Microbiological contamination of nebulizers used by cystic fibrosis patients: an underestimated problem

Evolution of Resistance against Ciprofloxacin, Tobramycin, and Trimethoprim/Sulfamethoxazole in the Environmental Opportunistic Pathogen Stenotrophomonas maltophilia

Stenotrophomonas maltophilia is an opportunistic pathogen that produces respiratory infections in immunosuppressed and cystic fibrosis patients. The therapeutic options to treat S. maltophilia infections are limited since it exhibits resistance to a wide variety of antibiotics such as β-lactams, aminoglycosides, tetracyclines, cephalosporins, macrolides, fluoroquinolones, or carbapenems. The antibiotic combination trimethoprim/sulfamethoxazole (SXT) is the treatment of choice to combat infections caused by S. maltophilia, while ceftazidime, ciprofloxacin, or tobramycin are used in most SXT-resistant infections. In the current study, experimental evolution and whole-genome sequencing (WGS) were used to examine the evolutionary trajectories of S. maltophilia towards resistance against tobramycin, ciprofloxacin, and SXT. The genetic changes underlying antibiotic resistance, as well as the evolutionary trajectories toward that resistance, were determined. Our results determine that genomic changes in the efflux pump regulatory genes smeT and soxR are essential to confer resistance to ciprofloxacin, and the mutation in the rplA gene is significant in the resistance to tobramycin. We identified mutations in folP and the efflux pump regulator smeRV as the basis of SXT resistance. Detailed and reliable knowledge of ciprofloxacin, tobramycin, and SXT resistance is essential for safe and effective use in clinical settings. Herein, we were able to prove once again the extraordinary ability that S. maltophilia has to acquire resistance and the importance of looking for alternatives to combat this resistance.

Effect of Disinfection Method and Testing Methodology on the Performance of a Breath-Enhanced Jet Nebulizer

National guidelines for cystic fibrosis recommend cleaning and disinfecting nebulizers after each use. We tested two groups of five reusable breath-enhanced nebulizers after 0, 5, 10, 15, 20, 30, 60, 90, 120, 150, and 180 sterilization (baby bottle sterilizer) or cleaning cycles. The nebulizers were operated for 7 min (6 L/min) after loading albuterol (2.5 mg/3 mL), and they were evaluated with and without breathing simulation after cleaning/sterilization (0-180 and 0-60 cycles, respectively). Over the course of 180 cleaning/sterilization cycles, the mean (SD) solution output was 1.33 mL (0.12 mL)/1.29 mL (0.08 mL); the nebulizer mass remaining in the nebulizer was 61.5% (5.2%)/63% (4%); sputtering time was 4.7 min (0.8 min)/4.8 s (0.6 min); inspiratory filter was 19% (3%)/18.5% (2.4%); expiratory filter was 6.7% (1.1%)/6.7% (0.8%); and difference in drug output calculated using the solution output and nebulizer mass was 6.8% (4%)/5.2% (2.9%). Thermal disinfection with a baby-bottle sterilizer did not alter the performance of a reusable breath-enhanced nebulizer. The nebulizer test performed without breathing simulation underestimated its performance. The calculation of the drug output based on the solution output resulted in its overestimation.

There Is a Risk of Spread During a Nebulization Session in a Patient with COVID-19

Introduction: A hypothetical risk of SARS-CoV-2 airborne transmission through nebulization was suggested based on a potential environmental contamination by the fugitive aerosol emitted in the environment during the procedure. The aim of this study was to verify this risk from the fugitive aerosol emitted by COVID-19 patients during one nebulization session. Methods: In this cohort study, COVID-19 patients treated with nebulization were recruited at their admission to the hospital. Patients had to perform a nebulization session while a BioSampler® and a pump were used to vacuum the fugitive aerosol and collect it for SARS-CoV-2 RNA detection. Results: Ten consecutive patients hospitalized with COVID-19 were recruited. The median viral load was 6.5 × 106 copies/mL. Two out of the 10 samples from the fugitive aerosol collected were positive to SARS-CoV-2. Conclusion: The risk of fugitive aerosol contamination with SARS-CoV-2 during nebulization has now been verified.

