Achromobacter xylosoxidans

Question

Dear expert team,
in diverse treads in the past there can again and again be read, that a colonization with Achromobacter xyl. should be treated according to the individual course.
Starting situation: my daughter (17y) is chronically colonized with Achromobacter + Staphylococcus and again and again also with Aspergillus.
In general she has quite a good health status, however since the last year still 13% creepingly loss of lung function (distributed over the year) until now, that could not be regained again.
And that in spite of constant oral treatment of the diverse germs with amoxicillin + claviulanic acid, cefalexin, cotrimoxazol, colistin (inhal), itraconazol for 4 months for aspergillus + additionally i.v. therapy in august 2014 - this did really bring no success, either! However, she has an allergic reaction to trimethroprim/sufametrol (i.v.) - we could finish the i.v. though - probably it however did not totally work therefore?
At the moment all germs are again present, including Aspergillus.
Now my questions: my observation concerning symptoms (suspicion of myself related to Achromobacter) are related to a dry unproductive cough, which is followed in the course of time by a produktive hawk. This is consistent with the statements of also Achromobacter-colonized patients on diverse internet platforms.

Are these symptoms correlated to Achromobacter known to you?

And which drugs could one still try if Trimethoprim/Sulfametrol (is mentioned to be the best against Achromobacter in our CF center) is not working?
One can find on diverse patients internet platforms Minocyclin respectively Cefpodoxim orally respecitvely Levofloxacin for inhalation? Is this going to help?
Many thanks in advance,
I.D.

Answer

Hello,
you ask, if there are typical clinical symptoms that speak for a clinical deterioration due to an existing colonization with Achromobacter xylosoxidans (in this case the loss of lung function of your daughter). You report a mostly dry cough, that is finally followed by some expectoration of mucus. Your daughter has a chronic colonization of the lung with Staph. aureus and Achromobacter xylosoxidans and recurrent finding of Aspergillus fumigatus.

The by you mentioned symptoms are not described as a typical form of symtoms in case of an active infection with Achromobacter. It has to be discussed, how one can clarify with more security if the Achromobacter plays indeed the "first fiddle" in case of the inflammatory process of the lung. You know, that one thought for quite a long time that Achromobacter was a harmless "accompanying germ" in case of CF patients.
In the meantime it is assumed that his germ can indeed influence the course of the illness of a patient quite negatively.
In the special situation of your daughter the following questions have to be clarified.

1) If there can acutally still be found Aspergillus in your daughter, the serum immunoglobulin E is of importance. If this is higher than 500 or even higher than 1000 kU, then a clinically relevant allergic bronchopulmonary aspergillosis has to be assumed. In case the value is under 500 kU, Aspergillus can be excluded as a reason for the deterioration of the lung function.

2) Staphylococcus aureus can in general well be treated with many different antibiotics, even if it does not come in many patients to a permanent elemination of this germ from the lungs. Under such an antibiotic therapy, the laboratory findings, that are typical for an active infection (e.g. leucocyte count, CRP and Immunoglobulin G) should normalize.

3) In case the inflammatory parameters should stay increased in spite of this, it can be suspected, that Achromobacter plays an active role in the inflammatory process. Collegues from Kopenhagen have reported in 2006, that in case of CF patients, who had been colonized with Achromobacter and had a clinical deterioration, specific precipitaiting antibodies could be detected in the blood.
As appropriate, the physicians of the CF center could clarify, if there is the possibility to have such an investigation of the antibodies done in Germany or in coopreration with the collegues from Kopenhagen.
To the question of a suitable antibiotic in case of an Achromobacter infection the following can be said:
Due to the high risk of the development of resistance, it should only be treated if there is a high security that the Achromobacter is responsible for the actual clinical situation. The dosage of the drugs should be in the upper therapeutical range and the duration of a therapy cycle should be at least 21 days.
The following substances aqre mostly effective: Minocyclin, Meropenem, Imipenem, Pireracillin/Tazobactam, Chloramphenicol
In the single case the drug has to be choosen on the basis of an underlying antibiogram of the identified germ.
I think that your daughter should discuss these aspects with the physician of your CF center.
Best regards,
Dr. H.-G. Posselt

06.05.2015