Empirical Antimicrobial Therapy for Children with Cystic Fibrosis
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Empirical antimicrobial therapy for children with Cystic Fibrosis Document ID CHQ-GDL-01073 Version no. 2.0 Approval date 17/12/2020 Executive sponsor Executive Director of Medical Services Effective date 17/12/2020 Director Respiratory Medicine Review date 17/12/2022 Author/custodian Director Infection Management and Prevention Service, Immunology and Rheumatology Supersedes 1.1 Applicable to All Children’s Health Queensland staff Authorisation Executive Director Clinical Services (QCH) Purpose This guideline provides Children’s Health Queensland (CHQ) recommendations for empirical antimicrobial therapy for children with Cystic Fibrosis (CF), for inpatient and outpatient management. Scope This guideline provides information for CHQ staff caring for paediatric CF patients. Related documents Procedures, Guidelines, Protocols • CHQ Paediatric Therapeutic Drug Monitoring – Tobramycin/Gentamicin • CHQ Paediatric Therapeutic Drug Monitoring - Vancomycin • CHQ@Home Outpatient Parenteral Antimicrobial Therapy Prescribing, Administration and monitoring guideline • CHQ-PROC-01036 Antimicrobial: Prescribing, Management and Stewardship and CHQ Antimicrobial Restriction list • CHQ-PROC-63223 Management of patients with cystic fibrosis • CHQ-GDL-01061 Immunisation Guideline for Medically at Risk Children • CHQ-GDL-01076 Paediatric antibiotic allergy assessment, testing and de-labelling • CHQ-GDL-70047 Clinical guidelines for the care of children and adolescents with Cystic Fibrosis - Volume 1: Respiratory Care Guideline Empirical antimicrobial therapy for patients with Cystic Fibrosis Part 1. Summary table of empirical antimicrobial therapy for children with Cystic Fibrosis (CF) • Pulmonary Exacerbation - Pseudomonas aeruginosa (PsA) negative • Pulmonary Exacerbation - PsA eradication • Chronic PsA colonisation – exacerbation • Chronic PsA colonisation – maintenance therapy • Methicillin Resistant Staphylococcus Aureus (MRSA) eradication – outpatient treatment • MRSA Pulmonary optimisation – inpatient treatment • Burkholderia cepacia complex eradication – inpatient treatment • Non-tuberculous mycobacterium (NTM) – induction and maintenance treatment (Quick reference guide) Part 2. Hospital In The Home (HITH) Part 3. Non-tuberculous mycobacterium (NTM) eradication – induction and maintenance treatment Part 4. Fungal infections • Allergic bronchopulmonary aspergillosis (ABPA) Part 5. Summary table of antibiotic doses recommended in Cystic Fibrosis (CF) • Additional monitoring whilst on intravenous (IV) antibiotics • Intravenous antibiotics • Oral antibiotics • Inhaled or nebulised antibiotics CHQ-GDL-01073 Empirical antimicrobial therapy for patients with Cystic Fibrosis - 2 - Part 1. Summary table of empirical antimicrobial therapy for children with Cystic Fibrosis For patients with a history of immediate or delayed type penicillin and/or cephalosporin hypersensitivity, please consult the Infectious Diseases team (ID) for advice on treatment options prior to commencement of antibiotics. Clinical Scenario Antibiotic Duration Alternative antibiotic Comments Cystic Fibrosis Inpatient Piperacillin/Tazobactam IV 14 days Ceftazidime (plus IV Tobramycin) is Monitoring: Baseline and then 100 mg/kg/dose 6-hourly (maximum 4 g an alternative if no S.aureus weekly Full blood count (FBC) & Exacerbation or Piperacillin component/dose) isolated Electrolytes and liver function HITH tests (eLFTS or CHEM20), PLUS Ceftazidime IV 100 mg/kg/dose vestibular toxicity monitoring Pseudomonas 8-hourly (maximum 4 g/dose) Tobramycin IV* whilst on IV Tobramycin aeruginosa (PsA) negative More than 1 month old to 12 years: *See Part 5 for IV Tobramycin 10 mg/kg once daily (maximum 640 mg initial If ceftazidime used and S.aureus therapeutic drug monitoring dose) present, add in Flucloxacillin: (TDM) More than 12 years: Flucloxacillin IV 50 mg/kg/dose Pre -approved HITH: 7.5 mg/kg once daily (maximum 640 mg initial 6-hourly (maximum 2 g/dose) IV Tobramycin (once daily) dose) or and IV Piperacillin/ Tazobactam (continuous (or previously optimised dose from a recent Oral Flucloxacillin infusion via ambulatory admission (within last three months), speak to a 25 mg/kg/dose four times daily device) or Ceftazidime (via Pharmacist for advice) (maximum 1 g/dose) intermate device) for 14 days. Cystic Fibrosis Outpatient Amoxycillin-clavulanic acid (DUO preparation) 14 days Trimethoprim/Sulfamethoxazole Monitoring: FBC and CHEM20 Oral 4 mg/kg/dose twice daily once a month whilst on high Exacerbation 25 mg/kg/dose orally 12-hourly to (maximum 160 mg/dose dose Pseudomonas (maximum 875 mg Amoxycillin component/dose) 6 weeks Trimethoprim component) Trimethoprim/ Sulfamethoxazole aeruginosa (PsA) negative CHQ-GDL-01073 