Pseudomonas Aeruginosa Infections

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com/article/226748-print
emedicine.medscape.com
Pseudomonas aeruginosa
Infections
Updated: Dec 01, 2017
Author: Marcus Friedrich, MD, MBA, FACP; Chief Editor: Michael Stuart Bronze, MD
Overview
Practice Essentials
Pseudomonas aeruginosa has become an important cause of gram-negative infection, especially in patients with compromised
host defense mechanisms. It is the most common pathogen isolated from patients who have been hospitalized longer than 1
week, and it is a frequent cause of nosocomial infections. Pseudomonal infections are complicated and can be life-threatening.
Signs and symptoms
Pseudomonal infections can involve the following parts of the body, with corresponding symptoms and signs:
Respiratory tract (eg, pneumonia)
Bloodstream (bacteremia)
Heart (endocarditis)
CNS (eg, meningitis, brain abscess)
Ear (eg, otitis externa and media)
Eye (eg, bacterial keratitis, endophthalmitis)
Bones and joints (eg, osteomyelitis)
GI tract (eg, diarrhea, enteritis, enterocolitis)
Urinary tract
Skin (eg, ecthyma gangrenosum)
Physical findings depend on the site and nature of the infection, as follows:
Endocarditis: Fever, murmur, and positive blood culture findings; peripheral stigmata such as Roth spots, Janeway
lesions, Osler nodes, splinter hemorrhages, and splenomegaly
Pneumonia: Rales, rhonchi, fever, cyanosis, retractions, and hypoxia; occasionally shock; with cystic fibrosis, clubbing,
increased anteroposterior (AP) diameter, and malnutrition
GI tract: Fever, signs of dehydration, abdominal distention, and signs of peritonitis; physical findings of Shanghai fever
Skin and soft tissue infections: Hemorrhagic and necrotic lesions, with surrounding erythema; subcutaneous nodules,
deep abscesses, cellulitis, and fasciitis; in burns, black or violaceous discoloration or eschar
Skeletal infections: Local tenderness and a decreased range of motion; neurologic deficits
Eye infections: Lid edema, conjunctival erythema and chemosis, and severe mucopurulent discharge
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Malignant otitis externa: Erythematous, swollen, and inflamed external auditory canal; local lymphadenopathy
Bacteremia: Fever, tachypnea, and tachycardia; hypotension and shock; jaundice
See Clinical Presentation for more detail.
Diagnosis
Laboratory studies that may be helpful include the following:
Complete blood count (CBC)
Blood cultures
In urinary tract infection (UTI), urinalysis
In pneumonia, culture of sputum and respiratory secretions, as well as blood gas analysis
Wound and burn cultures and cultures from other body fluids and secretions according to the clinical scenario
Gram stain and culture of CSF if meningitis is suspected
Imaging studies that may be warranted include the following:
Chest radiography
Triple-phase bone scanning in suspected skeletal infection (though many prefer MRI)
Brain CT or MRI of the brain for suspected pseudomonal brain abscess
Renal ultrasonography for suspected of perinephric abscess complicating UTI
Echocardiography for suspected endocarditis with positive blood culture findings
Other tests and procedures that may be helpful in specific scenarios include the following:
Fluorescein staining and slit-lamp examination of the cornea for keratitis
Flexible fiberoptic bronchoscopy with bronchoalveolar lavage or bronchial brushing
Thoracocentesis
Lumbar puncture with cell count and cultures
See Workup for more detail.
Management
Antimicrobials are the mainstay of therapy. It is important to consider antibiotic resistance when selecting the regimen.
Combination therapy should be used in severe infection. Recommended pharmacologic approaches to specific infections are as
follows:
Endocarditis: Give a high-dose aminoglycoside plus an extended-spectrum penicillin or antipseudomonal cephalosporin

for 6 weeks; surgical evaluation is required
Pneumonia: Start with 2 antipseudomonal antibiotics, then deescalating to monotherapy (eg, according to American
Thoracic Society-Infectious Diseases Society of America guidelines)
Bacteremia: Initiate intravenous antipseudomonal antibiotic therapy before a specific diagnosis is made; subsequent
presumptive therapy includes an aminoglycoside plus a broad-spectrum antipseudomonal penicillin or cephalosporin;
alternatives include fluoroquinolones and rifampin. In the setting of neutropenia, which carries a high mortality rate, two
intravenous antipseudomonal antibiotics from different classes should be used.
Meningitis: Ceftazidime is the antibiotic of choice; initial therapy in the critically ill should include an IV aminoglycoside;
therapy is ordinarily continued for 2 weeks
Ear infections: Treat external otitis with antibiotics and steroids; treat malignant otitis aggressively with 2 antibiotics (and
surgery)
Eye infections: Treat small superficial ulcers with topical therapy (eg, ophthalmic aminoglycoside solution rather than an
ointment) every 30-60 minutes; when perforation is imminent, subconjunctival (or subtenon) administration is preferred;
management of endophthalmitis requires aggressive antibiotic therapy (parenteral, topical, subconjunctival [or subtenon],
and, often, intraocular)
UTIs: Parenteral aminoglycosides are generally preferred, though quinolones are used; monotherapy is appropriate in
most cases; alternatives include antipseudomonal penicillins and cephalosporins, carbapenems, and aztreonam;
ciprofloxacin is the preferred oral agent
GI tract infections: Treatment includes antibiotics and hydration
Skin and soft tissue infections: Give double-antibiotic therapy in accordance with local susceptibility pattern.
Surgical debridement should be aggressive. Principles of surgical care are as follows:
As a rule, infected medical devices should be removed, although exceptions may occur
In wounds infected with Pseudomonas, surgical removal of eschars, debridement of necrotic tissue, or, in severe cases,
amputation may be required
Diabetic foot ulcers may require surgical debridement of necrotic tissue
Malignant otitis requires surgery to debride granulation tissue and necrotic debris
Surgery may be required for bowel necrosis, perforation, obstruction, or abscess drainage
See Treatment and Medication for more detail.
Background
Pseudomonas is a gram-negative rod that belongs to the family Pseudomonadaceae. More than half of all clinical isolates
produce the blue-green pigment pyocyanin. Pseudomonas often has a characteristic sweet odor.
These pathogens are widespread in nature, inhabiting soil, water, plants, and animals (including humans). Pseudomonas
aeruginosa has become an important cause of infection, especially in patients with compromised host defense mechanisms. It is
the most common pathogen isolated from patients who have been hospitalized longer than 1 week. It is a frequent cause of
nosocomial infections such as pneumonia, urinary tract infections (UTIs), and bacteremia. Pseudomonal infections are
complicated and can be life threatening.