Cystic fibrosis year in review 2019: Section 2 pulmonary disease and infections

During the year 2019, research and case reports or series in the field of cystic fibrosis (CF) were in abundance. To adequately address the large body of CF research published during 2019, the CF year in review will be divided into three sections. This report is the second section, focusing specifically on new research related to pulmonary disease and infections. Additional sections will concentrate on CF transmembrane conductance regulator modulators and the multisystem effects of CF. It is an exciting time to be providing care for patients and their families with CF with all the exciting new discoveries that will be shared in these reviews.

Recent advances predict a bright future for nebulizers

PURPOSE OF REVIEW

With the improvement in device technology and delivery methods of inhaled medications, along with development of novel compounds and recognition of the importance of personalized approach in the management of chronic airway diseases, nebulizers have not only maintained their place in the treatment hierarchy of airway disease but have also proven a vital platform for the development of new classes of drugs.

RECENT FINDINGS

This short review explores recent advances in nebulized drug delivery in chronic obstructive pulmonary disease and other chronic airway diseases, emphasizing the progress in nebulizer technology, physiologic advantages of nebulized drug delivery and the high versatility of currently available and developing nebulizer-delivered pharmacotherapies.

SUMMARY

Versatility and efficiency of nebulizers allows for a broad spectrum of existing and novel therapies to be clinically studied, facilitating the progress in phenotype-targeted pharmacotherapies in the management of chronic airway diseases.

Bacterial Contamination of Inhalation Chambers Used for Cats and Dogs with Chronic Airway Diseases

Inhalation chambers (ICs) are regularly used in veterinary medicine for the inhalative treatment of chronic respiratory diseases in dogs and cats. Since therapy is usually required lifelong and daily, devices are frequently in use. The aim of this study was to identify bacterial contamination of ICs used for cats and dogs in relation to the applied cleaning measures. Swabs from ICs of 66 cats and 19 dogs with chronic airway diseases were obtained using a standardized protocol and subsequently cultured. A questionnaire was completed by the pet owners regarding the history of their pet's illness and applied device cleaning measures. Overall, 64% (54/86) of the ICs were found to be contaminated; the mask was significantly (p < 0.001) more often contaminated than other device parts. Most cultured bacteria were environmental contaminants; however, some harbored pathogenic potential. Cleaning frequency and method did not significantly influence the presence of contamination. Bacterial contamination of ICs, used for cats and dogs, is common but is not significantly influenced by the type or frequency of cleaning. To avoid potential infection by opportunistic bacteria, the instruction of pet owners regarding the maintenance of the ICs is recommended.

[Inhalation therapy in dogs and cats with chronic lower airway disease - a literature review]

Chronic respiratory diseases are prevalent medical conditions in dogs and cats requiring lifelong treatment. Mainstay of therapy for chronic inflammatory respiratory diseases are glucocorticoids. Concurrent treatment with bronchodilators may be necessary to control clinical signs sufficiently. Due to the successful use in people as well as subsequent reduction of adverse effects of long-term glucocorticoid therapy, inhalative therapy has become increasingly important in veterinary medicine as well. Primarily spacers or valved holding chambers, in combination with metered dose inhalers, are used in dogs and cats. The technical properties of these devices, as well as their use and maintenance will be described in the following article. Furthermore, the existing literature regarding efficacy of inhalative medications for therapy of chronic inflammatory airway diseases in dogs and cats will be summarized.

Nebulizer Cleaning Practices and Adherence to Nebulized Therapies in People With Cystic Fibrosis When Traveling

BACKGROUND

Nebulized therapies form an important component of treatment in people with cystic fibrosis (CF). It is important for people with CF to continue to take their nebulized medications when traveling.

METHODS

A self-completing anonymous questionnaire was developed, as part of a quality improvement project, to support people with CF educational needs when traveling. The questionnaire was prepared to gain an insight into (1) adherence to nebulized therapies when traveling and (2) nebulizer cleaning and disinfection practices while traveling. Polar questions (yes/no response) were mainly employed as well as free text and closed questions.

