Pseudomonas aeruginosa Acquisition in Cystic Fibrosis Patients in Context of Otorhinolaryngological Surgery or Dentist Attendance: Case Series and Discussion of Preventive Concepts

Abstract

Introduction. P. aeruginosa is the primary cause for pulmonary destruction and premature death in cystic fibrosis (CF). Therefore, prevention of airway colonization with the pathogen, ubiquitously present in water, is essential. Infection of CF patients with P. aeruginosa after dentist treatment was proven and dental unit waterlines were identified as source, suggesting prophylactic measures. For their almost regular sinonasal involvement, CF patients often require otorhinolaryngological (ORL) attendance. Despite some fields around ORL-procedures with comparable risk for acquisition of P. aeruginosa, such CF cases have not yet been reported. We present four CF patients, who primarily acquired P. aeruginosa around ORL surgery, and one around dentist treatment. Additionally, we discuss risks and preventive strategies for CF patients undergoing ORL-treatment. Perils include contact to pathogen-carriers in waiting rooms, instrumentation, suction, drilling, and flushing fluid, when droplets containing pathogens can be nebulized. Postsurgery mucosal damage and debridement impair sinonasal mucociliary clearance, facilitating pathogen proliferation and infestation. Therefore, sinonasal surgery and dentist treatment of CF patients without chronic P. aeruginosa colonization must be linked to repeated microbiological assessment. Further studies must elaborate whether all CF patients undergoing ORL-surgery require antipseudomonal prophylaxis, including nasal lavages containing antibiotics. Altogether, this underestimated risk requires structured prevention protocols.

Figure 1

Different courses and outcomes after P. aeruginosa (P.a.) colonization in context of ORL-surgery or dentist treatment. Pat.: patient; FESS: functional endoscopic sinus surgery.

Figure 2

Progress of pulmonary function of patient number 1.

Figure 3

(a) and (b) Anterior rhinoscopy from patient number 3 six years after sinonasal surgery. (a) Abundant mucoid secretions draining from middle meatus left side; (b) # view into postoperative polyp-free ethmoid sinus, mucoid secretion on the roof of the sinus.

Figure 4

(a) and (b) right and left nasal sides prior to sinonasal surgery with a series of apical polyps (∗) on the right (a) and a big floating polyp (†) on the left nasal side, besides the middle turbinate. (c) and (d) Suction tube inside the opened left (c) and right (d) maxillary sinus.