Pathophysiology
P aeruginosa is an opportunistic pathogen. It rarely causes disease in healthy persons. In most cases of infection, the integrity
of a physical barrier to infection (eg, skin, mucous membrane) is lost or an underlying immune deficiency (eg, neutropenia,
immunosuppression) is present. Adding to its pathogenicity, this bacterium has minimal nutritional requirements and can tolerate
a wide variety of physical conditions.
The pathogenesis of pseudomonal infections is multifactorial and complex. Pseudomonas species are both invasive and
toxigenic. The 3 stages, according to Pollack (2000), are (1) bacterial attachment and colonization, (2) local infection, and (3)
bloodstream dissemination and systemic disease.[1] The importance of colonization and adherence is most evident when
studied in the context of respiratory tract infection in patients with cystic fibrosis and in those that complicate mechanical
ventilation. Production of extracellular proteases adds to the organism's virulence by assisting in bacterial adherence and
invasion.
Frequency
United States
According to the Centers for Disease Control and Prevention (CDC), an estimated 51,000 healthcare associated P aeruginosa
infections in US hospitals occur each year. More than 6,000 (13%) of these are multidrug-resistant, with about 440 deaths per
year.[2, 3] Multidrug-resistant P aeruginosa was given a threat level serious by the CDC.
International
P aeruginosa is common in immunocompromised patients with diabetes.
Mortality/Morbidity
All infections caused by P aeruginosa are treatable and potentially curable. Acute fulminant infections, such as bacteremic
pneumonia, sepsis, burn wound infections, and meningitis, are associated with extremely high mortality rates.
In patients with Charcot arthropathy of the foot, infections with P aeruginosa are associated with a greater number of surgical
procedures (1.71 vs 1.28) and longer hospital stays (52 vs 35 days) than infections with methicillin-resistant Staphylococcus
aureus (MRSA) or other bacteria, according to a study of 205 patients who underwent surgery for Charcot arthropathy of the
feet. The authors propose an algorithm for isolation and surgical and pharmacologic treatment of P aeruginosa infections in this
setting, similar to one for MRSA.[4]
Race
P aeruginosa endocarditis in individuals who abuse intravenous drugs is observed mainly among young black males.
Sex
Cases of endocarditis and vertebral osteomyelitis have been observed in young males who use intravenous drugs.
Age
Vertebral osteomyelitis due to pseudomonal infection mainly occurs in elderly patients and often involves the lumbosacral spine.
Young people who use intravenous drugs may also be affected.
Involvement of the GI tract most commonly occurs in infants and patients with hematologic malignancies and neutropenia that
has resulted from chemotherapy.
The incidence of pseudomonal pneumonia in patients with cystic fibrosis has shown a shift towards patients who are older than
26 years.
Epidemiology
P aeruginosa is the second most common cause of nosocomial pneumonia (17%), third most common cause of urinary tract
infection (7%), fourth most common cause of surgical-site infection (8%), and fifth most common isolate (9%) overall from all
sites.[5]
Prognosis
Pseudomonas causes a wide spectrum of diseases; therefore, prognosis is varied.
Prognosis of malignant otitis is improving with earlier recognition of the disease and appropriate antibiotic therapy.
Pseudomonal bacteremia, septicemia, meningitis, burn wound sepsis, and eye infections carry a grave prognosis.
Patient Education
Patients should be educated about good hygiene in the care of their ears.
Patients should be educated about the potential adverse effects of medications and should be monitored for the same.
For excellent patient education resources, visit eMedicineHealth's Ear, Nose, and Throat Center. Also, see eMedicineHealth's
patient education article Swimmer's Ear.
Presentation
History
Pseudomonal infections can involve any part of the body.
Respiratory tract
Pneumonia is observed in patients with immunosuppression and chronic lung disease. It can be acquired nosocomially in the
intensive care unit (ICU) setting and is associated with positive-pressure ventilation and endotracheal tubes. The pneumonia
may be primary, following aspiration of the organism from the upper respiratory tract, especially in patients on mechanical
ventilation. Alternatively, it may occur as a result of bacteremic spread to the lungs. This is observed commonly in patients
following chemotherapy-induced neutropenia.
Bacteremic pneumonia occurs in patients with neutropenia following chemotherapy and in patients with AIDS.
Chronic infection of the lower respiratory tract with P aeruginosa is prevalent among patients with cystic fibrosis. These patients
may present with chronic productive cough, anorexia, weight loss, wheezing, and tachypnea.[6]
Symptoms of pneumonia include fever, chills, severe dyspnea, cyanosis, productive cough, confusion, and other signs of a
systemic inflammatory response.
Bacteremia
Bacteremia may be acquired via medical devices in hospitals and nursing homes, and the mortality rate remains greater than
10%.
Signs and symptoms depend on the primary site of infection.
Endocarditis
P aeruginosa may infect native heart valves in individuals who abuse intravenous drugs and may infect prosthetic heart valves.
Right-sided and left-sided valve infections may occur.
Nonspecific symptoms include fever and malaise, with more specific symptoms depending on which cardiac valve is involved.
Left-sided endocarditis typically presents with symptoms of congestive heart failure and those resulting from systemic spread of
septic emboli.
Central nervous system
P aeruginosa infection can cause meningitis and brain abscess.
Most infections follow an extension from a contiguous parameningeal structure, such as an ear, a mastoid, paranasal sinus
surgery, or diagnostic procedures. In some patients, the involvement of the CNS is due to hematogenous spread of the
organism from infective endocarditis, pneumonia, or UTI.
Patients present with fever, headache, and confusion. The onset may be fulminant or subacute, often depending on the immune
status of the patient.
Ear
In otitis externa (swimmer's ear), patients present with pain, pruritus, and ear discharge. The pain is worsened by traction on the
pinna.
Pseudomonas infection is a common cause of chronic otitis media. Malignant otitis externa is a manifestation of invasive
infection predominantly observed in patients with uncontrolled diabetes. It begins as ordinary otitis externa that fails to respond
to antibiotic therapy. Presenting symptoms are persistent pain, edema, and tenderness of the soft tissues of the ear, with a
purulent discharge. Fever is uncommon, and some patients present with a facial nerve palsy. Extension of the infection to the
temporal bone can result in osteomyelitis, and further extension can create cranial nerve palsies and possibly a CNS infection.
Eye
The cornea, aqueous humor, and vitreous humor comprise an immunocompromised environment, and Pseudomonas, when
introduced, produces extracellular enzymes that cause a rapidly progressive and destructive lesion. P aeruginosa is a common
cause of bacterial keratitis, scleral abscess, and endophthalmitis in adults and ophthalmia neonatorum in children.
