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Suggest Treatment For Stage Three Lung Cancer

Posted on Wed, 30 Apr 2014

Question: Acinetobacter Baumannii (isolate 1) and Stenotrophomonas Maltophilia Isolate 2 was the bacteria found in my Dad's lungs from a sputum culture. He was given 500 mg of Levofloxacin a day for 14 days 2 weeks ago for either the same, or different type of bacteria. What is the BEST course of AGGRESSIVE TREATMENT? He has Stage III lung cancer and is 74 yrs. old.

Answered by Dr. Vaddadi Suresh (2 hours later)

Brief Answer: please post the culture report. Detailed Answer: Hi XXXXXXX This is Dr Suresh, infectious disease specialist answering you. Best course depends on the sensitivity pattern of these two bacteria and is not fixed. Meaning, it varies from patient to patient, even for the same organism. Acinetobacter is an extremely resistant organism, generally regarded as hospital acquired infection. Now this organism has developed resistance to almost all antibiotics ( Excepting very few drugs like COLISTIN). Stenotrophomonas Maltophilia is also a hospital aquired infection, spreading mainly through ventilator or other invasive tubings. Like Acinetobacter, it is also an extremely resistant organism and is very rare. Tackling both at a time is a hard task, but is best done by doing culture sensitivity of tissue fluids. The drug that shows highest in-vitro activity against these organisms should be used to treat these. MIC is used to select the best antibiotic. I guess these have been grown on culture from lung tissue of your father. you need to post the report of culture-sensitivity, so that we can help. Best and most aggressive treatment depends on the LEAST MIC of a sensitive drug. hope I am clear.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vaddadi Suresh (47 minutes later)

Thank you Doctor. I know that the anti-biotic my Dad was given (Levofloxacin) a month ago (I made a mistake when I said two weeks ago)has the lowest culture sensitivity of 0.12 for Acinetobacter and 0.25 sensitivity for Stenotrophomonas Maltophilia. I will confirm what type of bacteria he had a month ago (March 7th) and will let you know when my Dad looks at last month's culture results. My Dad noticed significant improvement on day 6 with taking the Levofloxacin. On April 3, 2014 my Dad was given Cyprofloxacin to take even before he received the culture results. I do not know why he wasn't given the same anti-biotic. He received the results of these cultures just this afternoon. Does Cyprofloxacin have any known culture-sensitivity to either of these bacteria? How long should he stay on the Cypro before it is deemed ineffective? Will it create more complications with taking this type of anti-biotic if he stays on it or stops taking it? He has been using a oxygen generator with a moisture bottle attachment. I'm wondering if this may have been the cause of him catching Stenotrophomonas Maltophilia bacteria. Any suggestions as to what he should do to minimize risk while using the oxygen generator? Thank you for your help. You have been very clear.

Answered by Dr. Vaddadi Suresh (16 minutes later)

Brief Answer: was he ever hospitalized in the past 6 months Detailed Answer: Hi, Ciprofloxacin is a sister drug for levofloxacin. since he had shown sensitivity earlier, he must have been given a similar drug. But here, I must say, there is a lot of difference between cipro and levo. There is no guarentee that new results of C/S should match the older ones. we might find a new organism with a new C/S pattern. However, Ciprofloxacin has known culture-sensitivity to these bacteria, but as i said, it varies from time to time. If there is no response after 5 days, there is no point in continuing it. Yes, by giving "PRESUMPTIVE DRUGS", the future chances of drug resistant organisms will only increase. Yes, i believe, oxygen generator may have been the cause, but tell me whether he was ever hospitalized in the past 6 months?

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vaddadi Suresh (38 hours later)

Doctor, He wasn't admitted into a hospital but, was treated in a hospital for 8.5 hours for digestive infection. Update: My Dad went to a pulmonologist who gave him Levo for treatment of both bacteria. What prescribed dose would you use to aggressively treat the Acinetobacter Baumannii and Stenotrophomonas Maltophilia bacteria with moderate colonization? The sputum culture came back with these bacteria but, the doctor says that the bacteria may be in his mouth and not in his lungs. I don't buy that rationale because if it is in his mouth, it can be inhaled into his lungs. The goal is to treat the bacteria anyway but, this doctor seems to think he may have pneumonitis in which he was treated for with prednisone 60 mg x 5 days, 30 mg x5 days, then 15 mg x5 days, then 5 mg x 5 days. This was the course of treatment for the pneumonitis while simultaneously taking the Levo 500 mg a day for 14 days. What are you thoughts here, as far as course of treatment given? What would you do? Thanks again. I appreciate all your help. XXXXXXX

Answered by Dr. Vaddadi Suresh (15 hours later)

Brief Answer: I would have treated him with Levofloxacin 750 mg Detailed Answer: hi, 1. I would have treated him with Levofloxacin 750 mg/day rather than 500 mg. Theoretically, this should totally cure the infection. 2. Oral colanization is possible, but it it was the case, he would not have shown improvement earlier. Also, after treatment, oral bacteria disappears much faster than their peers in lungs. 3. Few hours stay in a hospital is sufficient to contract a drug resistent organism, especially for someone with damaged lung. 4.Steroids are better avoided, especially so cos, cancer lung is a rich source of food for bacteria and steroids help them in blocking the self defense. however, under certain circumstances, they help and hence i do not defer with the point that he was given pred. Hope i am clear.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vaddadi Suresh (2 hours later)

