Prevention Pseudomonas

Question

Dear members of the expert team, some CF patients already have pseudomonas infection at the age of 2 where others are only infected at the age of 18 years. Is anything known about risk factors or in other words what can you do to prevent infection (of course I know the guidelines on hygiene and evitating contact with contaminated water). Should we for example forbid our daughter to play in the sand etc?

Answer

Dear parents, as you are aware, infections with pseudomonas are a major problem for children with cystic fibrosis. In case of recent infection this bacteria can often be eradicated but once the infection is chronic the long term evolution of lung function is less favorable in chronically infected children. It is therefore understandable that many parents wonder whether they can prevent infection with pseudomonas.
Pseudomonas is a ubiquitous bacteria; this means that it’s a common bacteria in the environment. It is frequently isolated in heated and still water, but can also be present on vegetables, fruit, for example, tomatoes. In general contact with pseudomonas is unavoidable.
It is not yet fully understood why CF patients are so vulnerable for pseudomonas infection. It is neither well known why some patients become infected early in life while some only much later. What we know is that pseudomonas infections are typical for CF and that almost every CF patient will be infected or colonized with pseudomonas sooner or later. Yearly about 20% of the patients will develop a new pseudomonas infection and the risk for chronic infection increases with age. In many European countries including Belgium, where intensive treatment is started as soon as pseudomonas is cultured from the airway, the average age at which chronic pseudomonas infection is diagnosed has increased. According to the Belgian patient registry only 16,4% of patients under the age of 18 are chronically colonized (data from the 2007 Belgian registry report).
Patients chronically colonized with pseudomonas may be a source of pseudomonas infection. Moreover these pseudomonas germs are often difficult to treat. Studies have shown that contact with chronically colonized patients or not treating a new pseudomonas infection are important risk factors for chronic infection.
Up till now no study has shown that avoiding contact with possible environmental pseudomonas sources can effectively prevent infection. Concerning contact with water, a swimming pool sufficiently chlorinated is considered safe. However tropical pools and jacuzzi’s are not considered as safe since the heated water can create vapor which can as an aerosol easily enter the airways. Playing in the sand is not a known risk factor and should thus not be forbidden.
The most important measures are still good hand hygiene as well as adequate maintenance of the nebulisor equipment and the PEP mask because the airways are in direct contact with these devices. As a rule patients become infected from the environment, less frequently infection through patient contact occurs. Avoiding close contact with other cystic fibrosis patients with pseudomonas infection remains important (keeping a distance of 1 meter) because often these pseudomonas bacteria carry some resistance. Of ut most importance is an adequate follow-up in a cystic fibrosis reference center including frequent sampling of the airway. If diagnosed early pseudomonas infection can frequently be treated efficiently. We hope this information sufficiently answers your questions.
Kind regards,
Dr. M. Boon and Dr. M. Proesmans

19.10.2009