Predisposing conditions for corneal involvement are trauma, contact lens use, predisposing ocular conditions, exposure to an
ICU environment, and AIDS. Corneal lesions can progress to endophthalmitis and orbital cellulitis. Symptoms are pain, redness,
swelling, and impaired vision.
Bones and joints
The most common sites of involvement are the vertebral column, the pelvis, and the sternoclavicular joint.
Infection may be blood-borne, as in individuals who abuse intravenous drugs or in patients with pelvic infections or UTI.
Alternatively, the infection may be contiguous, related to penetrating trauma, surgery, or overlying soft tissue infections. Patients
at risk for pseudomonal bone and joint infections include those with puncture wounds to the foot, peripheral vascular disease,
intravenous drug abuse, or diabetes mellitus.
Vertebral osteomyelitis may involve the cervical spine, and patients present with neck or back pain lasting weeks to months.
Occasionally, patients with complicated UTI may develop lumbosacral vertebral osteomyelitis.
Patients with pyoarthrosis present with swelling and pain in the affected joint. Patients are persistently febrile.
Gastrointestinal
Pseudomonal infections can affect every portion of the GI tract. The disease is often underestimated but usually affects very
young children and adults with hematologic malignancies and chemotherapy-induced neutropenia. Additionally, colonization of
the GI tract is an important portal of entry for pseudomonal bacteremia in patients who are neutropenic. The spectrum of
disease can range from very mild symptoms to severe necrotizing enterocolitis with significant morbidity and mortality.
Epidemics of pseudomonal diarrhea can occur in nurseries. Young infants may present with irritability, vomiting, diarrhea, and
dehydration.
The infection can cause enteritis, with patients presenting with prostration, headache, fever, and diarrhea (Shanghai fever).
Pseudomonas typhlitis typically presents in patients with neutropenia resulting from acute leukemia, with a sudden onset of
fever, abdominal distension, and worsening abdominal pain.
Urinary tract infections
Pseudomonal UTIs are usually hospital-acquired and are associated with catheterization, instrumentation, and surgery.
These infections can involve the urinary tract through an ascending infection or through bacteremic spread. In addition, these
infections are a frequent source of bacteremia.
No specific characteristics distinguish this type of infection from other forms of UTI.
Skin
Pseudomonas does not grow on dry skin, but it flourishes on moist skin.
Green nail syndrome is a paronychial infection that can develop in individuals whose hands are frequently submerged in water.
Secondary wound infections occur in patients with decubiti, eczema, and tinea pedis. These infections may have a characteristic
blue-green exudate with a fruity odor.
Pseudomonas is a common cause of hot tub or swimming pool folliculitis. Patients present with pruritic follicular, maculopapular,
vesicular, or pustular lesions on any part of the body that was immersed in water.
Pseudomonal bacteremia produces distinctive skin lesions known as ecthyma gangrenosum.
Pseudomonas also has emerged as an important source of burn wound sepsis. Invasive burn wound sepsis is defined as the
bacterial proliferation of 100,000 organisms per gram of tissue, with subjacent involvement of subjacent unburned tissue.
Physical
Endocarditis
Cardinal features of bacterial endocarditis include fever, murmur, and positive blood culture findings.
A new onset of cardiac murmur or a change in character of a preexisting murmur may develop, although these may be absent
on presentation.
Peripheral stigmata of endocarditis include Roth spots, Janeway lesions, Osler nodes, splinter hemorrhages, and splenomegaly.
Pneumonia
Patients have rales, rhonchi, fever, cyanosis, retractions, and hypoxia.
Shock may develop in patients with bacteremic pneumonia.
Patients with cystic fibrosis may develop clubbing, increased anteroposterior (AP) diameter, and malnutrition.
Gastrointestinal tract
Young infants with diarrhea may have fever, signs of dehydration, abdominal distension, and signs of peritonitis.
Physical findings of Shanghai fever may include fever, splenomegaly, and rose spots. Depending on the severity of the illness,
prostration, dehydration, and vascular collapse may be observed.
Skin and soft tissue infections
Ecthyma gangrenosum lesions are hemorrhagic and necrotic, with surrounding erythema. These characteristic lesions are
almost always caused by Pseudomonas infection and usually are found in the axilla, groin, or perianal area but may involve any
part of body.
Subcutaneous nodules, deep abscesses, cellulitis, and fasciitis may also occur.
Pseudomonal burn wound infections appear black or as a violaceous discoloration or eschar. Systemic manifestations of burn
wound sepsis may include fever or hypothermia, disorientation, hypotension, oliguria, ileus, and leukopenia.
Skeletal infections
Vertebral osteomyelitis manifests as local tenderness and a decreased range of motion.
Osteomyelitis may complicate puncture wounds.
Neurological deficits, when present, suggest spinal cord involvement.
Eye infections
With eye infections, the physical examination reveals lid edema, conjunctival erythema and chemosis, and severe mucopurulent
discharge adherent to an underlying corneal ulcer.
Malignant otitis externa
The external auditory canal is erythematous, swollen, and inflamed, and a discharge may be observed.
The tympanic membrane is hidden from view because of edema and may be ruptured.
Local lymphadenopathy may be present.
Bacteremia
Patients have fever, tachypnea, and tachycardia.
Hypotension and shock may develop.
Jaundice may occur.
Skin shows characteristic skin lesions called ecthyma gangrenosum.
Causes
Pseudomonal bacteremia occurs in association with malignancy, chemotherapy, AIDS, burn wound sepsis, and diabetes.
Certain populations of patients are especially susceptible to pseudomonal infections. Predisposing conditions include placement
of intravenous lines, severe burns, urinary tract catheterization, surgery, trauma, and premature birth (infants).
Conditions predisposing to pseudomonal infections and major manifestations include the following:
Diabetes - Malignant otitis externa

Drug addiction - Endocarditis, osteomyelitis
Leukemia - Sepsis, typhlitis
Cancer - Pneumonia, sepsis

Burn wound - Cellulitis, sepsis
Cystic fibrosis - Pneumonia
Surgery involving CNS - Meningitis
Tracheostomy - Pneumonia
Neonatal period - Diarrhea
Corneal ulcer - Panophthalmitis
Vascular catheterization - Bacteremia, suppurative thrombophlebitis
Urinary catheterization - UTI
Risk factors for infection with resistant P aeruginosa include the following:
Intensive care unit (ICU) stay

Bedridden status
Prior use of certain antibiotics, including broad-spectrum cephalosporins, aminoglycosides, carbapenems, and
fluoroquinolones
Presence of invasive devices
Diabetes mellitus
Undergoing surgery [7]
DDx
Differential Diagnoses
Acute Respiratory Distress Syndrome
Aspiration Pneumonitis and Pneumonia
Bacterial Pneumonia
Bacterial Sepsis
Community-Acquired Pneumonia (CAP)
Fungal Pneumonia
Pneumococcal Infections (Streptococcus pneumoniae)
Pneumocystis jiroveci Pneumonia (PJP)
Septic Shock
Stenotrophomonas Maltophilia
Viral Pneumonia
Workup
Workup
Laboratory Studies
CBC count
A CBC count may reveal leukocytosis with a left shift and bandemia. In patients with hematologic malignancy or status
postchemotherapy, leukopenia with neutropenia is expected. Leukopenia is a poor prognostic indicator.