Excellent reply.... crystal clear. How does one determine if they truly have pneumonitis? At what point do you begin to treat it? His SEG was 30 and his lymphocytes were 3 - with Normal WBC total. With a suppressed immune system, he is certainly more prone to infection. My next concern is Fibrosis - he still has more radiation to receive along with hyperthermia but, anytime his temperature exceeds 100 degrees F, they can not perform hyperthermia. It has been up above 102 degrees F daily. The fever go away once the Levo begins to work - I hope. What are your thoughts here? XXXXXXX

Answered by Dr. Vaddadi Suresh (49 minutes later)

Brief Answer: combination of clinical and radiological diagnosis Detailed Answer: Hi, Pneumonia is mainly a combination of clinical and radiological diagnosis. Any of the below: Spiking fevers+cough or chest pain or shortness of breath in a patient with an X ray showing infiltrate is the time to start aggressive treatment. Yes, he has slumped immunity, requires utmost care. Avoid unimportant visitors to visit him, Any body who touches him should do so after washing their hands, no socks or shoes near him, and if there are any pets, keep them away from him. These may look minor, but are invaluable in preventing infections. I donot understand the sentence: "anytime his temperature exceeds 100 degrees F, they can not perform hyperthermia" please explain. Did you mean RT for hyperthermia?????

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vaddadi Suresh (1 hour later)

He is receiving low dose (100 rad per treatment) radiation in conjunction with hyperthermia. Hyperthermia heats the tumor site using microwave or radiofrequency which is suppose to make the tumor more sensitive to the radiation. If his temperature exceeds 100 degrees F, they can not use the hyperthermia because they heat the tumor to between 108 to 114 degrees F. This form of treatment is used widely in Germany but with low dose chemotherapy. Are you familiar with this form of cancer treatment? Thanks again for the great reply. If so, what are your thoughts?

Answered by Dr. Vaddadi Suresh (2 hours later)

Brief Answer: Thermo-radiotherapy right? Detailed Answer: Hi, Yes, Thermo-radiotherapy. I have heard of it, but is not being practiced in India- so, sorry, I do not have knowledge about it. We have IMRT here, most advanced therapy for cancer with least side effects, which we routinely use. How is he responding to RT? Pneumonias are pretty manageable, don't worry. your father will come out of both for sure. All the best.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vaddadi Suresh (46 minutes later)

Yes - Thermo-radiotherapy. He had a tumor 5.4 cm x 4.3 cm in his right lung. It is now 4.9 cm x 2.2 cm. after 3 months of low dose IMRT radiation in conjunction with the hyperthermia. He has squamous and has not had any treatment for almost a month because of the pneumonia and pneumonitis. Doctor, Does pneumonitis go away on its own, or do you have to treat it with prednisone to make it go away? At what point should we consider this course of treatment again? Assuming the Levo starts working, at what point would you have him start back on I.M.R.T. treatment? He's concerned about the fact that he only received 3 treatments in the last month. What course of action do you consider "aggressive treatment" for the symptoms he is showing? Profuse sweating, coughing and low-grade fever. What else would you do? Thanks again, XXXXXXX

Answered by Dr. Vaddadi Suresh (17 minutes later)

Brief Answer: Reduction in size is a good sign. Detailed Answer: Hi, From the discussion till now, i get a fair idea that his pneumonitis is under reasonable control. As i told, prednisolone is a risky option to bring things under control as it might bring in another infection due to further immuno suppression. If i were your treating doctor, i would initiate IMRT after putting him on tylenol and bringing his temperature under control (IMRT is only a 5 min session). I do not claim i am correct, but this is a attempt to salvage the body from a growing tumor. As you know, delay not only reduces the effect of RT, but also slashes the confidence of the patient, and pushes him into depression. Anyways, with levofloxacin, your dad's pneumonia should be under control and soon he will be back to scheduled RT. Let us hope for the best.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vaddadi Suresh (17 hours later)

His fever was controlled the last time he had a bacterial infection after day 5 (as you predicted). Today is day 4 so, I'm hopeful he can begin IMRT again, as soon as Monday. Thanks again.

Answered by Dr. Vaddadi Suresh (5 hours later)

Brief Answer: Take care of your dad. Detailed Answer: ya.. All the best. Take care of your dad.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vaddadi Suresh (6 hours later)

Dr. XXXXXXX My Dad has another concern regarding his Thyroid output. When he had his thyroid tested the results showed the following: Test Result: TSH 2.71 Units: miu/mL Reference Range: 0.35 - 5.50 Test Result: Free T3 2.1(L) Units: pg/mL Reference Range: 2.3 - 4.2 Test Result: T4 Units: ng/dL Reference Range: 0.89 - 1.76 It is our understanding that if the Free T3 is low, it means the thyroid gland is not converting the thyroid hormone adequately which can cause major problems. What can you tell us about his levels? His basal temperature has been between 97.4 F. - 97.6 F. He is very cold. Thanks, XXXXXXX

Answered by Dr. Vaddadi Suresh (3 hours later)

Brief Answer: His free T3 level is consistent with his age. Detailed Answer: Hi XXXXXXX Don't worry. His free T3 level is not bad and is consistent with his age. Aged people can not tolerate excess hormone, and hence it is a safe level, forget about it. For any future correspondence, you may search for my name in HCM search engine and can directly post your query to me. I have a daily patient load of 70-100 and may not be answering you immediately, but i will make sure that i address your queries as early as possible. All the best.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vaddadi Suresh (8 hours later)

Dr. XXXXXXX Thank you for all your information. I will close this discussion for now. You were most helpful and I sincerely appreciate the services you and this program provides. Take care, XXXXXXX

Answered by Dr. Vaddadi Suresh (5 hours later)

Brief Answer: Thanks a lot. Bye. Detailed Answer: Thanks a lot. Please do not forget to rate. Bye.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar