Aerosolized antibiotics in cystic fibrosis

Inhaled antibiotics offer an attractive alternative to systemic administration in cystic fibrosis (CF) for several reasons. Antibiotics can be administered directly to the site of infection with little systemic absorption, thereby minimizing toxicity. Aerosolization will permit chronic administration of antipseudomonal antibiotics while avoiding the risks and inconvenience of intravenous access. Modern aerosolized drug delivery systems enable endobronchial delivery of very high antibiotic concentrations, resulting in clinical improvement even in patients with bacterial organisms that traditionally would have been considered resistant. This article summarizes basic concepts of aerosol drug administration and reviews available data on the administration of a variety of drug classes for both suppressive therapy and acute exacerbations of cystic fibrosis, including toxicity and safety data. The aminoglycosides have been by far the most extensively studied class of antibiotics, culminating in U.S. Food and Drug Administration (FDA) approval of a specifically formulated tobramycin solution for inhalation. The available data on the development of antibiotic resistance and emergence of other organisms with long-term use of this agent are reviewed. Finally, a brief guideline for initiating and monitoring patients on antibiotic aerosols is provided for the clinician caring for CF patients.