Pseudomonas (1st question)

Question

We have a patient in our clinic with Pseudomonas bacteria which are difficult to treat. Currently we rinse everything which gets in contact with the mouth, for example the toothbrush of the Güdeltubus (is being washed twice a day, in-between rinsed only), cottonwool sticks for the oral hygiene, medical drugs which are dissolved etc. with Bismark water Is that necessary or could we use tab water as well? Does a clinic bear an increased risk that the tab water is contaminated? Is it possible to administer the patient humid artificial ventilation or should we rather use HNE filter (which is what we are currently doing). (Humid ventilation surely would be better for his secretion, wouldn’t it?)

Thank you very much.

Answer

Hello,

Chronical colonisation with Pseudomonas aerigunosa (P. aeruginosa) is frequent with CF patients (with adult patients up to 80 %). P. aerigunosa in a CF lung very often are variants with an adaption to the specific environment in the CF airways and with reduced virulence. Since these germs hold diminished contagiosity for none-CF patients hospitalized CF patients as a rule need not be isolated from other patients - with the exception of “multiresistant” P. aerigunosa which, according to definition, are resistant to four out of five antibiotics with Pseudomonas-activity (Ceftazidim, Piperacilin, Meropenem, Ciprofloxazin, Gentamicin). In the latter case you absolutely should contact your clinic hygienist and discuss how further to proceed (e.g. organisation of care, isolation of the room, the bed etc.)

Chances are high that in the ward water tabs / pipes are contaminated with P. aerigunosa. It is a basic principal that water from tabs (e.g. when the patient is washed) must not get in contact with the ventilation system and tube because it is to be regarded as potentially contaminated. We use boiled water for oral medication, oral hygiene etc. (e.g. freshly prepared tea) or mineral water respectively. With patients under artificial ventilation oral decontamination with 2 % Chlorhexidine should be applied, additional to oral hygiene. This practise is supported by current meta analysis ((Tantipong H et al. Infect Control Hosp Epidemiol 2008; 29: 131-136).

Some studies suggest a preventive advantage concerning infection if instead of active humidification passive humidification with HME filters is chosen. The level of humidification is relevantly lower, though. Thus we establish active humidification for all patients with an indication of ventilation lasting probably several days. This applies especially to CF patients to keep the airway secretion humid and improve its clearance. Reusable medical equipment (e.g. in-line nebulisers) is to be cleaned thermally or chemically after use. Single-use medical devices (e.g. bladder syringes) should not be used again with patients being tube-ventilated.

The question allows to address a few points of general improtance:
The exist several guidelines relating to teh topic of infection in CF patients although not secifically mecahnical ventialteion (eg ECFS, CF Trust, Saiman et al.) There is a stong case for separation of PA pos and neg patients as in and out patients, which translates to separate care teams in teh intensive care setting.
Tap water shoud of course be avoided as there is risk of NTM and PA. Srerile water should always be used for humidification of oxgen etc
With kind regards
Thomas Hirche

03.12.2008