Blood cultures
Obtain at least 2 sets of blood cultures (2 aerobic, 2 anaerobic bottles) from different sites.
Positive results on blood culture in the absence of extracardiac sites of infection may indicate pseudomonal endocarditis.
However, bacteremia may complicate intravenous catheter infections, urinary tract instrumentation, trauma, and surgery in the
absence of endocarditis.
Other cultures
In UTI, urinalysis is helpful in determining a diagnosis. Culture confirms the diagnosis and provides information concerning
antibiotic susceptibility.
In pneumonia, sputum and respiratory secretions should be cultured. However, the isolation of Pseudomonas from sputum and
tracheal secretions might indicate airway colonization. The poor sensitivity and specificity of sputum in determining the bacterial
cause of pneumonia in patients who are mechanically ventilated has led to greater use of quantitative cultures obtained from
protected bronchoalveolar lavage and protected specimen brushings. Blood gas analysis to evaluate for hypoxia or hypercarbia
should also be performed in patients with pneumonia.
Obtain wound and burn cultures and cultures from other body fluids and secretions according to the clinical scenario. To aid in
diagnosis, obtaining burn wound biopsies with quantitative bacterial cultures is recommended. A bacterial count of greater than
105 organisms per gram of tissue is diagnostic of a burn wound infection.
Gram stain
Obtain Gram stain and culture of cerebrospinal fluid if meningitis is suspected.
Imaging Studies
Chest radiography
Abnormalities observed in pseudomonal pneumonia depend on the pathogenesis of the infections. In primary pseudomonal
pneumonia, in which aspiration of infected secretions results in pneumonia, the chest radiograph often reveals bilateral
bronchopneumonia consisting of nodular infiltrates with or without pleural effusion. Lobar pneumonia is uncommon.
Early pulmonary vascular congestion is found in patients with bacteremic pseudomonal pneumonia and rapidly progresses to
pulmonary edema and necrotizing bronchopneumonia. Within 48-72 hours, the radiograph demonstrates a mixture of alveolar
and interstitial infiltrates, and cavitation may be present.
Bone scan
Triple-phase bone scan may be useful in patients with suspected skeletal infection, although many would preferentially rely on
MRI.
Brain CT scan or MRI
Brain CT scan or MRI allows for evaluation of patients suspected of having a pseudomonal brain abscess.
Renal ultrasonography
Renal ultrasonography is useful in evaluating patients suspected of having a perinephric abscess complicating UTI.
Echocardiography
Echocardiography should be considered in patients with positive blood culture findings in whom endocarditis is suspected.
Normal transthoracic echocardiography findings do not rule out endocarditis in patients in whom clinical suspicion is high.
Transesophageal echocardiography should then be considered.
Other Tests
See the list below:
Gram stain of respiratory secretions and cerebrospinal fluid
Fluorescein staining and slit-lamp examination of the cornea for keratitis
Procedures
Procedures indicated for pseudomonal infections depend on the clinical picture and the site of infection.
Flexible fiberoptic bronchoscopy with bronchoalveolar lavage or bronchial brushing may be useful in pneumonia. Pleural
effusions may require thoracocentesis.
Lumbar puncture with cell count and cultures is indicated in suspected pseudomonal meningitis.
Histologic Findings
Pseudomonas infection causes necrotizing inflammation. Histologically, gram-negative rods are observed in the walls of blood
vessels, causing coagulation necrosis, along with thrombosis and hemorrhage.
Treatment
Approach Considerations
P aeruginosa is intrinsically resistant to certain antibiotics and can potentially acquire resistance during treatment (see
Presentation/Causes for risk factors).
Medical Care
Antimicrobials are the mainstay of therapy. Two-drug combination therapy, such as an antipseudomonal beta-lactam with an
aminoglycoside, can be used.
Endocarditis
A high-dose aminoglycoside (eg, tobramycin 8 mg/kg/d) and an extended-spectrum penicillin in combination with a beta-
lactamase inhibitor (eg, ticarcillin-clavulanate or piperacillin-tazobactam) or antipseudomonal cephalosporin (eg, cefepime) are
used for 6 weeks.
Renal function and aminoglycoside level should be monitored.
Surgical evaluation is required because many patients with right-sided endocarditis require valvulectomy, especially if the
bacteremia is not cleared after 2-6 weeks of antibiotics. For left-sided disease, early surgery is usually required for those with
refractory bacteremia or hemodynamic instability.
Pneumonia
Most experts recommend starting with 2 antipseudomonal antibiotics and then de-escalating to monotherapy.
Except in patients with cystic fibrosis, the role of an aerosolized aminoglycoside or ceftazidime is controversial. Efficacy appears
to be greater in patients with cystic fibrosis, in whom aerosolized aminoglycosides have been shown to assist clinical
improvement and symptom abatement.
Deciding when to switch from combination therapy to monotherapy: According to the American Thoracic Society-Infectious
Diseases Society of America guidelines for ventilator-assisted pneumonia, start with combination therapy that includes a beta-
lactam and aminoglycoside for 5 days and de-escalate to monotherapy based on organism culture sensitivity.
See also Complicated P aeruginosa infections (below).
Bacteremia
Antibiotic therapy is instituted before a specific diagnosis is made.
Once pseudomonal sepsis is suspected in patients with neutropenia, presumptive therapy is a combination of an
aminoglycoside and a broad-spectrum antipseudomonal penicillin or cephalosporin. The use of monotherapy ceftazidime, a
carbapenem (eg, imipenem-cilastatin, meropenem), or double beta-lactams in patients who are febrile and neutropenic is still
controversial. Fluoroquinolones provide an alternative for the beta-lactam–sensitive patient, and the addition of rifampin to the
beta-lactam and aminoglycoside combination may improve bacteriologic cure.
Early appropriate antibiotics and aggressive volume replacement have been shown to improve outcome in septic shock.
Positive-pressure ventilation may be required.
Meningitis
Ceftazidime is the antibiotic of choice because of its high penetration into the subarachnoid space and the high susceptibility of
Pseudomonas to this drug.
