Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guidelines
  3. Paediatrics
  4. Back
  5. Respiratory (Paediatric)
  6. Eradication of Burkholderia Species in Children with Cystic Fibrosis, Paediatrics (700)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Eradication of Burkholderia Species in Children with Cystic Fibrosis, Paediatrics (700)

Disclaimer:

The following guideline has been developed for use within the Royal Hospital for Children, NHS Greater Glasgow and Clyde (NHSGGC).   The guideline has been developed in collaboration with key stakeholders within NHSGGC, including Mircobiology, Cystic Fibrosis, Infectious Disease and Pharmacy teams.  The guideline has been approved by the Paediatric Antimicrobial Management Team and ratified by the NHSGGC Antimicrobial Utilisation Committee.

The guideline does not account for epidemiology and resistance patterns outside of NHS GGC and use outside of the designated organisation is at the individual’s risk. 

Background:

The Burkholderia cepacia complex (Bcc) consists of a group of genomic species called genomovars.  Some examples include B. cepacia, B.multivorans, B. cenocepacia, B.vietnamiensis, B. stabalis, B. dolosa and B. pseudomultivorans.  Reports have confirmed some strains as conferring an adverse prognosis, and colonisation with B. cenocepacia is one of the exclusion criteria from many transplant programmes.

As with P. aeruginosa, some isolates of Bcc, particularly B. multivorans, can be successfully eradicated with early aggressive antibiotic therapy before chronic infection becomes established (Etherington et al, 2003).) While a COCHRANE review in 2019 did not identify any studies of sufficient quality to draw conclusions regarding specific regimes for eradication of Burkholderia and acknowledged a paucity of evidence base, the CF Trust guidelines recommend eradication attempts should be considered. The aim is to prevent chronic colonisation and subsequent impairment of lung function and is routine in many centres based on cases studies and series.  Primary eradication therapy involves a combination of intravenous antibiotics.  Choice is based on culture and sensitivity results (including genome typing) and this therapy is given for a minimum of two weeks, followed by three consecutive months of nebulised TOBI®.  

It may be appropriate to start antibiotic therapy whilst awaiting confirmation as even if Burkholderia species are not identified, it is likely another gram negative organism (e.g Pseudomonas spp) will be identified.

Audit of this protocol shows a high level of success in eradication with currently only ~ 3.5% patients colonised with BCC. This prevalence has remained stable for many years and is in line with UK CF Registry data.

It will be important to monitor the situation as modulator drugs are more widely used and the risk benefit of antibiotics may change.

ERADICATION PATHWAY

Drug monographs

Intravenous drug dosing:

Drug

Dose

Frequency

Comments

Meropenem

40mg/kg (max 2 grams)

Every 8 hours

Consider administration as a prolonged IV infusion (over 3 hours) to achieve a more favourable pK profile.

Tobramycin

10mg/kg (max 660mg)

Once daily

Infuse over 30 minutes.

Level immediately prior to second dose. 

  • If >1mg/L OMIT next dose and re-measure.  Consider extended dosing intervals or reduce dose by 20%.  Repeat levels after 2 days.
  • If level ≤1mg/L, continue and repeat level immediately before day 8 dose.

Oral N-acetylcysteine should be prescribed with each course of IV tobramycin.

N-Acetylcysteine (NAC) for the prevention of aminoglycoside associated ototoxicity in children with cystic fibrosis

For dosing of alternative IV agents please refer to BNF-c, or contact Microbiology or Pharmacy for advice.

Nebulised drug dosing:

Drug

Dose

Frequency

Comments

Tobramycin

≥6 months – 2 years: 150mg

≥ 2 years: 300mg

 

Twice daily

Caution when switching between TOBI/Tymbrineb and Bramitob as solutions are different strengths.

Use in children <6years is unlicensed.

Alternative agents for nebulisation include aztreonam lysine, ceftazidime, meropenem and temocillin – Consultant Microbiology approval required.  For dosing advice following approval please contact Pharmacy.  Burkholderia cepacia complex spp are intrinsically resistant to colistin.

Aminoglycoside Ototoxicity Genetics Testing

If A1555G genetic testing has not been carried out, parents/ patients should  be provided with information about this and if consent obtained, blood should be sent for analysis. If the A1555G mutation is identified, the risks and benefits of continuing aminoglycoside treatment will be discussed and, where possible, alternative treatments will be considered.

Evaluation

ANNUAL AUDIT OF:

  • BURKHOLDERIA ACQUISITION RATE
  • BURKHOLDERIA ERADICATION RATE
  • ONGOING ASSESSMENT OF SERIOUS DRUG RELATED SIDE EFFECTS

Editorial Information

Last reviewed: 01/06/2022

Next review date: 31/05/2025

Author(s): Dr Jane Wilkinson – Associate Specialist, Paediatric Cystic Fibrosis; Dr Christine Peters – Consultant Microbiologist; Dr Rosie Hague – Consultant Paediatric Immunology and Infectious Disease; Susan Kafka – Specialist Pharmacist RHC.

Version: 2

Approved By: Paediatric Drugs & Therapeutics Committee

Document Id: 699

References
  1. Horsley A, Webb K, Bright-Thomas R, Govan J, Jones A. Can Early Burkholderia Cepacia Complex Infection In Cystic Fibrosis Be Eradicated With Antibiotic Therapy?. Front Cell Infect Microbiol. 2011;1:18. Published 2011
  2. “Intravenous Antibiotic Guidelines for Patients with Cystic Fibrosis at Leeds Cystic Fibrosis Units (Adult and Paediatric)”, The Leeds Centre for Cystic Fibrosis and Leed’s Children’s Hospital; Last revised December 2019
  3. Leeds Paediatric CF Unit: The Leeds Method Of Management. April, 2008.
  4. Clinical Guidelines: Care of Children with cystic Fibrosis, 2020; Royal Brompton and Harefield Hospitals NHS Trust.
  5. “Antibiotic Treatment for cystic fibrosis”; The UK Cystic Fibrosis Trust Antibiotic Working Group, Third Edition, May 2009.
  6. WEST OF SCOTLAND ADULT CF UNIT 2015- BURKHOLDERIA ERADICATION PROTOCOL 20187. Tobramycin (Inhaled) monograph – Paediatric; Children’s Antimicrobial Management Program (ChAMP); Perth Children’s Hospital
  7. Garcia, B.A., Carden, J.L., Goodwin, D.L. et al. Implementation of a successful eradication protocol for Burkholderia Cepacia complex in cystic fibrosis patients. BMC Pulm Med 18, 35 (2018). https://doi.org/10.1186/s12890-018-0594-8
  8. Regan, Kate H., and Jayesh Bhatt. "Eradication therapy for Burkholderia cepacia complex in people with cystic fibrosis." Cochrane Database of Systematic Reviews 4 (2019).