RESULTS

There were 68 respondents to the survey, including 31 males, 33 females, and 4 respondents who did not enter their sex. Respondents who declared their age (n = 63) ranged from 17-71 y (median = 30 y; with 94% of respondents in age range 20-39 y). When traveling, 38% (25/66) of respondents indicated that nebulized therapy was not performed during travel. The most common method of nebulizer maintenance while traveling was washing with soap and water (43%), followed by boiling water (18%), as well as the employment of 5 other methods of nebulizer maintenance. Some respondents (2%) indicated that they did not perform any method of nebulizer maintenance while traveling until they returned home.

CONCLUSIONS

This study identified that nebulizer care and hygiene are less than optimal when traveling as well as identifying a worrying trend of taking a "nebulizer vacation." People with CF need to be aware of risks to their health in being nonadherent with their nebulized medication(s) while traveling as well as risks of acquiring a new pathogen through suboptimal cleaning/disinfection/drying management of their nebulizer. CF multidisciplinary teams should emphasize the importance of sustaining nebulized treatments when traveling and practicing effective nebulizer washing, disinfection, and drying procedures.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

A Systematic Review on KAP of Nebulization Therapy at Home

Background: Inhalation is the preferred method of delivering medication for respiratory conditions such as asthma, chronic obstructive pulmonary disease, and other respiratory disease. A nebulizer converts a medication in liquid form to mist, so that the medication can be inhaled into the lungs. The aim of the study is to systematically review the knowledge, attitude, and practice of patients using nebulization therapy at home. The objective of the study is to review the procedure of nebulizer technique and to interpret the outcome of the studies. Method: Scopus, PubMed, BMJ, and other database from 2000 to 2020 were searched using Boolean operators. Title and abstract were screened for nebulizer technology and for inclusion and exclusion criteria. After full text screening 16 articles were included in the study. Result: Use of nebulizer at home was a challenge at all stages including setting up and operating nebulizer, filling up of medication, inhalation technique, end point dismantling, and maintenance. The main challenge experienced by the participants was with cleaning and disinfecting of nebulizer. There were studies that reported with 71.6% pathogen contamination due to inappropriate cleaning and disinfecting. Conclusion: Patients with respiratory disease using nebulizers at home find difficulty in appropriate and rational use of the device. Apart from the nebulizer user guidelines from the manufactures, it is suggested that a short audio visual demonstrating the appropriate and effective use of nebulizers and also its maintenance in their colloquial language with handout infographics would highly facilitate the effective use of nebulizers.

Assessment of the microbial load of airway clearance devices used by a cohort of children with cystic fibrosis

Background

Positive expiratory pressure (PEP) devices are an important element of the management of cystic fibrosis, and of other respiratory diseases. Whereas there have been reports in the literature of contamination of airway clearance devices and their surfaces by microbial pathogens, there is little evidence available regarding such contamination and its contribution to respiratory infection.

Aim

To establish whether pathogenic bacteria can contaminate PEP devices in the context of normal cleaning and maintenance practices.

Methods

Patients' home-use clearance devices were brought to a routine clinic appointment and collected for microbiology sampling and analysis. The patients were provided with replacement devices. Nineteen such devices were collected from 17 patients, reflecting use of multiple devices by some patients. Swabs were taken and cultured from each patient's used device, the patient's airway, as well as from new unopened and unused devices that acted as controls.

Results

Seven of 19 devices (37%) tested positive for presence of pathogenic bacteria. Device-cleaning methods varied among patients and non-sterilization methods were found to be ineffective at removing pathogens. Microbial species found on the devices did not correlate with those identified from airway swabs.

Conclusion

This study demonstrates the presence of pathogens on positive expiratory pressure devices. The potential for transmission of these pathogens to the patient's airway and the risk of infection remains unclear and requires further study.

The effects of nebulizer hygiene training on the practices of cystic fibrosis patients and caregivers

BACKGROUND

Nebulizers can be contaminated with microorganisms and may be a source of infection in the lower airways in patients with cystic fibrosis (CF).