Initial therapy in critically ill patients should include an intravenous aminoglycoside. The use of an intrathecal aminoglycoside
should be considered, especially in the setting of treatment failure or relapse.
In renal failure or in the setting of beta-lactam allergy, aztreonam may be an effective second-line drug. However, clinical
experience is limited, and careful observation is suggested.
Clinical experience with ciprofloxacin and meningitis is limited. Animal models suggest equivalent efficacy to that of ceftazidime
and tobramycin, but, for now, combination therapy is suggested.
Therapy is ordinarily continued for 2 weeks. Duration of therapy is determined by the severity of disease. Monitoring serial CSF
cultures and cell counts may be useful in evaluating response to treatment.
Undertreatment increases the relapse rate and probably the likelihood of acquired resistance, while overtreatment increases
costs and adverse medication effects. In meningitis, overtreatment is obviously preferred.
Ear infections
External otitis is treated locally with antibiotics and steroids.
Malignant otitis requires aggressive treatment with 2 antibiotics and surgery.
Duration of treatment is 4-8 weeks, depending on the extent of involvement.
Eye infections
In cases of small superficial ulcers, topical therapy, consisting of an ophthalmic aminoglycoside solution rather than an ointment,
is applied to the affected eye every 30-60 minutes.
An ophthalmic quinolone antibiotic is an alternative. When perforation is imminent, subconjunctival (or subtenon) administration
of antibiotics is preferred.
Management of endophthalmitis is quite complex, requiring aggressive antibiotic therapy (parenteral, topical, subconjunctival [or
subtenon], and, often, intraocular). Vitrectomy may be required to assist in eyesight preservation.
Urinary tract infections
Parenteral aminoglycosides may remain the antibiotics of choice, although quinolones are often used.[8]
Tobramycin is preferred to gentamicin in patients with renal dysfunction.
UTI can be treated with a single agent, except in cases of bacteremia and upper tract infections with abscess formation.
Alternative antibiotics include antipseudomonal penicillins and cephalosporins, carbapenems (eg, imipenem, meropenem), and
aztreonam. Ciprofloxacin continues to be the preferred oral agent.
Duration of therapy is 3-5 days for uncomplicated infections limited to the bladder; 7-10 days for complicated infections,
especially with indwelling catheters; 10 days for urosepsis; and 2-3 weeks for pyelonephritis. Longer duration of treatment is
necessary for those patients with perinephric or intrarenal abscesses.
GI tract infection
GI tract infection treatment includes administration of antibiotics and hydration.
Skin and soft tissue infections

Double antibiotic therapy should be instituted in accordance with the local susceptibility patterns because burn centers may
harbor Pseudomonas strains that are resistant to multiple drugs.
Silver sulfadiazine and sodium piperacillin have been shown to be effective in experimental models of burn sepsis.
Aggressive surgical debridement is necessary, and avoidance of whirlpool treatments is suggested.
Complicated P aeruginosa infections
Ceftazidime/avibactam (Avycaz) is a combination cephalosporin and beta-lactamase inhibitor that was FDA-approved in
February 2015. The ceftazidime component has activity against gram-negative bacteria, including P aeruginosa. The addition of
avibactam increases the spectrum of activity to organisms that produce beta-lactamase enzymes. Unlike other beta-
lactam/beta-lactamase inhibitors, however, this drug has no activity against anaerobic organisms.
Ceftazidime/avibactam is indicated for the treatment of patients aged 18 years or older with complicated intra-abdominal
infections and complicated UTIs. Phase II clinical trials for ceftazidime/avibactam have shown an 85.7% favorable clinical
response rate for complicated UTIs and 92.7% favorable clinical response rate for complicated intra-abdominal infections when
combined with metronidazole.[9] Full results from the Phase III trials and future studies are likely to expand the use of
ceftazidime/avibactam to include hospitalized adults with nosocomial and ventilator-associated pneumonia, hospitalized
pediatric patients aged 3 months to 18 years with complicated intra-abdominal infections, and patients with cystic fibrosis who
have resistant respiratory P aeruginosa infections.
Ceftolozane/tazobactam is a novel cephalosporin developed with a beta-lactamase inhibitor for the treatment of complicated
UTIs, complicated intra-abdominal infections, and ventilator-associated bacterial pneumonia. Ceftolozane has similar activity to
that of ceftazidime, piperacillin/tazobactam, and the carbapenemase family of antibiotics.[10] The tazobactam component allows
for the drug to act against extended-spectrum beta-lactamase (ESBL) bacteria, as well as some anaerobic species, although
data from previous Phase III trials show that, for anaerobic coverage, combining ceftolozane/tazobactam with metronidazole is
recommended.
Ceftolozane/tazobactam is a promising carbapenem-sparing alternative agent for the treatment of complicated UTIs and
complicated intra-abdominal infections, including those caused by ESBL-producing Enterobacteriaceae and multidrug-resistant
P aeruginosa.[11]
Surgical Care
As a rule, infected medical devices should be removed, although exceptions may occur.
In wounds infected with Pseudomonas, surgical removal of eschars, debridement of necrotic tissue, or, in severe cases,
amputation may be required.
Diabetic foot ulcers may require surgical debridement of necrotic tissue.
Malignant otitis requires surgery to debride granulation tissue and necrotic debris.
Surgery may be required for bowel necrosis, perforation, obstruction, or abscess drainage.
Consultations
Pulmonary and critical care medicine consultations are requested in pseudomonal pneumonia that requires bronchoalveolar
lavage, thoracocentesis, or ventilatory support.
Refractoriness to antibiotic therapy and hemodynamic instability in pseudomonal endocarditis directs toward valve replacement.
A cardiothoracic consultation is required.
If drainage of brain abscesses is required, neurosurgical consultation is requested.
Ophthalmology consultation should be requested without delay in cases of pseudomonal eye infection. Vitrectomy may be
needed in cases of endophthalmitis.
Diet
Always prevent malnutrition, and treat it when present.
General goals of nutritional support

Provide nutritional support consistent with the patient's medical condition, nutritional status, and available route of nutrient
administration.
Prevent or treat macronutrient and micronutrient deficiencies.
Provide doses of nutrients compatible with existing metabolism.
Avoid complications related to the technique of dietary delivery.
Improve patient outcomes, such as those related to disease morbidity (eg, body composition, tissue repair, organ function),
resource utilization, medical morbidities and mortalities, and subsequent patient performance.
Patients with cystic fibrosis
In patients with cystic fibrosis, when increased caloric support is needed, carbohydrates in large quantities can result in
increased carbon dioxide production and increased effort for breathing. Instead, an increased proportion of fat calories to
nonprotein calories should be provided. Medium-chain fatty acids can be very useful in these cases.
