Home intravenous antibiotics for cystic fibrosis - setting up a hospital @home service.

The use of home intravenous (IV) antibiotics is well-established in patients with Cystic Fibrosis (Balaguer, A. & Gonzalez de Dios, J. The Cochrane Library 2008; 3:CD001917). However, it is not common practice in adult patients with non-CF bronchiectasis (NCFB), who may be older, with increased co-morbidities and lower functional status. We evaluated a new home IV antibiotic program for NCFB through a retrospective case note review of patients receiving a course of home IV antibiotics at the Royal Devon and Exeter Hospital (UK) between November 2013 and June 2014. Antibiotic used, nurse appointments incurred, readmission rates (and reason) and other problems were recorded. Ten patients were eligible, 7 female. Average age was 64 (range 34 to 75). There were 16 inpatient and 18 home IV courses. The average home IV course was 9.2 days. There were 130 inpatient (including readmission) and 151 home IV treatment days. The home IV treatment included 39 nurse clinic appointments. Time of initiation of treatment to discharge improved from 5.3 to 3 days for subsequent home IV courses compared to first. Based on the average cost of an inpatient medical bed of £300.68 per day, the service saved £45,402 over 7 months, equivalent to £6,486 per month. Adverse events included four readmissions: two due to worsening symptoms despite antibiotics, one antibiotic reaction and one unrelated. There were two vascular access problems (leaking midlines) and one patient found home IV antibiotics tiring. Home IV antibiotics have generally been well-tolerated and resulted in significant inpatient days saved. Further evaluation of impact on quality of life, patient satisfaction and time to next IV antibiotic course is planned.

<h3>Introduction</h3> Allergic bronchopulmonary aspergillosis (ABPA) is increasingly prevalent among cystic fibrosis (CF) patients. Atopy, sex, season at diagnosis and cystic fibrosis transmembrane conductance regulator (CFTR) mutation are suggested risk factors for ABPA. Studies indicate that centres using a high amount of intravenous antibiotics have better outcomes, but this has also been linked to the increase in ABPA. The objective of this retrospective case-control study was to assess potential risk factors for ABPA, in particular intravenous antibiotic use. <h3>Methods</h3> Of 150 paediatric patients, 13 fulfilled the CF foundation consensus diagnostic criteria for ABPA. These were compared to 130 patients without evidence of ABPA. Seven patients were excluded from the study as they showed evidence of ABPA but did not fulfil the diagnostic criteria. The intravenous antibiotic data for the ABPA group was compared to 80 patients without ABPA using extended matching by age of diagnosis. The data collected included age, sex, CFTR mutation, atopy (history or family history of diagnosed hay fever, eczema or asthma), and weeks of intravenous antibiotics administered. Season of diagnosis was noted for the ABPA group. <h3>Results</h3> The median duration of use of intravenous antipseudomonal antibiotics in the ABPA group was 38 weeks, compared to 5 weeks in the non-ABPA group (p&lt;0.05). No difference was found in the duration of use of non-antipseudomonal antibiotics (median 12 weeks in ABPA group, 2 weeks in non-ABPA group). The average time since diagnosis of CF was higher in the ABPA group by 3 years (p=0.01). 12/13 (92%) of ABPA patients had a history of atopy compared to 50/105 (47%) of the non-ABPA group (p=0.05). There was no difference in CFTR mutation, sex or season of ABPA diagnosis. <h3>Conclusion</h3> Intravenous antipseudomonal antibiotic use was substantially higher in the ABPA population. This could be a factor in the increase in ABPA, suggesting that tighter microbiological guidance may be useful before initiating antibiotic treatment. However, this could also be that IV use and ABPA are both markers for increased disease severity. Atopy was also significantly higher in the ABPA population. This could potentially be used to highlight those CF patients at risk from this disease.

