Taccetti Giovanni, Terlizzi Vito, Campana Silvia, Dolce Daniela, Ravenni Novella, Fevola Cristina, Francalanci Michela, Galici Valeria, Neri Anna Silvia
Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, 50139, Florence, Italy.
Eur J Pediatr. 2024 Dec 14;184(1):82. doi: 10.1007/s00431-024-05905-9.
Bacterial infections of the lower airways are the main cause of mortality and morbidity in cystic fibrosis. The most frequently isolated pathogens are S. aureus and P. aeruginosa; bacterial co-infections are frequently observed. The aim of this review is to provide, in the current context, the indications regarding the best antibiotic strategy to adopt in subjects affected by CF infected with the most common pathogens. We selected relevant publications (guidelines, systematic reviews and clinical studies published so far on these topics) and we analysed the sampling methods used and antibiotic strategies adopted. Oropharyngeal sampling methods are considered less sensitive for pathogen detection than sputum. In non-expectorating people, induced sputum is considered equivalent to two-lobe bronchoalveolar lavage, which is considered invasive. Antibiotic treatment against the main pathogens can consist in eradication treatment in the early stages of infection, chronic suppressive therapy and treatment of the pulmonary exacerbations. This scheme is valid for P. aeruginosa but remains to be demonstrated for the other pathogens. For S. aureus, no evidence-based therapeutic strategies on how to treat the different stages of bacterial infection have been established with certainty. With regard to the treatment of the other classic pathogens (B. cepacia complex, A. xylosoxidans and S. maltophilia), no evidence-based indications exist and decision is left to the clinician. The recent introduction of highly effective modulators on the CFTR protein, in addition to the favourable effects described in regulatory trials, has led to a reduction in bacterial isolations; the real effect of which in clinical practice has still to be assessed on the basis of scientific data. CONCLUSIONS: The reliability of culture examination depends on sampling methods, and expectorated sputum continues to be the best method as it is simple and non-invasive. P. aeruginosa is the pathogen for which antibiotic strategies for the various stages of infection appear best established, and the efficacy of early eradication treatment and chronic suppressive therapy have been underlined in clinical trials and systematic reviews. The recent introduction of modulators into clinical practice, despite their widely described efficacy, has not yet led to suggestions for changes in antibiotic strategies against the pathogens most frequently isolated.
下呼吸道细菌感染是囊性纤维化患者死亡和发病的主要原因。最常分离出的病原体是金黄色葡萄球菌和铜绿假单胞菌；经常观察到细菌合并感染。本综述的目的是在当前背景下，提供关于感染最常见病原体的囊性纤维化患者应采取的最佳抗生素策略的指征。我们选择了相关出版物（指南、系统评价和迄今发表的关于这些主题的临床研究），并分析了所使用的采样方法和采用的抗生素策略。口咽采样方法被认为在病原体检测方面不如痰液敏感。对于不能咳痰的患者，诱导痰被认为等同于双叶支气管肺泡灌洗，而支气管肺泡灌洗被认为具有侵入性。针对主要病原体的抗生素治疗可包括感染早期的根除治疗、慢性抑制治疗和肺部加重期的治疗。该方案对铜绿假单胞菌有效，但对其他病原体仍有待证实。对于金黄色葡萄球菌，尚未确定关于如何治疗细菌感染不同阶段的循证治疗策略。关于其他经典病原体（洋葱伯克霍尔德菌复合体、木糖氧化产碱杆菌和嗜麦芽窄食单胞菌）的治疗，不存在循证指征，由临床医生自行决定。除了在监管试验中描述的有利作用外，最近高效的囊性纤维化跨膜传导调节因子（CFTR）蛋白调节剂的引入导致细菌分离减少；其在临床实践中的实际效果仍有待根据科学数据进行评估。结论：培养检查的可靠性取决于采样方法，咳痰仍然是最佳方法，因为它简单且无创。铜绿假单胞菌是感染各阶段抗生素策略似乎最完善的病原体，临床试验和系统评价强调了早期根除治疗和慢性抑制治疗的疗效。尽管最近调节剂已引入临床实践，且其疗效已被广泛描述，但尚未导致针对最常分离病原体的抗生素策略改变的建议。
