Can Two Patients with Cystic Fibrosis Play Together?
No, patients with cystic fibrosis should not play together due to the well-documented risk of cross-infection with antibiotic-resistant bacteria and dangerous pathogens. 1
Evidence-Based Distance Requirements
The most critical guideline is clear and specific:
- People with CF must maintain a distance of at least 3 feet (some guidelines recommend 6 feet) from all other CF patients in any setting, including outpatient clinics and social situations. 2, 1
- This separation requirement exists even when culture results are unavailable or negative, because respiratory secretions of all CF patients potentially harbor clinically important microorganisms that may not yet be detected. 3
Why This Matters: Documented Transmission Risk
The evidence supporting segregation is compelling:
- Person-to-person transmission of respiratory pathogens, particularly Pseudomonas aeruginosa and Mycobacterium abscessus, has been well-documented among CF patients. 1
- A randomized controlled trial from Wisconsin demonstrated that children with CF who were NOT isolated from other CF patients acquired P. aeruginosa at a median age of 1.0 years, compared to 5.6 years for those who were isolated—a dramatic 4.6-year difference. 1
- Whole genome sequencing studies have confirmed frequent transmission of M. abscessus between CF patients despite conventional infection control measures. 1, 4
Specific Pathogens of Concern
Multiple dangerous organisms can spread between CF patients:
- Burkholderia cepacia complex: 50 of 56 authors in systematic reviews strongly recommended isolation of CF patients infected with this organism. 5
- Pseudomonas aeruginosa: In 31 of 39 studies, interpatient spread was documented or brought to an end by isolation. 5
- Mycobacterium abscessus: This is the only documented exception to the general rule that non-tuberculous mycobacteria don't transmit between humans—it DOES transmit between CF patients. 4
Why Masks and Antibiotics Aren't Enough
Neither antibiotic therapy nor mask-wearing alone adequately prevents cross-infection between CF patients. 1
- Antibiotics treat existing infections but do not prevent transmission of antibiotic-resistant strains or new pathogens. 1
- Masks may reduce droplet transmission but cannot be relied upon as the sole protective measure. 1
Impact on Group Activities
This has practical implications for social activities:
- Local infection control policies may preclude participation of people with CF in standard group-based pulmonary rehabilitation programs. 2, 1
- If CF patients must participate in exercise programs together, they should exercise at stations several feet apart and pay close attention to hygiene techniques. 1
- However, the safest approach is complete segregation from other CF patients during recreational activities. 1
Quality of Evidence Caveat
While the recommendation is clear and universally accepted:
- No randomized controlled trials exist proving the efficacy of segregation (such trials would be ethically difficult). 6
- The certainty of evidence using GRADE criteria is low or very low. 6
- However, the observational studies consistently support segregation measures, and the potential consequences of cross-infection (including death from B. cepacia complex) are severe enough that all major CF organizations recommend segregation. 5, 7
Bottom Line for Clinical Practice
The evidence strongly supports avoiding close contact between children with CF to prevent cross-infection, and this recommendation should be followed strictly despite the social and psychological burden it places on patients and families. 1