Economic effects of an eradication protocol for first appearance of Pseudomonas aeruginosa in cystic fibrosis patients: 1995 vs. 2009.

BACKGROUND: Acquisition of Pseudomonas aeruginosa (Psa) and infection with mucoid strains is associated with repeated pulmonary exacerbations which often require intravenous and long-term nebulised antibiotic treatments, repeated hospitalizations and leads to a more precipitous decline in lung function. Anti-Psa antibiotic therapy early in the course of Psa infection in patients with cystic fibrosis (CF) may result in eradication of Psa and prevention or delay of colonization with the organism. From January 1995 to December 2009 our paediatric CF clinic has followed an early eradication protocol for the first appearance of Psa. In this paper we report on the economic effects after 15 years as reflected in hospitalization and antibiotic usage and cost. METHODS: The Psa-eradication protocol includes 2 weeks of IV piperacillin and tobramycin, followed by oral ciprofloxacin for 3 weeks, and nebulised colistimethate for 6 months. The same protocol is used for newly diagnosed CF patients who grow Psa on their first visit or who grow a mucoid strain, multiresistant strain of Psa or whose Psa co-cultured with Burkholderia cepacia complex, and for patients in whom Psa recurs after initial clearance. RESULTS: 195 Psa eradication courses were completed from 1995 to 2009 with an overall Psa clearance rate of 90%. Patients that only cultured a Psa classic (non-mucoid) strain had a clearance rate was 96.5%. The percentage of children chronically infected with Psa has declined from 44% in 1994 to 15% in 2009.Total days spent in hospital for all reasons declined by 43%; chronic Psa hospital days declined by 75%; IV and nebulised anti-Psa antibiotic costs reduced by 44%. CONCLUSIONS: Results indicate that application of a Pseudomonas eradication protocol as described in this report has economic and resource utilization benefits in addition to clinical benefits.

Renal function in pediatric cystic fibrosis patients in the first decade of life.

With increasing life expectancy and the need for lung transplantation in the cystic fibrosis (CF) population, there are increasing reports of chronic kidney disease (CKD). However, values for baseline or longitudinal glomerular filtration rate (GFR) as measured by exogenous clearance markers are lacking in this population. Retrospective cross-sectional study in 2 to 18-year-olds cared for at a single CF center who had a GFR measured by plasma disappearance of Technetium-99 m diethylenetriaminepentaacetic acid (mGFR). The primary outcome was evidence of renal dysfunction as defined by CKD stage II or below (mGFR <90 ml/min/1.73 m(2), persistent abnormalities in urinary sediment, abnormal renal imaging). Of 63 patients evaluated, four had apparent renal dysfunction, one demonstrated decreased mGFR, and three others had persistent microscopic hematuria. The mean mGFR was substantially higher (140 ± 24 ml/min/1.73 m(2)) than expected or previously reported for healthy children. We did not demonstrate the presence of significant renal impairment after limited aminoglycoside exposure in the first decade following diagnosis with CF. However, we did document the presence of glomerular hyperfiltration in a significant proportion of our CF patients.

Monitoring of serum prolactin in pediatric patients with cystic fibrosis who are receiving domperidone.

BACKGROUND: Since 2003, it has been routine practice at Children's and Women's Health Centre of British Columbia to monitor serum levels of prolactin in pediatric patients with cystic fibrosis who are receiving domperidone. Although a pharmacologic relationship between domperidone and prolactin has been documented in the literature, there is no information about routine monitoring of prolactin, and guidance on interpretation of prolactin values is lacking. OBJECTIVES: To characterize how prolactin levels were being used in monitoring patients with cystic fibrosis who were receiving domperidone therapy at this institution, to evaluate the need for this practice, and to formulate recommendations accordingly. METHODS: A chart review was conducted for pediatric patients with cystic fibrosis who had been receiving domperidone therapy and whose serum prolactin levels had been monitored between June 1, 2001, and October 1, 2005. RESULTS: A total of 219 samples had been drawn, from 49 patients, for determination of prolactin level. Of these, 100 (45.7%) were above the normal range. Of the values above the normal range, 86 (86%) led to no dosage adjustment of domperidone and 14 (14%) led to either a decrease in dose or discontinuation of therapy. None of the elevated prolactin levels were associated with supratherapeutic doses of domperidone. CONCLUSION: The role of routine monitoring of prolactin in this patient population requires further study. In particular, more information is needed about prolactin levels in pediatric patients and the relationship of prolactin level to domperidone dose.