Antibiotics: Resistance vs Getting Better

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One View:

Some clinics are very open to the frequent use of antibiotics and generally have their patients taking P.A. and B.C. sensitive drugs a couple times a year. Their concern is for immediate quality of life. IV drugs make a person feeling remarkably well so very quickly (leaping tall buildings in a single bound…) and there is no reason to make people suffer unnecessarily. Other clinics focus upon long-term results–the fact that the frequent use of antibiotics poses the greatest threat to long-term survival of CF patients as it promotes antiobiotic resistances. This development of resistances is particularly problematic with the introduction of lung transplants for end-stage CF. To be eligible and have a successful outcome post-transplant–one’s bugs must be sensitive to at least one antibiotic, preferably more.

In Canada, many clinics (especially for adults) are moving increasingly towards not use antibiotics with much frequency, and relying upon nutrition, exercise, mucolytics and more aggressive forms of lung clearance to keep maintain health over the long-term. My clinic is particularly vigilent against using antibiotics, and patients who use them are given very aggressive training on lung clearances therapies. (Of course, as my clinic nurse says “If you REALLY need them, of course, they’re here to be used. BUT ONLY IF YOU REALLY NEED THEM”) For someone in moderate health and in a stable condition, there is no need to use them. I have had only 4 IV treatments in the past 15 years and one course of Cipro, and I have never inhaled tobra… I don’t have a “mild” case of CF (I wish).

People with CF face a tragic dilemma in regards to the use of antibiotics. Either we could use them frequently and feel good more of the time, but this ends up shortening our life-spans. Or we could use antibiotics less frequently and not have as many times of “feeling great”, and spend more time and energy on methods of clearing the lungs through exercise and physio but develop antibiotic resistance more slowly, live longer and have a better shot at a transplant. Never an easy choice.

Now there are some clinics–especially in the US with their mania for lawsuits–who are more concerned with short-term results and less worried about antibiotic resistance. Even here in Canada, I know of one clinic about 100 miles from where I live which has its patients on P.A. sensitive antibiotics all the time–alternating inhaled tobra with cipro (three weeks cipro, then three weeks tobra). When I asked the clinic pharmacologist about the problems of developing resistances, he just said that they don’t think the bugs get resistant after only three weeks…But, personally, that’s a risk I don’t want to take–especially having had cepacia for almost 14 years, (and hope to have it for another 14 years before I need a transplant!).

So the use of antibiotics is partly a biological crap shoot and partly an evaluation of lifestyle and personally preferences in terms of quality and longevity of life. Difficult choices indeed! The question really touches upon many of the life-choices and dilemmas that living with CF inherently entails.

For parents who are making decisions on behalf of their children, these kinds of dilemmas are doubly difficult. One hates to see one’s child suffer any kind of discomfort; it is always easier to suffer on one’s own behalf than to choose to make another person (especially one’s child!) suffer for potential long-term benefit. I wish all the parents a double dose of Solomon’s wisdom to sort out this dilemma.

Fortunately my mother didn’t have those kinds of choices back in the 1960’s: there were no anti P.A. drugs (the first one, carbenicillin didn’t come on stream until 1970 (?)) no decent bronchodilators: just intal, mucomyst (yuck!) and anti-staph antibiotics like lincomycin (pi-yew!) and ceperol, and no mechnical percussors. When we got sick it was just more physio and more physio, then we tried run around outside and see if we could cough it up. (THE DARK AGES!)

When it comes to using anti-pseudomonas and anti-cepacia antibiotics, we all have to use them responsibly. They are not just a “free ride” to getting better faster. Frequent use of them increases our chances of getting resistances and shortening our life-spans. While we all need them sometime, we all improve our long-term survival if we lengthen the times between the “sometimes” through better lung clearance regimens.

Another view:

Neils Hoiby of Copenhagen, Denmark prescribes IV antibiotics for his patients every 3-4 months regardless of exacerbations. In between IV treatments colistin is inhaled. Clearly Professor Hoiby subscribes to the theory of suppressing bacteria.

There is no absolute answer regarding antibiotic use and opinions will vary considerably. There are two important things to remember regarding treatment of CF lung disease. The first is that lung tissue does not regenerate. Tissue destroyed by bacterial infection is gone forever. So it is important to treat exacerbations. Secondly, multi-resistant bacteria can turn sensitive again.

Yet Another View:

I am very interested in the recents discussion about developing resistances vis frequent antibiotic use. I go to the adult CF Clinic in Toronto. I have been culturing cepacia for close to ten years now. I have also been on inhaled tobra for approximately the same amount of time (80 mg bid). My strain of cepacia was never sensitive to tobra, but to ceftazidine, only available via iv use. My constant use of tobra has not caused my pseudo a. to become resistant to the drug. I am admitted to hospital approximately once every 12-18 months, for iv tobra and ceftaz. I am still sensitive to these drugs. My doctors have never discussed the future possibility of resistance with me, and I wasn’t even aware of this problem vis a vis transplants until this discussion. I am not on a transplant list, and I’m not even sure if I ever intend to be, but I certainly wouldn’t want to close any doors for myself unwittingly. However, I do feel that my constant use of these drugs is part of what has made my quality of life so good.

I am particularly upset by the descriptions of doctors refraining from antibiotic use in children in order to avoid resistances. Naturally exercise and lung clearance techniques are vital parts of our maintenance treatments, but when a bacteria is rearing its ugly head, doesn’t something need to be done? How do doctors draw the line? This child is sick enough to warrent antibiotic use, but not this one? How long do they let bacteria related problems go on before starting antibiotics? Isn’t the most important thing to PREVENT SCAR TISSUE from forming? If the child is kept as healthy as possible for as long as possible, and as little scar tissue as possible forms, who’s to say a transplant will be necessary? Why is a transplant a necessary assumption? I think [a member of CYSTIC-L] raises a vital point when she speaks of quality of life. If it weren’t for anitbiotics, I wouldn’t have graduated from high school, let alone university, let alone hold down a full time job, live alone, and have a productive vibrant life.

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