OBJECTIVE

Primary aim of this study was to determine the level of knowledge regarding nebulizer hygiene and adherence to CF foundation infection prevention and control (IPC) measures of CF patients in our center. We also evaluated the effect of a standardized training program on nebulizer cleaning and disinfection practises with pre and posttest.

METHODS

Caregivers of 173 CF patients followed at Marmara University CF Center filled a questionnaire (pretest) regarding nebulizer hygiene and received didactic education including pictures and videos based on the cystic fibrosis foundation (CFF) IPC guidelines, patients were also provided educational materials. Posttest was performed 1-3 months after the education session.

RESULTS

Following standardized training, usage of appropriate methods according to CFF IPC guidelines improved significantly. Frequency of nebulizer cleaning after each use increased from 58.4% to 78% (p < .01) and disinfection frequency after each/daily usage increased from 33.6% to 75.7% (p < .01). Additionally, methods of cleaning and storage of the nebulizer, also improved significantly (p < .01, p < .01).

CONCLUSION

Education was highly effective to increase the rate of proper practices for nebulizer hygiene. The necessity of cleaning, disinfection, careful drying, correct storage of the nebulizer parts, and changing the nebulizer equipment within recommended time should be emphasized to CF families regularly.

Efficacy and safety of inhaled dry-powder mannitol in adults with cystic fibrosis: An international, randomized controlled study

BACKGROUND

Mannitol is a mucoactive hyperosmotic agent used as add-on therapy in patients with cystic fibrosis (CF), administered twice-daily (BID) via a small, portable, breath-actuated dry-powder inhaler. This study was conducted to provide confirmatory evidence of mannitol's efficacy and safety in adults.

METHODS

This multicenter, double-blind, randomized, parallel-group, controlled clinical trial recruited adults (aged ≥18 years) with CF, and forced expiratory volume in 1 second (FEV₁) 40-90% predicted. Subjects received either mannitol 400 mg or mannitol 50 mg (control), BID via dry-powder inhaler for 26 weeks. Primary endpoint: FEV₁ averaged over the 26-week treatment period.

RESULTS

Of 423 subjects randomized (209 or 214 receiving mannitol 400 mg BID or control, respectively), 373 (88.2%) completed the study, with a similar proportion completing in the two groups. For FEV₁ averaged over 26 weeks, mannitol 400 mg BID was statistically superior to control (adjusted mean difference 54 mL [95% CI 8, 100 mL]; p = 0.020). This was supported by sensitivity analyses of the primary endpoint, and by observed improvements in secondary pulmonary function endpoints (eg, absolute adjusted mean difference in percent predicted FEV₁ averaged over 26 weeks 1.21% [0.07%, 2.36%]; p = 0.037). Adverse events were mainly mild or moderate in severity, with treatment-related adverse events in 15.5 and 12.2% of subjects receiving mannitol 400 mg BID and control, respectively.

CONCLUSIONS

In adults with CF, mannitol 400 mg BID inhaled as a dry-powder statistically significantly improved lung function (FEV₁) compared with control, with this improvement supported by sensitivity analyses and secondary pulmonary function endpoints. Mannitol had a good overall safety and tolerability profile. ClinicalTrials.gov: NCT02134353.

Evaluation of different cleaning methods for feline inhalation chambers after bacterial contamination

OBJECTIVES

Inhalation chambers are commonly used for the delivery of aerosol drugs to cats with respiratory disease. The aim of the study was to identify successful cleaning methods for inhalation devices after standardised bacterial contamination.

METHODS

Spacer devices of two different manufacturers were used: RC Chamber (Cegla Medizintechnik) and Aerokat (Trudell Medical International). The bacterial contamination was performed using Pseudomonas aeruginosa. Previously marked areas of the chamber were contaminated with 50 μl of bacterial solution, containing between 2.2 ×105 and 2.1 ×108 colony-forming units/ml each. After cleaning the devices as recommended by each manufacturer (RC Chamber: special microwave cleaning bag [n = 5] or boiling water with liquid dish detergent for 15 mins [n = 5]; Aerokat: rinsing in a solution of lukewarm water and liquid dish detergent for 15 mins), chambers were air-dried for 24 h and samples for bacterial culture were taken from three defined areas. Sample material was applied on Müller-Hinton agar plates and subsequently incubated for 24 h at 37°C.