To ascertain the effect of endoscopic sinus surgery (ESS) on lung function, intravenous (IV) antibiotic use, and hospitalization in adults with cystic fibrosis (CF). Retrospective analysis. Tertiary care center. Fifteen adults with a diagnosis of CF undergoing ESS between March 1, 2006, and June 31, 2008. Twelve-month preoperative and 12-month postoperative pulmonary function testing (forced vital capacity [FVC] and forced expired volume in 1 second [FEV1]), number of IV antibiotic courses, total number of days of intravenous antibiotic use, and number of inpatient hospital days (IHDs) were assessed. Twenty-two adults with CF underwent ESS; 15 patients had adequate data for evaluation. No significant differences were found between mean preoperative and postoperative FEV1 (61.3% vs 59.5%; P = .41) or FVC (76.4% vs 76.1%; P = .97) or between best preoperative and postoperative FEV1 (67.4% vs 67.0%; P = .95) or FVC (84.2% vs 83.0%; P = .86) (paired samples t test). The number of IV antibiotic courses and the total number of days of IV antibiotic use did not differ between the preoperative and postoperative periods (Wilcoxon signed rank test P = .61 and P = .10, respectively). However, the number of IHDs was significantly lower in the 1-year postoperative period (36.7 days) vs the 1-year preoperative period (59.1 days) (Wilcoxon signed rank test, z = -2.20, P = .03). This preliminary study of ESS in adult CF patients indicates significant reduction in the number of IHDs in the postoperative period. However, there is no evidence that ESS improved lung function or the need for IV antibiotics.

The misuse and overuse of intravenous (IV) antibiotics contribute to the spread of multidrug resistance, consequently increasing mortality. These effects can be minimised through treatment reviews that aim to optimise antibiotic therapy without compromising patient clinical outcomes. There is therefore a need to evaluate and monitor intravenous antibiotic usage in hospitals. To describe IV antibiotic use in admitted patients at a private hospital in North West Province, South Africa. A cross-sectional study design was followed using retrospective data from patient files and the hospital electronic healthcare software (TriMed) between 1 January and 31 December 2022. A Microsoft Excel spreadsheet was used to capture demographic information for each patient profile that met the inclusion criteria, and data on IV antibiotic use were captured for each admission episode. The data were analysed using IBM statistical software. Demographic data were recorded for 677 patient profiles, with males representing 53.8% (n=364). A total of 731 admissions occurred during the study period. The most prevalent indication for IV antibiotic use, according to the provisional diagnosis, was upper and lower respiratory tract disorders, which represented 25.2% of the total admissions. Staphylococcus aureus was the most commonly treated micro-organism, representing 22.8% (n=23) of the total isolated micro-organisms. IV antibiotics were initiated 885 times, and amoxicillin-clavulanic acid was the most used antibiotic (51.2%). Most antibiotics (48.2%) were used at a dose of 1 200 mg, with a dosing frequency of three times a day (72.3%). A total of 806 review actions, out of 885 intravenous antibiotic initiations, were conducted (91.1%). The prevalence of IV-to-oral switch was 49.0%, while 41.3% of IV antibiotics were stopped after review. IV antibiotic de-escalation represented 7.2% of the total reviews, while an oral antibiotic was added to 1.7% of the IV antibiotics after review. At review, the prevalence of adding IV antibiotics to another IV antibiotic was 0.7%. The average length of hospital stay was 5.8 days, while patients continuously received IV antibiotics for 3.4 days on average. There is a need to monitor IV antibiotic use and encourage IV antibiotic de-escalation to limit the rampant use of broad- spectrum antibiotics and manage the most prevalent infections effectively in the shortest possible time, consequently reducing the average duration of hospitalisation. IV antibiotic treatment review is therefore pivotal to optimise antibiotic therapy, the transition of IV to oral antibiotics, and discontinuation of IV antibiotics when they are no longer necessary.

Recurrent endobronchial infection in cystic fibrosis requires treatment with intravenous antibiotics for several weeks, which is usually administered in hospital, affecting health costs and quality of life for patients and their families. It is not known whether patients receiving intravenous treatment at home have better or equivalent health outcomes, if costs are reduced or if it is preferred than in-hospital treatment. Home treatment requires training to patients and carers and usually needs a few previous days in hospital. To determine whether home intravenous antibiotic therapy in cystic fibrosis is as effective as in-patient intravenous antibiotic therapy and if it is preferred by patients and/or families. References to trials were obtained from the specialist cystic fibrosis trials register held by the editorial base of the Cochrane Cystic Fibrosis and Genetic Disorders Group. Handsearching of the abstracts books of all Spanish Conferences on cystic fibrosis and the last European Conference (Stockholm, 2000) was carried out by authors. Randomised controlled trials where home intravenous antibiotic treatment for patients with cystic fibrosis was compared with in-hospital intravenous antibiotic treatment, including adults and children with cystic fibrosis. All kinds of antibiotics and regimens administered intravenous were included. Three reviewers independently selected the trials to be included in the review, assessed methodological quality of each trial and extracted data using a standardised form. Because of several limitations, narrative synthesis was used at this stage. One study was included with 17 patients aged 10 to 41 years with an infective exacerbation by Pseudomonas aeruginosa. All their 31 admissions were analysed as independent events. Outcomes were measured at 21 days of follow-up after initiation of treatment. Home patients had fewer investigations performed than hospital patients (p<0.002) and general activity was higher in the home group. No differences were found for clinical outcomes, adverse events, complications of intravenous lines or line changes or time to next admission. Home patients received less low-dose home maintenance antibiotic. Quality of life measures showed no differences for dyspnoea and emotional state, but fatigue and mastery were worse for home patients, possibly due to a higher general activity and need of support. Personal, family, sleeping and eating disruptions were less important for home than hospital admissions. Home therapy was cheaper for families and the hospital. Indirect costs were not determined. The current evidence is restricted to one small study. It suggests that in the short term home therapy does not harm patients and in general reduces social disruptions. The decision to attempt home treatment should be based on an individual basis and appropriate local resources. More research is urgently required.

