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Inhalation in case of resistant Pseudmonas

Question
My son is 33 years old, mutation genotype deltaF508 and R553x. He has inhaled colistin for decades and now his Pseudomonas germs are resistant.
Furthermore I ask myself if it is not possible however, that in case of such a long exposure colistin passes minmally the blood-brain barrier as he reacts so solwly in his verbal communication....I ask myself if the colistin makes sense anymore. Against tobramycin there were resistances since he is 9. At his yearly i.v. therapy he always got ceftazidim in combination with amikacin. There is partly sensibiltiy to aztreonam that would also be possible to inhale and seemingly also to amikacin - that has not been tested at the last antibiogram and he should soon get his next i.v. with tazobactam. Probably Slit amikacin would be a good alternative to inhale - as he has a stop-mutation. I would like to thank you very much in advance for your commitment.
Answer
Hello,
after years of usage of those medications a selction of resistant germs can unfortunately not be excluded. One has to know, however, that we see quite often while giving the i.v. therapy, that in spite of a shown resistance there is a clinical effect. Also amikacin can like tobramycin be used as a generic or in a special galenics for inhalation - the effect to have an improvement of the CFTR-synthesis in case of a stop-mutation however, was not able to win through from the experimental approach to the clinical usage. Unfortunately there is often an underlying resistance or it is developing fast also against amikacin if such a resistance is already present against other aminoglycosides (e.g. tobramycin).
Best regards,
Prof. Dr. TOF Wagner
21.10.2013
21.10.13
There is a publication on the actual strategies of treating chronic lung infection in CF patients, with some helpful information (Döring et al. 2012 in the Journal of Cystic Fibrosis "Treatment of lung infection in patients with CF: current and future strategies") that can be summerized as follows:
For the therapy of chronic Pseudomonas infection, several inhalative antibitoics come into account: tobramycine, aztreonam Lysine, colistin; several medications are still in development: liposomal amikacin, ciprofloxacin dry powder inhaler and others. Certain medicactions, such as inhaled aminoglycosides are recommended as an intermittend one moth-on one month-off regimen, some medications, such as colistin, for example, are recommended rather as continous administration. However, the on-off stratgey for decreasing the development of resistance, has been challenged as to whether it is the optimum strategy, noting the observation of a decrease in lung function during the off-cycle. Potential strategies could employ continous antibiotic rahter than an intermittend approach or to use a rotation of antibiotics rather than a single antibiotic.
Therefore, in this special case, some options are possible: inhalation of a new drug with residual sensitivity, such as aztreonam, would be possible as well as rotating different antibiotics according to the actual resistance pattern. This however, has to be discussed in detail with the treating CF-Center.
D. d'Alquen