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Pseudomonas in the nasal lavage

Question
Dear expert team,
First of all many thanks for your efforts. As a partner of a CF patient I am already for a longer time silent reader of your expert advice. Now I would like to pose a question for the first time. In the nasal lavage of my wife (CF, 31 years old, FEV1 85%) Pseudomonas had been detected at the beginning of this year, however not in the lungs. After this, she was recommended to do an inhalation with colistin with the Pari Sinus (twice a day). After a short-termed success (no detection of the germ in the nasal lavage), Pseudomonas aeruginosa could however again be detected in spite of ongoing inhalation. Now the antibiotic has changed to "tobramycin". Unfortunately the nose of my wife is markedly irritated (blood in the mucus) due to the long lasting inhalation. Unfortunately we have the feeling now, not to be really taken for serious in the CF center, as my wife has a very good health condition.
Now to my question:
How high is the risk, that the germ spreads to the lungs? Can something be done inhere preventively?
Furthermore, I would be interested in further therapeutical methods that would be sensible in order to eliminate the germ from the nose. Is for example an i.v. therapy sensible?
Many thanks for your help,
P.
Answer
Dear P. and wife,
first of all I have to emphazise that your CF center has shown a very important involvement in our opinion. Via the additional testing of germs in the upper airways of your wife, who shows an joyfully compensated lung function, an isolated colonization of the nose/ sinuses with Pseudomonas could be detected.
In many, respectively in most of the CF centers worldwide, this would not have happened, because except from the German guidelines concerning the new colonization with P. aeruginosa, the upper airways are hardly mentioned up to now. Therefore I assume, that the isolated, respectively early new colonization of the nose and its sinuses is frequently overlooked.
Because the germs can reach the lungs from this upper etage and with this it could result a permanent colonization with a markedly stronger inflammatory stimulus, this dynamic attracts more and more interest (1,2). An exact quantification of this risk is not possible according to the actual literature.
Your CF center did also do the following step. With the inhalation of vibrating aerosols via the Pari Sinus it has been tried with colostin and then tobramycin (dosage?), to get rid of the germ from the upper airways. That these vibrating aerosols can reach the sinuses, has been shown by Möller (3) with scintigraphic investigations. We have reported single cases, in that the eradication of an isolated first colonization with Pseudomonas was successful with this device, once the germ rested also after an i.v. therapy only in the upper airways (4). Recently we have shown in a pilot study the tolerance of 80 mg tobramycin in case of inhalation into the sinuses (5). A study group from London has looked for problematic germs in the nasal lavage of all cared children and reported, that they were also able to eradicate the germs from this airway segment in some patients with the Pari Sinus (6).
Therefore it has to be assumed, that the initiated therapy from your CF center could have had success. However the germ can still be detected in the nasal lavage of your wife and she has problems of an irritated and inflamed nasal mucosa under the sinu-nasal inhalation.
A limitation of the inhalation with Pari Sinus is, that the drug cannot reach those sinuses, that are blocked completely via swelling of the mucosa, polypes....
In such a case, the operative widening of the entrances to the nasal sinuses (ostia) according to the model from Copenhagen (7) could be sensible: the ostia are widened with fine endoscopic tools, mucus, pus, polypes and swelling of the mucsa are removed and an intensive after-care follows: the patients are receiving around the time of the operation a 14-day i.v. therapy against Pseudomonas. They receive for the coming 3-6 months daily nasal washings with Nacl solution and added colistin and for improvement of healing and reduction of relapses they get over 1 year every evening nasal sprays with a small amount of cortisone (like Avamys®, Flutide nasal® or Nasonex®) (7).
In general before such a procedure, one can try a therapy with a combination of the by you mentioned i.v. therapy with sinu-nasal inhalation of antibiotic drugs. Data about the therapeutical success of such a procedure is lacking, either.
It is important, that you do not accept, that the germ rests in the upper airways of your wife. The successful eradication takes the risk of dripping of the infection to the lungs away and with that the substantial extra effort that is necessary for stability under a permanent colonization with Pseudomonas.
For further questions you can turn to me at any time and I have added several sources with that we can provide you in case you need it.

All the best,
Dr. Mainz

1. Hansen SK, Rau MH, Johansen HK, Ciofu O, Jelsbak L, Yang L, et al. Evolution and diversification of Pseudomonas aeruginosa in the paranasal sinuses of cystic fibrosis children have implications for chronic lung infection. Isme J. 2011;6(1):31-45. Epub 2011/07/01.
2. Mainz JG, Nährlich L, Schien M, Kading M, Schiller I, Mayr S, et al. Concordant genotype of upper and lower airways P aeruginosa and S aureus isolates in cystic fibrosis. Thorax. 2009;64(6):535-40. Epub 2009/03/14.
3. Möller W, Saba GK, Haussinger K, Becker S, Keller M, Schuschnig U. Nasally inhaled pulsating aerosols: lung, sinus and nose deposition. Rhinology. 2011;49(3):286-91. Epub 2011/08/23.
4. Mainz JG, Michl R, Pfister W, Beck JF. Cystic fibrosis upper airways primary colonization with Pseudomonas aeruginosa: eradicated by sinonasal antibiotic inhalation. Am J Respir Crit Care Med. 2011;184(9):1089-90. Epub 2011/11/03.
5. Mainz JG, Schädlich K, Schien C, Michl R, Schelhorn-Neise P, Koitschev A, et al. Sinonasal inhalation of tobramycin vibrating aerosol in cystic fibrosis patients with upper airway Pseudomonas aeruginosa colonization: results of a randomized, double-blind, placebo-controlled pilot study. Drug Des Devel Ther. 2014;8:209-17. Epub 2014/03/07.
6. Wilson P, Lambert C, Carr SB, Pao C. Paranasal sinus pathogens in children with cystic fibrosis: Do they relate to lower respiratory tract pathogens and is eradication successful? J Cyst Fibros. 2014;13(4):449-54. Epub 2014/04/10.
7. Aanaes K. Bacterial sinusitis can be a focus for initial lung colonisation and chronic lung infection in patients with cystic fibrosis. J Cyst Fibros. 2013;12 Suppl 2:S1-20. Epub 2013/09/27.




21.08.2014