references. Their recommendation for first-line treatment is amoxicillin 500 mg three times a day or clarithromycin 500 mg twice daily (inpatients
1
Department of Infectious Diseases, Greenslopes Private Hospital, Brisbane, Queensland, Australia 2 School of Medicine, University of Queensland, Brisbane, Queensland, Australia Corresponding author: I Gassiep, Department of Infectious Diseases, Greenslopes Private Hospital, Newdegate St Greenslopes, Queensland 4120, Australia. Email: [email protected]
Downloaded from crd.sagepub.com at East Tennessee State University on June 11, 2015
2
Chronic Respiratory Disease
Figure 1. Ten most prescribed antibiotic regimens for infective exacerbation of NCFB. NCFB: non-cystic fibrosis bronchiectasis.
who are penicillin allergic) for 14 days. Patients colonized with PA should be treated with oral ciprofloxacin during an episode of infective exacerbation. Furthermore, only patients unresponsive to this course should be treated with a single intravenous antipseudomonal agent, unless they have proven resistance to one or more antibiotics, including ciprofloxacin.1 The ATG recommends considering dual intravenous therapy for PA infection upon failure of oral therapy.2 Management of infective exacerbations of NCFB poses a significant AMS challenge. The treatment regimens at this hospital vary markedly, highlighting a lack of consensus among specialists regarding which regimen may be most effective and least harmful to the patient. Author declaration This study is unfunded. The authors report no conflicts of interest. The Greenslopes Private Hospital Ethics committee
gave permission for this paper to be submitted for publication.
Authors’ contribution Dr Ian Gassiep performed data collection and analysis. Drs Gassiep and Chaudhuri had equal input regarding intellectual planning and writing of the article.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Pasteur MC, Bilton D, Hill AT, et al. British thoracic society guideline for non-CF bronchiectasis. Thorax 2010; 65: i1–i58. 2. Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited, 2010.
Downloaded from crd.sagepub.com at East Tennessee State University on June 11, 2015
