The major cause of mortality in people with cystic fibrosis (pwCF) is progressive lung disease characterised by acute and chronic infections, the accumulation of mucus, airway inflammation, structural damage and pulmonary exacerbations. The prevalence of Pseudomonas aeruginosa rises rapidly in the teenage years, and this organism is the most common cause of chronic lung infection in adults with cystic fibrosis (CF). It is associated with an accelerated decline in lung function and premature death. New P. aeruginosa infections are treated with antibiotics to eradicate the organism, while chronic infections require long-term inhaled antibiotic therapy. The prevalence of P. aeruginosa infections has decreased in CF registries since the introduction of CF transmembrane conductance regulator modulators (CFTRm), but clinical observations suggest that chronic P. aeruginosa infections usually persist in patients receiving CFTRm. This indicates that pwCF may still need inhaled antibiotics in the CFTRm era to maintain long-term control of P. aeruginosa infections. Here, we provide an overview of the changing perceptions of P. aeruginosa infection management, including considerations on detection and treatment, the therapy burden associated with inhaled antibiotics and the potential effects of CFTRm on the lung microbiome. We conclude that updated guidance is required on the diagnosis and management of P. aeruginosa infection. In particular, we highlight a need for prospective studies to evaluate the consequences of stopping inhaled antibiotic therapy in pwCF who have chronic P. aeruginosa infection and are receiving CFTRm. This will help inform new guidelines on the use of antibiotics alongside CFTRm.

Cork Adult Cystic Fibrosis Centre Cork University Hospital University College Cork Republic of Ireland

Department of Medical Microbiology 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Pulmonology University Medical Center Utrecht Utrecht The Netherlands

Division of Respiratory Medicine University Children's Hospital Zurich Switzerland

ERN lung CF Network Frankfurt Germany

HMU Health and Medical University Potsdam Internal Medicine and Pneumology Clinic Westbrandenburg Division of Cystic Fibrosis CF Center Westbrandenburg Campus Potsdam Potsdam Germany

Kinder und Jugendklinik der Universitätsmedizin Rostock Rostock Germany

Leeds Institute of Medical Research University of Leeds Leeds UK

Lifespan and Population Health School of Medicine University of Nottingham Nottingham UK

Medizinische Hochschule Brandenburg University Klinikum Westbrandenburg Brandenburg an der Havel Germany

Meyer Children's Hospital IRCCS Cystic Fibrosis Regional Reference Centre Department of Paediatric Medicine Florence Italy

Respiratory Medicine and Cystic Fibrosis National Reference Center Cochin Hospital Assistance Publique Hôpitaux de Paris Paris France

Université Paris Cité Institut Cochin Inserm U1016 Paris France

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