Intravenous antibiotics for pulmonary exacerbations in people with cystic fibrosis.

Summary

Across 45 trials (n=2810), evidence supporting IV antibiotics for CF pulmonary exacerbations is generally low certainty; no clear differences between IV regimens or routes versus inhaled/oral were demonstrated. Limited evidence suggests shorter IV courses may be comparable in early responders.

Key Findings

• Forty-five RCTs/cross-over trials (n=2810) included; most were small and older with low-certainty evidence.
• No clear differences between specific IV antibiotic combinations, or between IV vs inhaled/oral routes.
• Limited evidence suggests shorter IV durations may be non-inferior in adults who respond early.

Clinical Implications

Consider individualized therapy and antimicrobial stewardship; avoid defaulting to prolonged IV courses without strong evidence, particularly if early response is achieved; prioritize participation in robust trials.

Limitations

• Many trials were small, old, and inadequately reported; heterogeneity limited firm conclusions.
• Patient-important outcomes and long-term endpoints were often underreported.

Future Directions

Well-powered pragmatic RCTs comparing routes, combinations, and durations with patient-centered outcomes; biomarker-guided strategies to define early responders.