The aim of this study was to survey cystic fibrosis (CF) patients to determine the frequency of breast-feeding and its association with onset and severity of CF symptoms. Three thousand, two hundred questionnaires were sent to 30 accredited CF centers for anonymous completion. Eight hundred and sixty-three questionnaires were returned and scanned into a database. All results were adjusted for age at time of filling out the questionnaire. Age at onset of symptoms, percent forced expired volume in 1 sec (FEV1%) predicted, and intravenous (IV) antibiotic use were analyzed based on breast-feeding history. Approximately 49% of respondents received human breast milk at some time, but only 18% were exclusively breast-fed. Breast-feeding exclusively for greater than 6 months was associated with a decrease in disease severity based on recent intravenous antibiotic use compared to no breast-feeding (P = 0.03). There was no statistically significant change in onset of symptoms in the setting of breast-feeding; however, a trend toward delayed onset was seen in those receiving human milk. Fifty-three percent of those who breast-fed exclusively > or = 6 months had FEV1% values > 90%, compared to 47% of those not breast-fed. This is a suggestive but not statistically significant difference. In conclusion, breast-feeding for > or = 6 months is associated with decreased use of intravenous antibiotics in the 2 years prior to administering the questionnaire. This survey indicates that breast-feeding is not harmful to children with CF, and may be beneficial.

SummaryBackgroundChronic pulmonary infection with Pseudomonas aeruginosa is one of the most important causes of mortality and morbidity in cystic fibrosis. If antibiotics are commenced promptly, infection can be eradicated. The aim of the trial was to compare the effectiveness and safety of intravenous ceftazidime and tobramycin versus oral ciprofloxacin in the eradication of P aeruginosa.MethodsWe did a multicentre, parallel group, open-label, randomised controlled trial in 72 cystic fibrosis centres (70 in the UK and two in Italy). Eligible participants were older than 28 days with an isolate of P aeruginosa (either the first ever isolate or a new isolate after at least 1 year free of infection). Participants were excluded if the P aeruginosa was resistant to, or they had a contraindication to, one or more of the trial antibiotics; if they were already receiving P aeruginosa suppressive therapy; if they had received any P aeruginosa eradication therapy within the previous 9 months; or if they were pregnant or breastfeeding. We used web-based randomisation to assign patients to 14 days intravenous ceftazidime and tobramycin or 12 weeks oral ciprofloxacin. Both were combined with 12 weeks inhaled colistimethate sodium. Randomisation lists were generated by a statistician, who had no involvement in the trial, using a computer-generated list. Randomisation was stratified by centre and because of the nature of the interventions, blinding was not possible. Our primary outcome was eradication of P aeruginosa at 3 months and remaining free of infection to 15 months. Primary analysis used intention to treat (powered for superiority). Safety analysis included patients who received at least one dose of study drug. TORPEDO-CF was registered on the ISRCTN register, ISRCTN02734162, and EudraCT, 2009-012575-10.FindingsBetween Oct 5, 2010, and Jan 27, 2017, 286 patients were randomly assigned to treatment: 137 to intravenous antibiotics and 149 to oral antibiotics. 55 (44%) of 125 participants in the intravenous group and 68 (52%) of 130 participants in the oral group achieved the primary outcome. Participants randomly assigned to the intravenous group were less likely to achieve the primary outcome, although the difference between groups was not statistically significant (relative risk 0·84, 95% CI 0·65–1·09; p=0·18). 11 serious adverse events occurred in ten (8%) of 126 participants in the intravenous antibiotics group and 17 serious adverse events in 12 (8%) of 146 participants in the oral antibiotics group.InterpretationCompared with oral therapy, intravenous antibiotics did not achieve sustained eradication of P aeruginosa in a greater proportion of patients with cystic fibrosis and was more expensive. Although there were fewer hospitalisations in the intravenous group than the oral group during follow-up, this confers no advantage over oral treatment because intravenous eradication frequently requires hospitalisation. These results do not support the use of intravenous antibiotics to eradicate P aeruginosa in cystic fibrosis.FundingNational Institute for Health Research Health Technology Assessment Programme.

