Filippo Festini

Early eradication therapy against Pseudomonas aeruginosa in cystic fibrosis patients

In cystic fibrosis (CF) patients early antibiotic treatment of lung infection has been shown to lead to Pseudomonas aeruginosa eradication. The present study determined: 1) the time period from eradication to new P. aeruginosa acquisition; 2) P. aeruginosa re-growth and new acquisition; and 3) the impact of eradication therapy on lung function, antimicrobial resistance, emergence of other pathogens and treatment costs. Ciprofloxacin and colistin were used to eradicate P. aeruginosa in 47 CF patients. Bacterial pathogens, lung function decline, P. aeruginosa antimicrobial resistance and anti-pseudomonal serum antibodies were assessed quarterly and compared with an age-matched CF control group. Additionally, costs of antibiotic therapy in both groups were assessed. Early antibiotic therapy leads to a P. aeruginosa free-period of a median (range) of 18 (4–80) months. New acquisition with different P. aeruginosa genotypes occurs in 73% of episodes. It also delays the decline of lung function compared with chronically infected patients, prevents the occurrence of antibiotic resistant P. aeruginosa strains, does not lead to emergence of other pathogens, and significantly reduces treatment costs. The treatment substantially lowers P. aeruginosa prevalence in CF. In conclusion, early antibiotic therapy exerts beneficial effects on the patients clinical status and is cost-effective compared with conventional antibiotic therapy for chronically infected cystic fibrosis patients.

Management of fever in children: Summary of the Italian pediatric society guidelines

OBJECTIVE This article summarizes the Italian Pediatric Society guideline on the management of the signs and symptoms of fever in children, prepared as part of the National Guideline Program (NGLP). METHODS Relevant publications in English and Italian were identified through searches of MEDLINE and the Cochrane Database of Systematic Reviews from their inception through December 31, 2007. Based on the consensus of a multidisciplinary expert panel, the strength of the recommendations was categorized into 5 grades (A-E) according to NGLP methodology. SUMMARY In the health care setting, axillary measurement of body temperature using a digital thermometer is recommended in children aged <4 weeks; for children aged > or =4 weeks, axillary measurement using a digital thermometer or tympanic measurement using an infrared thermometer is recommended. When body temperature is measured at home by parents or care-givers, axillary measurement using a digital thermometer is recommended for all children. Children who are afebrile when seen by the clinician but are reported to have had fever by their caregivers should be considered febrile. In special circumstances, high fever may be a predictive factor for severe bacterial infection. Use of physical methods of reducing fever is discouraged, except in the case of hyperthermia. Use of antipyretics-paracetamol (acetaminophen) or ibuprofen-is recommended only when fever is associated with discomfort. Combined or alternating use of antipyretics is discouraged. The dose of antipyretic should be based on the childs weight rather than age. Whenever possible, oral administration of paracetamol is preferable to rectal administration. Use of ibuprofen is not recommended in febrile children with chickenpox or dehydration. Use of ibuprofen or paracetamol is not contraindicated in febrile children with asthma. There is insufficient evidence to form any recommendations concerning fever in children with other chronic conditions, but caution is advised in cases of severe hepatic/renal failure or severe malnutrition. Newborns with fever should always be hospitalized because of the elevated risk of severe disease; paracetamol may be used, with the dose adjusted to gestational age. Use of paracetamol or ibuprofen is not effective in preventing febrile convulsion or the adverse effects of vaccines.