When enteral feeding is chosen, take special care to avoid aspiration and other mechanical complications.
Electrolytes, trace elements, and vitamins are provided as needed.
Remember that hypophosphatemia and, in particular, hypomagnesemia impair diaphragmatic function. Commercial products,
such as Pulmocare, that are targeted to meet these needs are available. Specific data demonstrating efficacy, however, are not
readily available.
Activity
Patients require no specific limitations on activity.
Complications
Pseudomonal endocarditis may cause brain abscess, cerebritis, and mycotic aneurysms. Septic emboli to the lungs and spleen
are not uncommon, and cardiac complications may include conduction blocks and congestive heart failure.
Pseudomonal bacteremia can cause septic shock and death.
Pseudomonal pneumonia may be severe enough to require respiratory support.
Ear infections can cause perichondritis; sinusitis; mastoiditis; osteomyelitis of the temporal bones; cranial nerve involvement of
seventh, ninth, eleventh, and twelfth nerves; and thrombosis of the lateral and sigmoid sinuses. Meningitis and brain abscesses
are relatively rare.
Eye infections can result in corneal perforations, endophthalmitis, and orbital cellulitis.
GI involvement by Pseudomonas can cause typhlitis, cecal perforation, and peritonitis.
A severe bout of diarrhea can result in vascular collapse and death.
Pseudomonas skin and soft tissue infections can be destructive and can cause massive necrosis and gangrene.
Prevention
Catheter-induced UTIs are very common, and preventive measures are extremely important. An obvious preventive measure is
to avoid catheterization. If this is not possible, the catheter should be removed as soon as possible. Catheters should be
inserted aseptically under sterile conditions. The most important hygienic measure is hand washing by health care personnel. If
a urinary catheter is required for long periods, it should be replaced often. Patients should drink plenty of fluids every day.
Catheters and the area around the urethra should be cleaned with soap and water daily and after each bowel movement.
Prophylactic use of antibiotics is not recommended because it leads to the emergence of antibiotic-resistant strains of bacteria.
Intravenous catheters should be inserted under sterile conditions and with aseptic precautions. Palpate the catheter site for
tenderness daily through an intact dressing. Record the date and time of catheter insertion in an obvious location near the
insertion site.
To prevent cross-contamination, strict isolation is required for patients with severe burns.
Pseudomonas can multiply in nebulizer fluid; therefore, proper cleaning, sterilization, and disinfection of reusable equipment are
required.
Failure to cover bacteremic pneumonia with double antibiotics may lead to a potential lawsuit.
Obtain ophthalmology consultation without delay in cases of suspected pseudomonal eye infections.
Further Outpatient Care

Carefully monitor patients for adverse effects of medications.
Relapses are common in meningitis, and re-treatment may be necessary. Intrathecal antibiotics may be required.
Treatment failures can occur after terminating antibiotic therapy for malignant otitis, thereby requiring careful outpatient follow-up
care.
Further Inpatient Care

Patients receiving intravenous therapy are usually admitted, although home antibiotic programs exist.
Admission is required for surgical management, if necessary.
Critically ill patients require ICU care.
Inpatient & Outpatient Medications

Aminoglycosides in combination with beta-lactam agents with good antipseudomonal activity may be prescribed on an inpatient
or outpatient basis.
Transfer
Patients may need transfer to a facility where ICU care is available.
Patients with endocarditis refractory to antibiotics may need transfer to a facility with arrangements for cardiothoracic surgery for
valve replacement.
Patients with malignant otitis may need to be transferred to a facility where surgery can be performed.
Medication
Medication Summary
Pseudomonal infections are increasingly resistant to certain antibiotics, and the organism may acquire resistance during
therapy. Two agents from different classes should be used when the risk of antibiotic resistance is high (eg, in severe sepsis,
septicemia, and inpatient neutropenia).
Pseudomonas infection can be treated with a combination of an antipseudomonal beta-lactam (eg, penicillin or cephalosporin)
and an aminoglycoside. Carbapenems (eg, imipenem, meropenem) with antipseudomonal quinolones may be used in
conjunction with an aminoglycoside. With the exception of cases involving febrile patients with neutropenia, in whom
monotherapy with ceftazidime or a carbapenem (eg, imipenem, meropenem) is used, a 2-drug regimen is recommended.
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Gentamicin
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms
and one that covers anaerobes.
Not the DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed
infections caused by susceptible staphylococci and gram-negative organisms.
Dosing regimens are numerous. Adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.
Piperacillin and tazobactam (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall and is effective during stage of active
multiplication.
Aztreonam (Azactam)
Monobactam that inhibits cell wall synthesis during bacterial growth. Active against gram-negative bacilli but very limited gram-
positive activity and not useful for anaerobes. Lacks cross-sensitivity with beta-lactam antibiotics. May be used in patients
allergic to penicillins or cephalosporins.
Ciprofloxacin (Cipro, Cipro XR)
Exerts bactericidal effect against both actively dividing and dormant bacteria. Fluoroquinolone effective against pseudomonads,
streptococci, some MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes.
Inhibits bacterial DNA synthesis and, consequently, growth. Continue treatment for at least 2 d (7-14 d typical) after signs and
symptoms disappear.
Cefepime (Maxipime)
For the treatment of Pseudomonas infections. Fourth-generation cephalosporin. Gram-negative coverage comparable to
ceftazidime but has better gram-positive coverage. Cefepime is a zwitterion that rapidly penetrates gram-negative cells. Best
beta-lactam for IM administration. Poor capacity to cross blood-brain barrier precludes use for treatment of meningitis.
Ceftazidime (Fortaz, Tazicef)
Third-generation cephalosporin with high activity against Pseudomonas. Arrests bacterial growth by binding to 1 or more
penicillin-binding proteins.
Tobramycin
Obtained from Streptomyces tenebrarius. Two to 4 times more active against pseudomonal organisms as compared to
gentamicin.
Meropenem (Merrem)
Ultra–broad-spectrum beta-lactam semisynthetic carbapenem antibiotic that inhibits bacterial cell wall synthesis.
Doripenem (Doribax)
Binds to several of penicillin-binding proteins, which in turn inhibit bacterial cell wall synthesis. Bacteria eventually lyse due to
ongoing cell wall autolytic enzymes.
Ceftazidime/avibactam (Avycaz)
Ceftazidime/avibactam (Avycaz) is a combination cephalosporin and beta-lactamase inhibitor that was FDA-approved in
February 2015. The ceftazidime component has activity against gram-negative bacteria, including P aeruginosa. The addition of
avibactam increases the spectrum of activity to organisms that produce beta-lactamase enzymes. Unlike other beta-
lactam/beta-lactamase inhibitors, however, this drug has no activity against anaerobic organisms.