Background: Several studies have suggested that clinical outcomes in adults with cystic fibrosis (CF) are equivalent after home and hospital treatment with intravenous antibiotics, but these studies were small and...

Background To address increasing antibiotic use in acute hospitals, the Scottish Antimicrobial Prescribing Group developed a quality improvement (QI) initiative to support reliable review of patients started on intravenous (IV) antibiotics within 72 hours. This will reduce unnecessary continuation of antibiotics, ensure personalised treatment and appropriate IV to oral switch with associated benefits for patients of reduced risk of device related infections and potential for earlier discharge from hospital. Methods Using data obtained from the Hospital Medicines Utilisation Database, a national database of secondary care medicines use in Scotland, we examined trends in IV antibiotic use between 2013 and 2017. We then projected the current trend forward to 2021 to inform development of national indicator to optimise IV antibiotic use. Results In 2017, IV antibiotics accounted for 32.9% of all antibiotic use in Scottish hospitals. Annual IV antibiotic use (defined daily doses per 1000 population per day) increased by 20.5% between 2013 and 2017. We estimated a further projected increase of 12.5% between 2018 and 2021. To measure the impact of our QI initiative SAPG agreed to employ a national indicator with a target that ‘use of IV antibiotics in hospitals will be no higher in 2021 than it was in 2018’. Conclusion This national indicator will evaluate progress with achieving reliable and timely review of IV antibiotic therapy to reduce hospital antibiotic use and contribute to reduction in total antibiotic use in humans which is a key ambition of the UK AMR National Action Plan.

Introduction and objectivesThe UK Cystic Fibrosis (CF) registry has been in its current form since 2006 offering annual review data comprising of detailed demographic and clinical information on 99% of...

In 1982, a small adult cystic fibrosis (CF) unit was initiated by a respiratory physician (AKW) and a paediatric CF-trained physiotherapist in the physiotherapy department at Monsall Hospital. Monsall Hospital was an old-style fever hospital based in the North District of Manchester. There was a need for a regional adult CF unit as about 30 CF adults were still under the care of the two specialist paediatric CF centres. The newly-forged adult CF unit prospered. The unit received large numbers of referrals from the paediatricians and GPs in the North West Region. The Regional Health Authority provided funding for expensive drugs and some crucial posts such as physiotherapists, social workers and dieticians. In 1986, the Cystic Fibrosis Trust provided funding for a clinical fellow to assist with clinical support and also to undertake clinical research. Patients and families began to raise funds for equipment and facilities to improve patients’ hospital stay. As the patient numbers outgrew the limited facilities, a ward with 10 cubicles was established in 1990. In 1990, the minister for health initiated the provider/purchaser interface whereby the NHS health authority covering the area in which a patient resided was cost accountable for services provided by hospitals to that patient, wherever that might be (this health authority responsibility has now been modified to be the primary care trust to which the patient’s GP ‘belongs’). A research grant provided by the Cystic Fibrosis Trust was used to undertake an accurate costing by an economist from York University of the regional adult CF service to the North West Region. CF adult patients were categorized by cost according to four bands of disease severity. At a later date, a fifth band for very costly patients on continuous intravenous antibiotics was added (Table 1). These bandings and attributable costs were accepted by the purchasers of the service. As a result, the adult CF unit, by bringing an income to the hospital immediately became an asset rather than a financial millstone. In 1992, through the Cystic Fibrosis Trust, a foreign benefactor provided a substantial sum to the Unit to build a dedicated CF building for adults with CF in the North West Region. It seemed reasonable for the dedicated building to be established in a hospital in South Manchester where the main regional respiratory services were established including lung transplantation. The move was opposed by the North Manchester District, probably because of the defined income which they received for care provided by the adult CF unit to the region rather than consideration of the medical benefit which the CF adults would receive by their care being relocated to South Manchester. A prolonged bitter conflict was only resolved by the CF adults saying they would go wherever the unit went. In 1993, the CF Unit went to South Manchester and was housed on a temporary ward until the new building was completed in 1994. DECLARATIONS