Twenty five years of the one child family policy in China

Problems and future prospects Praised for saving China from a demographic catastrophe or blamed as a violation of a basic human right, the one child family policy (OCFP) is reaching its 25th year and a recent law1 has confirmed this demographic strategy for the future. The government decision to limit the number of children to one per couple, taken in 1979, was a response to the threat that the country’s massive demographic growth cast on the future of economic development and of living conditions of the Chinese people. The goal set was to limit the total population to about 1.2 billion for the year 2000 and to significantly reduce the natural increase rate.2 The OCFP has been implemented—with some exceptions to the rule and a varying severity3,4—mainly through economic incentives and aids for families with a single child, and taxes, fines, and various social disadvantages for the families who do not abide by the rule,5 together with a strong social pressure on women not to have a second pregnancy. The acceptance of the OCFP on the part of the people has been sometimes reported as difficult5 as the rule seems to conflict with the deep rooted Confucian tradition that emphasises the importance of numerous offspring, in order to pass on the responsibility of supporting the old people and of perpetuating traditions. Coercion to oblige women to sterilisation, abortion, or insertion of IUDs has also been reported.5,6 A quarter century after its introduction the OCFP has achieved most of its objectives. The birth of 250–300 million Chinese has been prevented and the rate of natural increase dropped from 11.6 per thousand in 1979 to 8 per thousand in 2001. The population of China was 1273 million in the 2000 census and the …

Antibiotic Therapy against Pseudomonas aeruginosa in Cystic Fibrosis

Abstract Antibiotic strategies against Pseudomonas aeruginosa infection in cystic fibrosis (CF) patients should consider the natural history of the P. aeruginosa infection, ranging from the first isolation of the germ in the airways to isolation at every microbiological culture, and the patients clinical condition. Antibiotic treatment against P. aeruginosa given at the time of first isolation may prevent or delay chronic infection. The period of intermittent colonization can be considered the time before the development of mucoid P. aeruginosa phenotype. The optimal treatment strategy in this stage remains unclear in terms of agents used and duration of treatment. To treat acute exacerbation, the authors suggest using intravenous administration of two different classes of antibiotics. Maintenance antibiotics are administered to slow the decline in pulmonary function for P. aeruginosa chronic infection. The meaning of maintenance therapy has changed over time, beginning from intravenous quarterly anti- Pseudomonas antibiotics, irrespective of symptoms, to other strategies such as oral macrolides, ciprofloxacin or inhaled antibiotics (tobramycin and colistin). Aerosol delivery can provide a high concentration at the desired site with minimal absorption and therefore low risk of toxicity. There is scientific evidence that antibiotics are clinically effective in CF patients. Antibiotic selection should be based on periodic isolation and identification of pathogens and antimicrobial susceptibility.

Update of the 2009 Italian Pediatric Society Guidelines about management of fever in children.

BACKGROUND In 2009, the Italian Pediatric Society developed national guidelines for management of fever in children for health care providers and parents/caregivers; an update of these guidelines was scheduled after 2 years. OBJECTIVE This article summarizes the update of Italian guidelines on managing fever in children, focusing specifically on measuring body temperature and using antipyretic agents. METHODS Relevant publications in English and Italian were identified through searches of MEDLINE and the Cochrane Database of Systematic Reviews from January 1, 2008, to May 1, 2012. On the basis of consensus of a multidisciplinary expert panel, evidence levels and strength of recommendations were reviewed. RESULTS Axillary temperature measurement using a digital thermometer is recommended in children younger than 4 weeks. In the hospital or ambulatory care setting, axillary temperature measurement using a digital or infrared thermometer (tympanic or skin contact or nocontact) is recommended in children older than 4 weeks. Paracetamol and ibuprofen are the only antipyretic drugs recommended for use in children; however, combined or alternating use of these agents is not recommended. CONCLUSIONS Recent scientific evidence mainly supports previous recommendations. The aim of the present article was to support pediatric knowledge and stimulate application of guidelines in daily clinical practice.

Birth weight for gestational age centiles for Italian neonates

Objective: To provide centiles for birth weight (BW) according to gestational age (GA) and sex for infants born in Italy. Methods: We used records of the whole neonatal population of Tuscany, a region in Italy, from July 1991 to June 2002 as resulting from the database of the cystic fibrosis neonatal screening program (n = 290 129). We excluded as unlikely for GA those BW that were more than two interquartile ranges above the 75th centile or below the 25th centile for each GA and gender group. Results: We present the 3rd, 10th, 25th, 50th, 75th, 90th and 97th centiles of BW for GA from the 24th to 43rd week of gestation for male and female Italian neonates, as both tables and smoothed curves. Conclusions: The large size of the examined population allows us to provide up-to-date, reliable BW for GA centiles for Italian newborns, especially for lower GAs.