Ceftazidime/avibactam is indicated for the treatment of patients aged 18 years or older with complicated intra-abdominal
infections and complicated UTIs. Phase II clinical trials for ceftazidime/avibactam have shown an 85.7% favorable clinical
response rate for complicated UTIs and 92.7% favorable clinical response rate for complicated intra-abdominal infections when
combined with metronidazole. Full results from the phase III trials and future studies are likely to expand the use of
ceftazidime/avibactam to include hospitalized adults with nosocomial and ventilator-associated pneumonia, hospitalized
pediatric patients aged 3 months to 18 years with complicated intra-abdominal infections, and patients with cystic fibrosis who
have resistant respiratory P aeruginosa infections.
Ceftolozane/tazobactam (Zerbaxa)
Ceftolozane/tazobactam is a novel cephalosporin developed with a beta-lactamase inhibitor for the treatment of complicated
UTIs, complicated intra-abdominal infections, and ventilator-associated bacterial pneumonia. Ceftolozane has similar activity to
that of ceftazidime, piperacillin/tazobactam, and the carbapenemase family of antibiotics. The tazobactam component allows for
the drug to act against extended-spectrum beta-lactamase (ESBL) bacteria, as well as some anaerobic species, although data
from previous Phase III trials show that, for anaerobic coverage, combining ceftolozane/tazobactam with metronidazole is
recommended.
Ceftolozane/tazobactam is a promising carbapenem-sparing alternative agent for the treatment of complicated UTIs and
complicated intra-abdominal infections, including those caused by ESBL-producing Enterobacteriaceae and multidrug-resistant
P aeruginosa.
Questions & Answers

Overview
What is Pseudomonas (P) aeruginosa?
How do Pseudomonas (P) aeruginosa infections manifest?
What are the physical findings in Pseudomonas (P) aeruginosa infections?
Which lab studies are used in the workup of Pseudomonas (P) aeruginosa infections?
Which imaging studies are used in the workup of Pseudomonas (P) aeruginosa infections?
What are the secondary tests and procedures used in the workup of Pseudomonas (P) aeruginosa infections?
Which medications are used to treat Pseudomonas (P) aeruginosa infections?
What is the role of surgical care in the treatment of Pseudomonas (P) aeruginosa infections?
What is Pseudomonas aeruginosa?
What type of pathogen is Pseudomonas (P) aeruginosa?
What is the pathogenesis of Pseudomonas (P) aeruginosa infections?
What is the prevalence of Pseudomonas (P) aeruginosa infections in the US?
What is the worldwide prevalence of Pseudomonas (P) aeruginosa infections?
What is the mortality/morbidity of Pseudomonas (P) aeruginosa infections?
Who is at greatest risk of Pseudomonas (P) aeruginosa endocarditis?
What are the age-related demographics of Pseudomonas (P) aeruginosa infections?
What is the epidemiology of Pseudomonas (P) aeruginosa infections?
What is the prognosis of Pseudomonas (P) aeruginosa infections?
What is included in the patient education information for Pseudomonas (P) aeruginosa infections?
Presentation
Where in the body do Pseudomonas (P) aeruginosa infections occur?
How does Pseudomonas (P) aeruginosa infections affect the respiratory tract?
What are symptoms of Pseudomonas (P) aeruginosa pneumonia?
How is Pseudomonas (P) aeruginosa bacteremia acquired?
What are the signs and symptoms of Pseudomonas (P) aeruginosa infection?
How does Pseudomonas (P) aeruginosa endocarditis manifest?
How is the CNS affected by Pseudomonas (P) aeruginosa infection?
How is the ear affected by Pseudomonas (P) aeruginosa infection?
How is the eye affected by Pseudomonas (P) aeruginosa infection?
What are the most common sites of Pseudomonas (P) aeruginosa infection?
How do Pseudomonas (P) aeruginosa infections manifest in the bones and joints?
How is the GI tract affected by Pseudomonas (P) aeruginosa infection?
How is the urinary tract affected by Pseudomonas (P) aeruginosa infection?
Does Pseudomonas (P) aeruginosa grow on skin?
How does green nail syndrome manifest from Pseudomonas (P) aeruginosa?
How are secondary wound infections associated with Pseudomonas (P) aeruginosa characterized?
What are the symptoms of swimming pool folliculitis caused by Pseudomonas (P) aeruginosa?
How is the skin affected by pseudomonal bacteremia?
How is burn wound sepsis caused by Pseudomonas (P) aeruginosa characterized?
What are the characteristics of bacterial endocarditis associated with Pseudomonas (P) aeruginosa?
What are the respiratory features of Pseudomonas (P) aeruginosa infections?
What are the GI findings in infants with Pseudomonas (P) aeruginosa infection?
What are the cutaneous characteristics of Pseudomonas (P) aeruginosa infections?
What are the characteristics of skeletal infections caused by Pseudomonas (P) aeruginosa?
What are the characteristics of eye infections caused by Pseudomonas (P) aeruginosa?
What are the characteristics of malignant otitis externa caused by Pseudomonas (P) aeruginosa?
What are the characteristics of bacteremia caused by Pseudomonas (P) aeruginosa?
What causes pseudomonal bacteremia?
What are the predisposing conditions of Pseudomonas (P) aeruginosa infections?
Which conditions are predisposing to Pseudomonas (P) aeruginosa infections and how do they manifest?
What are the risk factors for infection with resistant Pseudomonas aeruginosa?
DDX
What are the differential diagnoses for Pseudomonas aeruginosa Infections?
Workup
What is the role of a CBC in the workup of Pseudomonas (P) aeruginosa infection?
How are blood cultures used in the workup of Pseudomonas (P) aeruginosa infection?
Which cultures other than blood cultures are used in the workup of Pseudomonas (P) aeruginosa infection?
How is Gram stain used in the diagnosis of Pseudomonas (P) aeruginosa infection?
What is the role of chest radiography in the workup of Pseudomonas (P) aeruginosa?
What is the role of bone scanning in the workup of Pseudomonas (P) aeruginosa infection?
What is the role of brain CT scanning or MRI in the workup of Pseudomonas (P) aeruginosa infection?
What is the role of renal ultrasonography in the workup of Pseudomonas (P) aeruginosa infection?
What is the role of echocardiography in the workup of Pseudomonas (P) aeruginosa infection?
Which other tests are used in the workup of Pseudomonas (P) aeruginosa infection?
Which procedures are indicated in the workup of Pseudomonas (P) aeruginosa infection?
[combine with previous]
What are the histologic findings in Pseudomonas (P) aeruginosa infection?
