Scheduled Use of IV Antibiotics:
The Scandinavian Experience

Notes on a talk given at the Annual CFRI Conference by Professor Neils H°iby, M.D., Ph.D.

Fall 1995

Professor Neils H°iby, M.D., Ph.D., from Rigshospitalet in Copenhagen, Denmark, introduced the audience to the routine care administered to cystic fibrosis patients in that country. Because Denmark is such a small country and most of the population is clustered near Copenhagen, Dr. H°iby's clinic sees 90 percent of the CF population in Denmark. After a very bad year, in which many of their CF patients died, Dr. H°iby closely examined their treatment procedures looking for a way to more effectively treat CF patients. From this study he developed his current treatment plan.

His primary concerns are the following bacteria: Staphylococcus aureus, Haemophilus influenzae, Burkholderia cepacia, and especially Pseudomonas aeruginosa. He feels strongly that early, aggressive treatment is essential to fight the infections causing lung tissue damage. More precisely, Dr. H°iby believes that S. aureus, H. influenzae and P. aeruginosa should be eradicated when present in the lower respiratory tract whether there are clinical symptoms or not.

He has had success in preventing subsequent chronic infections by early antibiotic treatment of the initial intermittent P. aeruginosa colonizations with oral ciprofloxacin and inhaled colistin. Once P. aeruginosa has become a chronic infection, treatment can no longer eradicate the bacteria from the lungs. Rather, he advocates and has had impressive success with a maintenance therapy, which includes two-week intravenous (IV) antibiotic treatments every three months with tobramycin and pipercillin (or cefsulodin, ceftazidime, aztreonam, thienamycin, or meropenem) in combination with aerosolized colistin and sometimes oral ciprofloxacin in between courses to unstable patients. He suggested aerosolized tobramycin as an efficient alternative to IV antibiotics. He treats B. cepacia with oral doxycycline as continuous suppressive therapy, and acute exacerbations are treated with cotrimoxazole, chioramphenicol, or tobramycin with ceftazidime and/or aerosolized ceftazidime and/or oral rifampicin.

Dr. H°iby acknowledged problems with his more intensive, regularly scheduled antibiotic treatment procedures including allergic reactions and the development of resistance to certain drugs. He desensitizes patients to drugs that cause allergies, and when this is unsuccessful in certain cases, he switches to another drug. He is very aware of the problems with drug resistancies but believes that there are enough antibiotics available to alternate drug use when a resistance arises and that the benefits far outweigh the dangers. His results are impressive, especially among the adults with CF who have better lung function that lasts longer into their adult lives. His country has also not seen the recent stagnation in survival rates that other countries have seen (in the U.S. the median age of survival has remained at 30 for several years). The average life expectancy in Denmark is 40 years! He promised to have these results published in a medical journal in the near future.

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