RESULTS

Bacterial contamination was not detected in any of the examined inhalation devices using the recommended cleaning methods.

CONCLUSIONS AND RELEVANCE

If inhalation chambers are cleaned following the manufacturers' recommendations, successful bacterial decontamination can be expected.

Distribution of Burkholderia cepacia complex species isolated from industrial processes and contaminated products in Argentina

Burkholderia cepacia complex (Bcc) members have clinical relevance as opportunistic pathogens in patients with cystic fibrosis and are responsible of numerous nosocomial infections. These closely related bacteria are also reported as frequent contaminants of industrial products. In this retrospective study, we use PCR and recA gene sequence analysis to identify at species level Bcc isolates recovered from massive consumption products and industrial processes in Argentina during the last 25 years. The sequences obtained were also compared with recA sequences from clinical Bcc isolates deposited in GenBank database. We detected Bcc in purified water and preserved products from pharmaceutics, cosmetics, household cleaning articles, and beverages industries. B. contaminans (which is prevalent among people with cystic fibrosis in Argentina) was the most frequent Bcc species identified (42% of the Bcc isolates studied). B. cepacia (10%), B. cenocepacia (5%), B. vietnamiensis (16%), B. arboris (3%), and the recently defined B. aenigmatica (24%) were also detected. Rec A sequences from all B. cepacia and most B. contaminans industrial isolates obtained in this study displayed 100% identity with recA sequences from isolates infecting Argentinean patients. This information brings evidence for considering industrial massive consumption products as a potential source of Bcc infections. In addition, identification at species level in industrial microbiological laboratories is necessary for a better epidemiological surveillance. Particularly in Argentina, more studies are required in order to reveal the role of these products in the acquisition of B. contaminans infections.

Steam disinfection of toothbrushes from patients with cystic fibrosis: Evidence-based recommendations

BACKGROUND

Patients with cystic fibrosis have increased morbidity/mortality due to chronic respiratory infections, which primarily originate from the environment. Infection prevention and control emphasize the importance of cleaning and disinfection of respiratory devices, however, there is a paucity of guidance on toothbrush hygiene, which have been shown to be a source of cystic fibrosis (CF) pathogens.

METHODS

This study examined steam disinfection of toothbrushes contaminated with clinically significant CF isolates (n = 80; Gram positive = 33; Gram negative = 32, and non-tuberculous mycobacteria = 6) and yeasts (n = 9), as well as oral streptococci (n = 26) and environmental Pseudomonas aeruginosa (n = 12).

RESULTS

Steam disinfection eradicated all organisms tested, as well as all organisms in CF sputum applied to toothbrushes.

CONCLUSIONS

Steam disinfection offers a relatively simple, cheap and available method of eliminating non-spore-forming CF pathogens on toothbrushes. Toothbrushes should be thoroughly rinsed after each use before steam disinfection, to remove plaque, epithelial cells, and residual toothpaste. Toothbrushes should be steam disinfected after each use employing a baby bottle steam disinfector, adhering to manufacturers' operating instructions and stored in the disinfector until next used within 12 to 24 hours. Toothbrushes should be replaced every 3 to 4 months, or sooner if the bristles look worn out, as well as every time a pulmonary exacerbation occurs or every time the patient is treated for a pulmonary/throat infection. Steam disinfection of toothbrushes is crucial when the patient is undergoing eradication regimes for P. aeruginosa and methicillin-resistant Staphylococcus aureus, so that the patient does not become reinfected from this source, thereby aiding eradication and enhancing patient safety.