Empirical antimicrobial therapy for patients with Cystic Fibrosis - 3 - Clinical Scenario Antibiotic Duration Alternative antibiotic Comments Cystic Fibrosis – Inpatient Piperacillin/Tazobactam IV 100 mg/kg/dose 14 days Ceftazidime (plus IV Tobramycin) Monitoring: Baseline and then Pseudomonas 6-hourly (maximum 4 g Piperacillin an alternative if no S.aureus weekly FBC & CHEM20, or aeruginosa (PsA) component/dose) isolated vestibular toxicity monitoring HITH whilst on IV Tobramycin Eradication PLUS Ceftazidime IV 100 mg/kg/dose 8-hourly (max 4 g/dose) *See Part 5 for IV Tobramycin Tobramycin IV* TDM More than 1 month old to 12 years: 10 mg/kg once daily (maximum 640 mg initial If Ceftazidime used and S.aureus dose) present, add in Flucloxacillin: Pre-approved HITH: More than 12 years: Flucloxacillin IV 50 mg/kg/dose 7.5 mg/kg once daily (maximum 640 mg initial IV Tobramycin (once daily) 6-hourly (max 2 g/dose) dose) and IV Piperacillin/ or Tazobactam (continuous (or previously optimised dose from a recent infusion via ambulatory admission (within last 3 months), speak to a Oral Flucloxacillin 25 mg/kg/dose device) or Ceftazidime (via Pharmacist for advice) four times daily (max 1 g/dose) intermate device) for 14 days. Followed by Tobramycin inhaled: 4 weeks 0 to 18 years: 300 mg nebulised 12 hourly Cystic Fibrosis – Outpatient Tobramycin inhaled (use preservative free 4 weeks Eradication should be attempted Pseudomonas formulation) 0 to 18 years: 300 mg 12-hourly for all children on first/new aeruginosa (PsA) isolation of Pseudomonas If treatment failure or Tobramycin resistant: aeruginosa Eradication Oral Ciprofloxacin 20 mg/kg/dose 4 weeks Consider the impact of type of orally 12-hourly (maximum 1 g/dose) nebuliser when choosing PLUS Colistin dose see Part 5 (29) Prescription for Sodium Chloride Inhaled Colistin (Tadim®) 12 weeks 0.9% ampoules also required 1 to 2 years: 1 million units inhaled 12-hourly when prescribing Inhaled 2 to 18 years: 2 million units inhaled 12-hourly Colistin (required for reconstitution). CHQ-GDL-01073 Empirical antimicrobial therapy for patients with Cystic Fibrosis - 4 - Clinical Scenario Antibiotic Duration Alternative antibiotic Comments Cystic Fibrosis Inpatient Piperacillin/tazobactam IV 14 days Ceftazidime (plus IV Tobramycin) an Monitoring: Baseline and then Exacerbation alternative if no S.aureus isolated. weekly FBC & CHEM20, or 100 mg/kg/dose 6-hourly (maximum 4 g vestibular toxicity monitoring Chronic Piperacillin component/dose) Ceftazidime IV 100 mg/kg/dose 8-hourly HITH whilst on IV Tobramycin. Pseudomonas (maximum 4 g/dose) PLUS Tobramycin IV* aeruginosa *See Part 5 for IV tobramycin If Ceftazidime used and S.aureus colonisation More than 1 month old to 12 years: TDM present, add in Flucloxacillin: 10 mg/kg once daily (maximum 640 mg Pre-approved HITH: IV initial dose) Flucloxacillin IV 50 mg/kg/dose 6-hourly Tobramycin (once daily) and IV (maximum 2 g/dose) More than 12 years: 7.5 mg/kg once daily Piperacillin/ Tazobactam (maximum 640 mg initial dose) OR Oral Flucloxacillin (continuous infusion via ambulatory device) or 25 mg/kg/dose four times daily (or previously optimised dose from a recent Ceftazidime (via intermate (maximum 1 g/dose) admission (within last 3 months), speak to a device) for 14 days. Pharmacist for advice) Cystic Fibrosis Outpatient Tobramycin inhaled (use preservative free 4 weeks If on cyclical inhaled Tobramycin may Exacerbation – formulation): consider adding oral Ciprofloxacin Chronic 0 to 18 years: 300 mg nebulised 12-hourly 20 mg/kg/dose twice daily Pseudomonas or (maximum 1 g/dose) for two weeks. aeruginosa More than 6 years old: colonisation TOBI® podhaler 112 mg (4 caps) 12-hourly Cystic Fibrosis Outpatient Alternate month Tobramycin inhaled Long If resistant organism or intolerant of TOBI® Consider the impact of type of – Chronic (use preservative free formulation): term consider alternate month inhaled Colistin nebuliser when choosing Colistin Pseudomonas plus Oral Ciprofloxacin (2 to 4 weeks). dose see Part 5 (29) 0 to 18 years: 300 mg nebulised 12-hourly aeruginosa If deterioration consistently in the month off Prescription for Sodium Chloride Maintenance Or inhaled antibiotics or frequent exacerbations 0.9% ampoules also required when therapy More than 6 years: (three or more/ year) consider continuous prescribing Inhaled Colistin (required alternating inhaled therapy (CAIT) using inhaled for reconstitution) TOBI® podhaler 112 mg (4 caps) 12-hourly Tobramycin alternating with inhaled Colistin plus oral Ciprofloxacin for two of the four weeks. CHQ-GDL-01073 Empirical antimicrobial therapy for patients with Cystic Fibrosis - 5 - Clinical Scenario Antibiotic Duration Alternative antibiotic Comments Methicillin Outpatient Oral Rifampicin 15 mg/kg/dose once daily 14 days Check MRSA antibiotic