P. aerugionsa repeatedly in the nose swab

Question

Dear expert team,
I have read the very helpful contribution of Dr. Jochen G. Mainz about the question:
"Pseudomonas in the nasal washing" (dated 01.07.2014).
In my 10-year-old son, P.a. has been found repeatedly again and again occasionally, we have had different therapies, oral and inhalative, as well as i.v. against it, unfortunately without success. Hereby we used for inhalation mostly Colistin, also once Tobramycin, as well as Ciprofloxacin orally. In the middle of may a mucoid form has been diagnosed the first time, again occasionally -->immediately i.v. therapy.
Now the germ can still be found after i.v. therapy in the nose swab, however not in the throat swab.
For this, our center in Munich, Germany, has only few experience how this can be delt with success.
The Pari-Sinus device is seemingly quite a crude device, especially for a young child (as mentioned 10 years old).
Which way would you propose (I know about legal disclaimer and the aims of remote diagnosis).
I would be very happy about an answer,
many thanks in advance and best regards,
H.S.

Answer

Dear family S.,
if one looks at the upper airways, one will find after first or new colonization often P. aeruginosa there.
This can be done with a deep nose swab or better with a nasal shower with 10 ml of isotonic saline solution, which we also show as a film in the internet as an online attachment to an article
dx.doi.org/10.1016/j.jim.2013.12.003
The stay of the problematic germ in the niche of the upper airways and the sinuses is obviously a relevant reason for the persistence of P.a. in the airways of CF patients.
Your question is important in order to take the chances optimally to get rid of P.a. of this part, either.
In general, the sinuses cannot be reached via conventional inhalations without widening of their openings. Only vibrating aerosols can reach the sinuses. With the by you mentioned device we have treated quite a lot of patients in the same situation as your son - as well as many other centers - e.g. with inhalation of 80mg Tobramycin or 1 million units of Colistin - 2 times daily for cyles of 28 days.
With that, in quite some patients the germ could be eradicated from the airways for a long term period, sometimes only after many months of therapy and after repeated additional i.v. cycles and/or ciprofloxacin orally.
Due to the finding of a mukoid Pseudmonas germ, the chance in case of your son could be reduced a bit. Even with that, we can report about successful eradications, especially if the antibodies against Pseudomonas in the blood remained negativ or borderline.
You mention the threat to use the device correctly. Yes, here it requires an intensive teaching, that is also done by the producing company. With the age of 10 years it can be expected that your son learns the inhaaltion after teaching sucessfully, so that he feels a vibration of the root of the nose or the maxillary sinuses, as a sign for reaching the sinuses. A few years ago, we published a case of a first colonization and eradication with a vibrating nebulizer in a 6-year-old boy, who remained free of P. aeruginosa since then.
I wish you success via a consequent and patienceful therapy, the effort is worth it!
Best regards,
Dr. Jochen Mainz

12.09.2015