Nebulizer Care and Inhalation Technique in Children with Cystic Fibrosis

Nebulizers are used by the great majority of cystic fibrosis patients for delivery of cornerstone treatments. Inhalation technique and adequate disinfection and maintenance are important for optimizing medication delivery. In this study, inhalation technique and nebulizer disinfection/maintenance were assessed in cystic fibrosis patients by direct observation in clinic and completion of a scoring sheet. A total of 108 patients were recruited. The maximum inhalation technique score was attained by 30.5% and adequate inhalation technique score by 74.08% of patients. The inhalation technique score was best with the vibrating mesh nebulizer (p = 0.038), while patient age and number of nebulized medications did not affect ITS significantly (p > 0.05). Nebulizer disinfection/maintenance score was excellent in only 31.48%. Most families kept the nebulizer clean and used appropriate disinfection method, but only half of them replaced the nebulizer and nebulizer cup at the recommended time intervals. Nebulizer disinfection/maintenance score was positively affected by a number of nebulized medications and negatively by years of equipment use (p = 0.009 and p = 0.001, respectively). Even though inhalation technique and disinfection/maintenance practices were found to be adequate in a large proportion of cases, there is still a need for regular review and education. The type of nebulizer was associated with improved inhalation technique, but more data are required before making specific recommendations.

Colistin dry powder inhalation with the Twincer™: An effective and more patient friendly alternative to nebulization

Background

Nebulization of antimicrobial drugs such as tobramycin and colistin is a cornerstone in the treatment of patients with cystic fibrosis (CF) infected with Pseudomonas aeruginosa. However, nebulization has a high treatment burden. The Twincer^™ is a dry powder inhaler specifically developed for the inhalation of antibiotics such as colistin. The aim of this study was to compare patient outcomes and experience with colistin dry powder by the Twincer with nebulization of colistin or tobramycin in adult CF patients in a real-life setting.

Methods

This was a retrospective study from 01-01-2015 until 01-07-2018. Effectiveness was evaluated by comparing FEV₁ decline and exacerbation rate during a mean of 4.1 years of nebulization therapy prior to the initiation of the Twincer against the same values during a mean of 1.7 years of treatment with the Twincer.

Results

Twenty-one patients were evaluated, of whom twelve could be included in the effectiveness analysis, with a total of twenty patient years. Of all patients 71.4% preferred therapy with the Twincer over nebulization. Twincer use resulted in high treatment adherence with an average adherence rate of 92.5%. There was no significant difference in annual decline in FEV₁%pred prior to and after start changing from nebulization to the use of the Twincer powder inhaler (median decline -1.56 [-5.57–5.31] and 1.35 [-8.45–6.36]) respectively, p = 0.45 (linear mixed effect model)). No significant difference was found in the number of intravenous or combined total intravenous and oral antibiotic courses during Twincer therapy compared to when using nebulization (1.68 and 2.49 courses during Twincer therapy versus 1.51 and 2.94 courses during nebulization, p = 0.88 and p = 0.63).

Conclusion

Colistin dry powder inhalation with the Twincer is a more patient friendly alternative to nebulization, and we did not observe significant differences in the clinical outcome, regarding lung function and exacerbation rates.

Nebuliser hygiene in cystic fibrosis: evidence-based recommendations

Nebulised therapies are extensively used in the daily therapeutic management of cystic fibrosis both for mucociliary clearance and for the management of chronic infections. Extensive developments have been made in relation to nebulised drug delivery mechanisms and drug formulations, and guidelines have been prepared that have addressed the appropriate use of such therapies. However, due to these developments, a plethora of nebuliser devices and drug chambers exist, and frequently, the limited guidance provided in relation to nebuliser hygiene is to follow manufacturers' instructions. Such instructions are inconsistent and at times confusing, translating to an increase in the burden associated with nebuliser maintenance. An evidence-based universal guideline relating to nebuliser care and hygiene is urgently required that is applicable to both at-home use and inpatient use. This article reviews the scientific literature in order to propose an evidence-based approach to nebuliser hygiene to ensure optimum drug delivery, and infection prevention and control.

EDUCATIONAL AIMS

To understand the reasons why nebuliser hygiene is important.To give an overview of the current nebuliser care instructions that have been described by manufacturers, societies and the scientific literature.To outline the current nebuliser hygiene practices used by persons with cystic fibrosis in the home and hospital settings.To highlight areas that need further evaluation to promote optimum nebuliser care.To establish an evidence-based guideline for nebuliser hygiene in relation to cystic fibrosis.