Permanent antibiotic therapy

Question

Dear expert team,
our daughter is 16 months old an has CF. Until now we had only problems with the intestine and not with the lung. No colonization with germs, no cough or higher susceptibility for infections.
In our town there are two CF outpatient clinics. We are cared for in one of them, a permanent antibiotic therapy has never been mentioned there.
We wanted to look at the second outpatient clinic and did refer our daughter there. They said there, that they would recommend a permanent antibiotic therapy to all patients. What do you think of a permanent antibiotic therapy?
Best regards,

Answer

Hello,
from the past it is known to me, that in Munich at a CF center of the "von Haunerschen childrens hospital" a permanent antibiotic therapy had been initiated at all CF patients from the day of the diagnosis on. As far as I know, this is not the case anymore.
The results of international studies with CF patients do not show an advantage for patients, which had received a permanent antibiotic therapy compared to those with an infection oriented therapy. It has even been shown that patients under a permanent antibiotic treatment rather show a colonization with the problematic germ Pseudomonas aeruginosa.
In such small children as your daughter, one does therefore mostly react to acute signs of infection. Some centers treat even without signs of infection, if e.g. Staph. aureus or H. influenza have been detected in a routine throat swab or sputum. It is important, that every infection is treated as fast and effective, that means with the right antibiotic drug, as possible.
You should discuss with your center which kind of therapeutic route everybody agrees on so that a confidental care of your child can be assured for the future.
Yours sincerely,
Dr. H.-G. Posselt

26.05.2009

9.7.09

Hello, the leader of the above mentioned out-patient department, who we ask also to comment on this topic, did answer in the meantime and now we are publishing his views of the situation, as we are interested in presenting the situation as it is: not always we have clear results, on which one could base his decision. He writes:
„Dear parents,
the treatment of patients with CF is based on a holistic concept, which has been developed mostly from experiences of former generations of individual patients and partly form research results of groups of patients. The many therapeutic options, which are available, are composed to an individual treatment concept, which does include the respective age, the circumstances of life and the predictable consequences as well as the calculable events. Many single aspects of this treatment plan complete and serve the other; the parents and in the course of time also the child, the adolescent and the adult patient learn to understand backgrounds, necessities of therapeutic measures and also to comprehend these. For this reason, a single therapeutic measure should not be regarded in isolation, rather it’s about using the available therapeutic measures so skillfully, that they have the most effect in the individual case.

In the Christinane-Herzog out-patient department of the LMU Munich (Germany) we recommend to all patients with CF a permanent antibiotic treatment. We know, that this concept has clear advantages in many respects (e.g. no Staphylococci in the airways, reduced side-effects in “habitual” therapy) and possible disadvantages, like the mentioned, however not for sure proved concern of increased infections with Pseudomonas (please see on this e.g. Cochrane Review www.cochrane.org/reviews/en/ab001912.html), as well as other feared effects, which are mostly avoided. Therefore this form of treatment can be performed for a long time without justified concern. The recommendation of the British CF association include after all a permanent antibiotic therapy in CF at least for the first 2 -3 years of life. (www.cftrust.org.uk/aboutcf/publications/consensusdoc/C_3200Antibiotic_Treatment.pdf).
In addition, an actual work from this center about children under the age of 6 shows, that the extent of the inflammatory reaction in the lung is proportional to the infection with Staphylococci.
Even if the “antibiotic-question” does cause controversial discussions again and again, the focus on this point shows, that the essential aspects of the treatment of CF are still not being conveyed or understood.
…
Of course there can be good reasons in the individual case to deviate from a permanent antibiotic therapy; this is discussed with the parents and the patient in detailed conversations and then put in a clear holistic concept.
As you see, this question cannot be answered in a monotonous yes/no way, but it has to be tried permanently together with the single patient, to improve the treatment. We have experienced, that such an approach is capable of improving the life expectancy and quality of life further and further.
Yours sincerely,
Prof. Dr. med. M. Griese"

To avoid misunderstandings: there is no doubt, that we all have to care for permanent improvement, but up to now there is no data, that the improved life expectancy of CF patients, which could have been achieved in the last decades, could be the result of the one or the other point of view concerning the “permanent antibiotic treatment”.
What is right, then? What should you as worrying parents do in such a situation? In case you are content with the holistic concept of your familiar center – or rather not- the question of the handling of the permanent antibiotic treatment should not decide, where you go to – there seem to be more important factors. Because it is like this, different groups of experts (UK, USA, Germany) come therefore to different summaries.
Yours sincerely,
Prof. Dr. TOF Wagner