Is there a role for antimicrobial stewardship in cystic fibrosis?

There is currently considerable interest in developing antimicrobial stewardship programs in pediatric and adult acute and chronic care hospitals as a method of preserving the activity of existing antimicrobial agents against an increasing number of multidrug-resistant organisms. Cystic fibrosis (CF) is recognized as one of the conditions associated with the highest use of antimicrobials in pediatrics and has thus been identified as a potential target of antimicrobial stewardship programs. The benefits of aggressive antibiotic use to treat pulmonary infections in individuals with CF are well defined and it is not always possible to follow the stewardship principle of narrowing antimicrobial spectrum based on susceptibility testing and treating with short antibiotic courses. However, antimicrobial stewardship still has a role to play in CF. There are practical solutions that can be currently applied. For chronic suppressive antimicrobial therapy, aerosolization is the most effective route, achieving high intrapulmonary concentrations with few systemic toxicities. Given the absence of evidence demonstrating benefit, prolonged intravenous and oral antibiotic courses should generally be avoided. Increasing the number of antibiotics does not necessarily confer a clinical advantage; trials of cycling different antibiotics should be studied as it may have potential benefits both regarding efficacy and development of resistance. Further research is clearly needed in this area to optimize the antibiotic management of this population.