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MRGN (multi-resistant gram-negative rod-shaped bacteria)

Question
Dear ladies and gentlemen,
after 3 years, there has been a renewed finding of Pseudomonas in my son (23 years old).
10.000 - 100.000 Pseudomonas (mucoid stem) with the warning, it was a 4MRGN-stem (multi-resistant gram-negative rod-shaped bacteria against 4 main antibiotic groups). Sensibility still only to piperacillin, tobramycin and colistin.
Would you in this case recommend a combinded oral and inhalative therapy or an intravenous therapy?
Many thanks in advance for your efforts,
Yours sincerely,
S. A.
Answer
Dear questioner,
you ask which therapy is now the optimal one in the case of your son with a renewed finding of Pseudomonas aeruginosa (PA), now as a 4MRGN-stem (before he has been free of PA for 3 years). In advance it has to be said that we cannot give concrete recommendations via the internet, as we physicians only give information on this platform and general advice. Please bear with me.
As I do not know your son (Susceptibility for infections? Findings? Accompanying problems? Recent therapy? Tolerance of antibiotics? Reaction to therapy? Course of the illness? Number of Pseudmonas-free sputum investigations? etc......) I can only answer your question partly.
In case of your son, there are quite many "right" ways to treat, that have the aim of fighting of PA. Here only 2 examples for this:
You are aware of the definition of a 4MRGN-PA. Fortunately, the germ shows in vitro (in the laboratory) besides the susceptibility to piperacillin also still a reaction to tobramycin and colistin. Taking the 3-years PA-free time interval into account, one could try a 14-days intravenous therapy with piperacillin and tobramycin and in parallel an inhalation with colistin. The colistin inhalation 2x/daily, on/off would be performed in combination with tobramycin inhalation 2x/daily on/off (28 days colistin-inhalation followed by 28 days tobramycin inhalation in turns) until a renewed PA-disappearance. After that, a new decision concerning the ongoing PA-effective inhalative therapy has to be made. In case the PA-germ should continue being detectable, generally a long-term therapy with inhalative PA-effective antibiotics is recommended.
A second therapeutic option could be an exclusively inhalative antibiotic therapy: 28 days colistin inhalation followed by 28 days tobramycin inhalation until the renewed disappearance of PA and in case the PA-germ would still remain detectable, then go on (as described above) with a long-term therapy with PA-effective antibiotics.
A combined oral and inhalative therapy would rather not be recommended in the case of your son, as the sole PA-effective antibiotic, that can be given in form of tablets, belong to the group of chinolons (group of antibiotic drugs), that obviously according to your information, came out to be resistet in the sensitivity testing of the germ in vitro.
We recommend to you in any case to discuss the therapeutic options with your CF-physician of your son you trust. Probably our information could be helpful for you during the talk.
I hope to have helped you a bit,
Best regards,
Yours
Dr. Christina Smaczny
01.07.2013