ECFS 2020 - Optimizing pharmaceutical care in cystic fibrosis

34    www.ecfs.eu OPTIMIZING PHARMACEUTICAL CARE IN CYSTIC FIBROSIS CYSTIC FIBROSIS MEDICATION: PRESENT AND FUTURE CHAPTER 2 base to support the basis for all current CF supportive care. Without rational evidence- based use of antibiotics, we could poten- tially do more harm than good, given the growing insight into the lung microbiota, in particular the links between lower lung microbiota diversity, increased airway inflammation and current antibiotic use [11]. This is also borne out with potential links between the use of anti-staphylococcal prophylaxis and acquisition of Pseu- domonas aeruginosa [12], and use of anti- microbial medicines and increasing inci- dence of fungus [13] and nontuberculous mycobacterium [14]. Similarly, antibiotics can influence lung immunity by altering the gut microbiota through the gut lung axis [15, 16]. Antibiotics tend to shift the gut microbiota towards decreased abundance of beneficial bacterial species and increase the outgrowth of pathogenic ones such as Clostridium difficile . Alteration of gut bacte- rial diversity can change local and systemic metabolism, immunity and can increase susceptibility to pulmonary infection and inflammation [15-17]. With an increasing burden of highly resistant pathogenic organisms affecting patients with CF, new antibiotic classes and non-antimicrobial adjuncts are urgently needed. At the same time, we must opti- mize existing medicines by collaborating to develop robust evidence to guide best practice, and reduce the negative effects of antimicrobial use. gaps are related to drug therapy, especially the use of antibiotics, where there has long been diversity in clinical practice. This is highlighted by the differences reported in a survey assessing the dosing schedule for 24 intravenous antibiotics used in the manage- ment of CF. The authors found significant disparity between units, with the average consensus rate for the most commonly prescribed dosing schedule being 58.2% (range = 23.1–100%). Full concordance was reported for only two antibiotics [5]. This does not mean that treatment is ineffectual as the introduction of aggressive antibiotic therapy, including evidence-based nebu- lized antibiotics, has played a major role in reducing morbidity and mortality in people with CF [6]. The low level of consensus partly reflects the complex nature of CF, variations between individuals in the clin- ical response to treatment, the inextricable link between infection and inflammation, and the limited effectiveness of antibiotic treatment in some patients [7, 8]. Devel- oping an evidence-based and standardized approach towards antibiotic treatment has become particularly important in the global context of growing antimicrobial resist- ance and the proliferation of multiresistant organisms [9]. In patients with CF, antibiotic resistance has significant implications as it will limit treatment options, reduce the effectiveness of antimicrobial activity and may preclude lung transplantation. Similarly the overuse of antibiotics can also result in an increased prevalence of drug allergy and other drug-related complications [10]. Indeed, the seemingly simple question of “which antibiotics, when, at what dose, and for how long?” lacks a robust evidence