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Chronic colonization with Staphylococci

Dear expert team!

Request for help for a very worried mother:

my daughter (16 years old) had until about one year ago, a very good lung function (97%) and a very good general condition. As she is also an extreme allergic patient, one has the creeping worsening of the lung function not regarded to be so dramatic. In summer 2014, we have however decided to do a bronchoscopy not to miss anything at all (lung function 84%). This looked really horrible - mucus everywhere - germ finding Achromobacter, Staphylococci, Haemophilus (no Aspergillus) - admission to iv-therapy - after iv-therapy no change of the lung function - on the contrary, middle and small airways nearly completely closed - and at once Aspergillus in the sputum - therefore suspicion of ABPA and therefore start of anti-fungal therapy (itraconazole and cortisone) for 3 months - however acutally germ findings still unchanged - that means chronic colonization with Stapyhlococci by all means, Achromobacter would allegedly not going to disappear anymore anyway - now they want to start additionally a long term treatment with flucloxacillin:
My worry: long term treatment in this high dosage (is given in double dosage as normal) - what do we have to take into account? How often controls of the sputum because of aquisition of Pseudomonas, how often control of liver enzyme values respectively kidney values?
What about the growth of fungi, then?
Does one do long term antibiotic therapies in case of chronic colonization with Staphylococci?
I am really despaired and have in the meantime really given up the hope to bring my daughter again on the good lung function values!
I know that a therapy is always a double-edged sword - for one thing good, for the other bad - however I do not want to miss anything, if one could do probably it another way!
Thank you while waiting for your appreciated opinion.

you report, that in case of your 16-year-old daughter, who did very well until one year ago, it came in the last months to a marked worsening of the lung function and that during the made investigations (bronchoscopy), Achromobacter, Staph. aureus and Haemophilus influenzae have been found in the bronchial secretions. The initiated iv-therapies did not show an improvement and one has now found Aspergillus fumigatus and your daughter received a therapy with itraconazole and cortisone for 3 months. Due to the unchanged finding of Staphylococci, you have additionally been recommended to perform a long term therapy with flucloxacillin.
You are worrying because of potential side effects of the proposed therapy and ask for alternatives respectively a judgment of the situation.

At first I would like to point out, that the lung function with 97% one year ago and also the finding of 84% before the performance of the bronchoscopy have to be juged to be very good, even if of course a decrease of 13% in one year has to be judged as critical. However, the value of 84% is still in the lower normal range and it could not be expected automatically, that now those deteriorations are going on.
I would like to comment first of all on the germ situation. Primarily it has to be stated, that it is very positive, that your daughter has at the moment no Pseudmonas aeruginosa. For the three germs, that have been found in the bronchoscopy, it is rather unusual that they lead to such a quick worsening of the lung function. This is more often seen in case of ABPA. It has therefore to be discussed, if not primarily the ABPA has caused the worsening, even if Aspergillus could not be found in the bronchoscopy anymore. It is correct that the germ Achromobacter - like Pseudomonas aeruginosa - can nearly not for sure be eliminated from the lungs of a CF patient anymore, if a colonization took place. This however means in no way, that the lung findings have to deteriorate constantly now.

The long-term colonization with Staph aureus is judged differently under CF experts. There are arguments for a longterm antibiotic therapy as well as arguments for an interval therapy, that orientates itself more to the clinical symptoms and treats only a pulmonary exacerbation.
As long as considerable dosages of cortisone have to be administered due to the ABPA, an aggresive accompanying antibiotic therapy seems to be reasonable in any case. Hereby Staph. aureus and in the interval also Achromobacter should be attacked.
If the ABPA therapy is finished, probably in the special situation rather an interval therapy against Staphylococcus aureus and Achromobacter should be intitiated, as a longterm therapy could probably rather lead to an anew outbreak of the ABPA.

As your daughter is for sure moitored rather closely in the CF center due to the actual situation, and respective laboratory controls are performed, you should for sure not worry about potential side effects on liver and kideny function, as those problems can for sure be recognized early.

It is in the underlying situation difficult for all, to say for sure, why the initial worsening of the lung situation occurred. It is important, that still a consequent therapy is performed in order to be able to recognize from the course, which germ is the most important. Hereby the most important aim is, to stabilize the health status of your daughter on the actual level and to hope in the future that it is going to improve.

We wish you and your daughter all the best,
Dr. H.-G. Posselt