Blood in the sputum

Question

Dear expert team,
Pseudomonas aeruginosa has been found in my sputum. Already a few months ago, I did inhalations with Colistin (2 x 1 Mio). I tolerated the inhalations well. The health condition improved. As Pseudomonas has soon been found again, we decided to do a 3 months eradication therapy with an increased dosage of Colistin (2x2 Mio) and additionally Ciprofloxacin (2 x 750).
The therapy has been tolerated well for 4 weeks (apart from the amount of mucus increased markedly,it is turning however more and more lighter). After 4 weeks of therapy, blood in the sputum occurred. On the first day it was quite much (a few ml). After this, Ciprofloxacin had been stopped, as coughing blood is listed in the leaflet as a possible side effect. Colstin was intermittendly reduced to 2 x 1 Mio dosage.
I continue the therapy like this for further 6 days (thus only Colistin 2 x 1 Mio). At the daily coughing-up however, still blood is coming, in the form of several little blood streaks.
I read in the literature, that coughing blood can also be a side effect of Colistin inhalation. On the question, if one could go on inhaling Colistin, it is written: “benefit and risk have to be weighed against thoroughly.” Now I would like to weigh up damage/risk and benefit.
The side of the benefit is clear: it is the hope to eradicate PA. For this reason my treating physician is of the opinion, that I should continue the therapy. On the question, which damage I may cause due to ongoing inhalations of Colistin in spite of hemoptysis, he could unfortunately not make a comment.
My questions concern the topic damage/risk. Which risk do I have if I would go on inhaling Colistin in spite of hemoptysis? I imagine it to be like this, that the mucosa is very irritated by the Colistin and therefore turn out to be thinner or more inflamed, so that it is bleeding now. Is there the risk, that by further inhalations the damage of the mucosa is getting so hard, that this damage stays irreversibly in the mucosa? Or that the ciliae will be damaged irreversibly at the places of bleeding?
Or can one assume, that no irreversible damage is staying in the mucosa as soon as inhalations are finished?
According to the opinion of my doctor, a short term interruption of therapy would risk the success of the eradication therapy: due to one moth of the intensive therapy the number of germs was markedly reduced. Due to a pause, the resting PA could start again multiplying massively. Therefore I could in the worst case come back to “point zero” of therapy.
Many thanks for your answer,
Best regards,
L.A.

Answer

Hello,
in case of any therapy, weighing up „damage/risk“ is necessary. I do not know any data on the question, if irreversible damage is possible in case of an ongoing inhalative therapy with Colistin and emoptysis. In case however, that side effects occur during therapy, an alternative therapy haspossibly to be taken into account. According to the guideline on “diagnostics and therapy after the first finding of Pseudomonas aeruginosa”, in case of a second finding of Pseudomonas aeruginosa after the first intervention, for example an intravenous combination therapy for 14 days could be done. As we could not give medical recommendations in the frame of the expert panel however can only inform, I recommend in case the complaints do not disappear, to discuss with your treating physician, if this alternative could come into question for you.
Best regards,
Dr. Christian Hügel

04.07.2016