Fluoroquinolones in the treatment of cystic fibrosis: a critical appraisal

Abstract

While the appropriate usage of antibiotics in cystic fibrosis patients is still a matter of debate, the introduction of oral antipseudomonal antibiotics such as fluoroquinolones represents an eagerly awaited addition to the therapeutic armamentarium. Ciprofloxacin is the single agent most often studied and used in this population for treatment of pulmonary exacerbations. Altered pharmacokinetics of fluoroquinolones have been described in cystic fibrosis patients as for other drugs, and a higher dosage than usual is recommended. Open clinical trials have shown good efficacy of ciprofloxacin in acute infection. A few comparative trials have demonstrated that ciprofloxacin is as effective clinically as conventional intravenous agents. As with other agents, a lack of correlation between clinical improvement and bacteriologic evaluation has been observed. Ciprofloxacin (and possibly ofloxacin) are considered useful alternatives to parenteral agents in therapy of cystic fibrosis patients older than 18 years of age with exacerbations of pulmonary infection. Intermittent therapy with ciprofloxacin alternating with other conventional treatment appears to be a rational approach; clinical trials evaluating the alternation of fluoroquinolones with intravenous anti-pseudomonal therapy are necessary. Considering the potential for emergence of resistance and the not completely elucidated implication of increasing MICs during ciprofloxacin therapy, the duration of treatment should be limited to 2 to 4 weeks. In older children (12 to 18 years old), ciprofloxacin provides an alternative to intravenous agents when clinically justifiable. In view of the possibility of fluoroquinolone associated-arthropathy in younger children, ciprofloxacin should be used judiciously when no alternative agents are available or in life-threatening situations.