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In presenting various therapeutic approaches for the management of cystic fibrosis (CF), Smyth primarily considers evidence obtained from The Cochrane Library as either systematic reviews of randomised controlled trials (RCTs) or RCTs.1 The antibiotic treatment of Pseudomonas aeruginosa (PA) when first isolated, is still an open question. When discussing this aspect, Smyth considers only the RCT by Valerius and colleagues.2
In our critical review of published clinical studies evaluating the early antibiotic treatment in asymptomatic PA colonised CF patients,3 we identified three relevant RCTs (two versus placebo).2,4,5 Our study also included eight cohort studies, two of which were with historical controls. Overall, 309 patients (range 7–91) were recruited. There was a high variability between the individual studies for age, outcome measures, duration of follow up, and treatment (three studies: two RCTs; 1 cohort used only aerosol tobramycin, 1 colistin, 4 aerosol colistin plus ciprofloxacin, 1 intravenous treatment, and 2 miscellaneous therapy).
An overall critical evaluation indicated that early antibiotic treatment can reduce the rate of positive cultures and of anti-PA antibody titres. Long term benefit is expected but not yet proven. Moreover, we recently conducted an observational study which found that nearly all CF centres in Italy treat asymptomatic PA colonised patients in order to prevent or postpone chronic pulmonary infection (unpublished data). However, the adopted prescribing practice varies largely even within the same centre, highlighting the existing lack of formal consensus on this subject.
Several therapeutic options (aerosol therapy alone or oral therapy associated with aerosol inhalation) are available for the early treatment of PA colonisation, but no direct comparison has so far been made. Prospective multicentre randomised studies with relevant outcomes measures6 are needed to investigate which of the different proposed antibiotic schemes has the best benefit/risk ratio and the best patient compliance.