How to proceed?

Question

Hello,

Would like to give you a short account of our situation:
Three years ago our daughter (6, CF) was for the first time diagnosed with Pseudomonas a. This germ was treated with an IV for 14 days and a three months´ inhalation with TOBI. After that the Pseudomonas was no longer detectable and the Pseudomonas antibodies continued to be negative.

This April Ps. was detected again in one single swab. A treatment with Ciprobay (orally) for 8 weeks followed / in parallel TOBI was inhaled for 3 months.

The finding of the antibody control was as followed:
One antibody was 0, one 860 and one more than 1250 (I guess 1300); which shows that the immune system this time reacted to the Pseudomonas. This year our daughter had many infections in the paranasal sinus area as well.

In June she had a paranasal sinus surgery – it cannot be excluded that the Pseudomonas hid somewhere in this area

Since her surgery she has been absolutely free of infections. So far all further swabs were Ps.-free.

And this is my question now:

How can this increase of pseudomonas antibodies be explained???
Or, should this part rather indicate that a changing of the therapy is necessary? Our doctor is considering starting TOBI inhalation again, and an IV treatment is being discussed also.


Lungfunction:
FeV1 110%
VC >105 %
We simply feel very insecure, and we wonder if with a good general condition free of infections such a brutal proceeding is really necessary because of these findings?
We are eager to learn your opinion and what you think about this situation.

Answer

Good day,
as you describe in detail your daughter had a Pseudomonas colonisation for the first time three years ago. Treatment with a fortnights' IV and following inhalation of TOBI surely was a correct decision which proved successful in eradicating the Ps. germ. We speak of colonisation when any detectable reaction of the immune system to the germ did not occur yet and hence no Pseudomonas antibodies are detectable.

Now, after three pseudomonas -free years the germ has been traced again. This time it caused a generation of antibodies since it probably already had had longer contact with the mucosa. In spite of your child's normal lung function a new effort to eradicate the germ is urgently to be recommended. You already treated orally with Ciprobay and via inhalation with TOBI, and additionally the upper airways were sanitized as far as this is possible by surgery.

Now it is necessary to find out by regular throat swabs -or, which would be better, by sputum examinations, which can be forced by provocation with hypertonic sodium chloride solution, if your child is pseudomonas -free or if colonisation continues.

If pseudomonas is found again an adequate therapy should be initiated. There are many possible ways of therapy which differ from country to country and center to center; the i.v. therapy is often an important part of it. One possible option, that I would recommend is that after the i.v. therapy she should be treated again with Ciprofloxacin and perhaps inhalations with Colistine two ampules twice instead of TOBI for three months. In order to find the right therapy regimen for you, it is necessary to discuss this with the doctors at your CF center who know all about your special course of the illness.

Concerning the raised Pseudomonas antibody levels: it might be helpful to do another control in order to reduce the risk that they have been false positive. The question how to interprete positive antibody levels without detection of pseudomonas in the microbiological cultures themselves is not easy to answer and opinions between experts differ, if a treatment should only be initiated because of positive antibodies. It can not be excluded that the antibody level rises unspecifically in some cases.

Therefore, however, should there no pseudomonas be detectable in the throat swab, or better, in the sputum, I would currently not perform an antibiotic therapy based only on the slightly increased antibodies but for the time being control the throat swab or sputum every four weeks to be able to start therapy at once as soon as Pseudomonas is detected again.

With kindest regards,

Ernst Rietschel

12.01.2009