The objective of the study was to determine if the use of locally implanted, synthetic calcium sulfate tablets, impregnated with antibiotics, can heal lower-extremity osteomyelitis, without the use of oral and/or intravenous antibiotics or wound complications associated with similarly used mined or refined calcium sulfate. Over a 5-year period, 354 patients with clinically confirmed osteomyelitis of the lower extremity were evaluated, and 337 met the inclusion criteria; 14 were lost to follow-up. Devitalized or infected bone was debrided to the level of healthy cancellous and cortical bone. Compromised soft tissue was resected. At the onset of each operative encounter, the synthetic calcium sulfate tablets were mixed with a standard antibiotic mixture: 500 mg of powdered vancomycin mixed into 240 mg of gentamicin (normally supplied as a liquid in a concentration of 80 mg/2 mL). Vancomycin and gentamicin were chosen because they cover a broad spectrum of both gram-positive and gram-negative bacteria. A total of 279 of 323 patents (86.4%) clinically healed without the use of intravenous antibiotics following surgical debridement and tablet implantation. In addition, 24/323 (7.4%) required the use of intravenous antibiotics, but still healed; 20/323 (6.2%) required amputation, of which, 12 (3.7%) were digital amputations, 2 (0.6%) were ray amputations, and 6 (1.9%) were below-knee amputations. The use of locally implanted antibiotic-impregnated, synthetic calcium sulfate tablets in the surgical debridement site for bone infections of the lower extremity, without the concurrent use of intravenous antibiotics, has shown encouraging results.

WS14.2 Potential factors influencing reduced requirements for intravenous antibiotics during the COVID-19 pandemic

Pseudomonas aeruginosa is the commonest micro-organism associated with respiratory infections in cystic fibrosis. Retrospective studies have suggested that using an aggressive policy of intravenous anti-pseudomonal antibiotics at regular intervals, irrespective of symptoms, increases survival. To determine whether there is evidence that an elective (regular) versus symptomatic intravenous antibiotic regimen is associated with an improvement in clinical status and survival rates in people with cystic fibrosis. To identify any adverse effects associated with the use of elective intravenous antibiotics, including an increase in the development of resistant organisms. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 15 March 2012. All randomised or quasi-randomised controlled trials describing the use of elective compared with symptomatic intravenous antibiotic policies for any duration or dose regimen. Elective versus symptomatic intravenous antibiotic regimens against any organisms were considered. People with cystic fibrosis of any age or disease severity were included. Both authors independently assessed trial eligibility and quality; both extracted the data. Searches identified four studies. Two studies reporting results from a total of 79 participants were included in the review. Differences in study design and objectives meant that data could not be pooled for meta-analysis. Neither study demonstrated significant differences in outcome measures between intervention and comparison groups. Studies are insufficient to identify conclusive evidence favouring a policy of elective intravenous antibiotic administration, despite its widespread use, neither are the potential risks adequately evaluated. The results should be viewed with caution, as participant numbers are small. Clearly there is a need for a well-designed, adequately-powered, multicentred randomised controlled trial to evaluate these issues.

Pseudomonas aeruginosa is the commonest micro-organism associated with respiratory infections in cystic fibrosis. Retrospective studies have suggested that survival is increased by using an aggressive policy of intravenous antipseudomonal antibiotics at regular intervals, irrespective of symptoms. To determine whether there is evidence that an elective (regular) versus symptomatic intravenous antibiotic regime is associated with an improvement in clinical status and survival rates in patients with cystic fibrosis. To identify any adverse effects associated with the use of elective intravenous antibiotics, including an increase in the development of resistant organisms. The Cochrane Cystic Fibrosis and Genetics Disorders Group Specialist Trials Register was used. This comprises references identified from comprehensive electronic database searches, hand searching relevant journals and abstracts from conference proceedings. Date of the most recent search of the Group's specialised register: October 2000. All randomised or pseudo-randomised controlled trials describing the use of elective compared with symptomatic intravenous antibiotic policies for any duration or dose regimen. Elective versus symptomatic intravenous antibiotic regimes against any organisms were considered. Patients with cystic fibrosis were of any age or disease severity. Trials were independently assessed for inclusion criteria, methodological quality and data extraction by the two reviewers. Three trials were identified by the initial search. Two trials reporting results from a total of 79 patients were included in the review. Differences in study design and objectives meant that data could not be pooled for meta-analysis. Neither trial demonstrated significant differences in outcome measures between intervention and comparison groups. Studies are insufficient to identify conclusive evidence favouring a policy of elective intravenous antibiotic administration, despite its widespread use. Neither are the potential risks adequately evaluated. The results should be viewed with caution as patient numbers are small. Clearly there is a need for a well-designed, adequately powered, multi-centred randomised controlled trial to evaluate these issues.