Rational use of antibiotics for the management of children's respiratory tract infections in the ambulatory setting: An evidence-based consensus by the Italian Society of Preventive and Social Pediatrics

BACKGROUND Several guidelines for the management of respiratory tract infections in children are available in Italy, as well as in other European countries and the United States of America. However, poor adherence to guidelines and the sustained inappropriate use of antibiotics have been reported. In the outpatient setting, almost half of antibiotics are prescribed for the treatment of common respiratory tract infections. In Italy the antibiotic prescription rate is significantly higher than in other European countries, such as Denmark or the Netherlands, and also the levels of antibiotic resistance for a large variety of bacteria are higher. Therefore, the Italian Society of Preventive and Social Paediatrics organised a consensus conference for the treatment of respiratory tract infections in children to produce a brief, easily readable, evidence-based document. METHODS The conference method was used, according to the National Institute of Health and the National Plan Guidelines. A literature search was performed focusing on the current guidelines for the treatment of airway infections in children aged 1 month-18 years in the ambulatory setting. RESULTS Recommendations for the treatment of acute pharyngitis, acute otitis media, sinusitis, and pneumonia have been summarized. Conditions for which antibiotic treatment should not be routinely prescribed have been highlighted. CONCLUSION This evidence-based document is intended to accessible to primary care pediatricians and general practice physicians in order to make clinical practice uniform, in accordance with the recommendations of the current guidelines.

Totally implantable central venous access ports in patients with cystic fibrosis: a multicenter prospective cohort study.

Purpose The aim of this study was to assess the incidence of late onset complications of totally implantable venous access devices (TIVAD) in patients with cystic fibrosis (CF) and to investigate possible associations between the rate of complications and different policies of TIVAD management. Methods A multicenter prospective cohort study was performed in 11 Italian CF Centers. Patients with CF and a TIVAD were recruited and followed-up. Results The study commenced on May 2008 and ended on September 2010. Eighty subjects were studied (77.5% women - mean age 27.2 years). Eighteen late complications of ports were observed (22.5%; incidence 0.96 per 1000 days of observation): three lumen occlusions, seven catheter-related infections, three port-related venous thrombosis, in addition to five other complications. A statistically significant association was found between the onset of catheter-related infection and the presence of CF-related diabetes (CFRD) (P=.0064) Conclusions Our data suggest that TIVADs represent a safe and effective device for the intermittent IV administration of drugs in people with CF. However, people with CFRD have a higher risk of developing TIVAD-related infection.

The Costs of Treatment of Early and Chronic Pseudomonas aeruginosa Infection in Cystic Fibrosis Patients

Abstract The aim of cystic fibrosis (CF) care is to improve both the life expectancy and quality of life of patients. However, rising costs and limited resources of health services must be taken into account. There are many different antibiotic strategies for therapy of Pseudomonas aeruginosa infection in CF patients. In this 5-year retrospective study we found that the cost of treatment of initial infection is considerably lower than the cost of treating chronic P. aeruginosa infections. The percentage distribution of costs of antibiotic treatment in relationship to the administration route was considerably different between outpatients and inpatients. We observed an increase in antibiotic costs with the age of the patient and the decrease in FEV1 values. The implementation of early eradication treatment, in addition to decreasing the prevalence of patients chronically infected by P. aeruginosa, might also bring about a notable decrease in costs.

Eradication of Pseudomonas aeruginosa in cystic fibrosis patients

To the Editors: We share the opinion that the optimal therapeutic strategy to eradicate Pseudomonas aeruginosa from the airways of patients with cystic fibrosis (CF) is still unclear. This situation is not likely to change by comparing small studies employing different methodologies in different settings, particularly our study 1 with that of Eber et al. 2. Clearly, larger studies have to be undertaken to provide a better basis for a consensus in this context. We do not share the opinion of Eber et al. 2 that “true eradication” of P. aeruginosa is …