Treatment
What are the approach considerations on the treatment of Pseudomonas (P) aeruginosa infection?
How are GI tract infections due to Pseudomonas (P) aeruginosa treated?
What is the mainstay therapy for Pseudomonas (P) aeruginosa infection?
What are the treatment options for Pseudomonas (P) aeruginosa endocarditis?
What are the treatment options for Pseudomonas (P) aeruginosa pneumonia?
What are the treatment options for bacteremia due to Pseudomonas (P) aeruginosa?
What are the treatment options for meningitis due to Pseudomonas (P) aeruginosa?
How are ear infections caused by Pseudomonas (P) aeruginosa treated?
How are eye infections caused by Pseudomonas (P) aeruginosa treated?
How are urinary tract infections (UTIs) due to Pseudomonas (P) aeruginosa treated?
What are the treatment options for skin and soft tissue infections due to Pseudomonas (P) aeruginosa?
What is the efficacy of ceftazidime/avibactam (Avycaz) combination therapy for Pseudomonas (P) aeruginosa infections?
What is the efficacy of ceftolozane/tazobactam combination therapy for Pseudomonas (P) aeruginosa infections?
What are the surgical options for the treatment of Pseudomonas (P) aeruginosa infections?
What are the consultations indicated in the treatment of Pseudomonas (P) aeruginosa infections?
How is nutritional support addressed in the treatment of Pseudomonas (P) aeruginosa infections?
How is nutritional support addressed in the treatment of cystic fibrosis and Pseudomonas (P) aeruginosa infection?
Are activity restrictions indicated for patients with Pseudomonas (P) aeruginosa infection?
What are the complications of pseudomonal endocarditis?
What are the complications of pseudomonal bacteremia?
What are the complications of pseudomonal pneumonia?
What are the complications of ear infections caused by Pseudomonas (P) aeruginosa?
What are complications of eye infections caused by Pseudomonas (P) aeruginosa?
What are the complications of GI infections caused by Pseudomonas (P) aeruginosa?
What are the complications of skin and soft tissue infections caused by Pseudomonas (P) aeruginosa?
How are Pseudomonas (P) aeruginosa infections prevented when catheters are necessary?
How can Pseudomonas (P) aeruginosa infections be prevented?
How are patients with Pseudomonas (P) aeruginosa infections monitored in an outpatient setting?
When is inpatient care indicated for patients with Pseudomonas (P) aeruginosa infections?
When are aminoglycosides indicated for the treatment of Pseudomonas (P) aeruginosa infections?
When is transfer indicated for patients with Pseudomonas (P) aeruginosa infection?
Medications
What medications are used in the treatment of Pseudomonas (P) aeruginosa infections?
Which medications in the drug class Antibiotics are used in the treatment of Pseudomonas aeruginosa Infections?
Contributor Information and Disclosures
Author
Marcus Friedrich, MD, MBA, FACP Medical Director Office of Quality and Patient Safety, New York State Department of
Health; Assistant Professor, Hofstra North Shore-LIJ School of Medicine at Hofstra University
Marcus Friedrich, MD, MBA, FACP is a member of the following medical societies: American Academy of Family Physicians,
American College of Physicians, American Medical Association
Disclosure: Nothing to disclose.
Coauthor(s)
Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious
Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of
Physicians, Infectious Diseases Society of America
Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical
Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of
Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians,
American College of Physicians, American Medical Association, American Thoracic Society, Society of Critical Care Medicine
Kevin Gerard G Lazo, DO Attending Hospitalist, Division of Hospital Medicine, Department of Medicine, Northwell Health;
Assistant Professor of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Kevin Gerard G Lazo, DO is a member of the following medical societies: American College of Physicians, American Thoracic
Society
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine
and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases
Society of America
Chief Editor
Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed
Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American
College of Physicians; Fellow, Infectious Diseases Society of America
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of
Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America,
Oklahoma State Medical Association, Southern Society for Clinical Investigation
Additional Contributors
Pratibha Dua, MD, MBBS Staff Physician, Internal Medicine, United Medical Park
Pratibha Dua, MD, MBBS is a member of the following medical societies: American Medical Association
Thomas J Marrie, MD Dean of Faculty of Medicine, Dalhousie University Faculty of Medicine, Canada
Thomas J Marrie, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians,
American Society for Microbiology, Association of Medical Microbiology and Infectious Disease Canada, Royal College of
Physicians and Surgeons of Canada
Acknowledgements
Samer Qarah, MD Pulmonary Critical Care Consultant, Department of Internal Medicine, Division of Pulmonary and Critical
Care, The Brooklyn Hospital Center and Cornell University
Samer Qarah, MD is a member of the following medical societies: American College of Critical Care Medicine
References
1. Pollack M. Pseudomonas Aeruginosa. Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 5th ed.
New York, NY: Churchill Livingstone; 2000. 2310-27.
2. CDC. Antibiotic Resistance Threats in the United States, 2013. Centers for Disease Control and Prevention. Available at
http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf.
3. Textbook of Bacteriology. Todar's Online Textbook of Bacteriology. [Full Text].
4. Illgner U, Uekoetter A, Runge S, Wetz HH. Infections with Pseudomonas aeruginosa in Charcot arthropathy of the foot. Foot Ankle
Int. 2013 Feb. 34(2):234-7. [Medline].
5. National Nosocomial Infections Surveillance (NNIS) System. National Nosocomial Infections Surveillance (NNIS) System Report,
data summary from January 1992 through June 2004, issued October 2004. Centers for Disease Control and Prevention. Available
at http://www.cdc.gov/nhsn/pdfs/datastat/nnis_2004.pdf.
6. Ratjen F, Munck A, Kho P, Angyalosi G. Treatment of early Pseudomonas aeruginosa infection in patients with cystic fibrosis: the
ELITE trial. Thorax. 2010 Apr. 65(4):286-91. [Medline].
7. Aloush V, Navon-Venezia S, Seigman-Igra Y, Cabili S, Carmeli Y. Multidrug-resistant Pseudomonas aeruginosa: risk factors and
clinical impact. Antimicrob Agents Chemother. 2006 Jan. 50 (1):43-8. [Medline].
8. Bitsori M, Maraki S, Koukouraki S, Galanakis E. Pseudomonas aeruginosa urinary tract infection in children: risk factors and
outcomes. J Urol. 2012 Jan. 187(1):260-4. [Medline].
9. Hidalgo JA, Vinluan CM, Antony N. Ceftazidime/avibactam: a novel cephalosporin/nonbeta-lactam beta-lactamase inhibitor for the
treatment of complicated urinary tract infections and complicated intra-abdominal infections. Drug Des Devel Ther. 2016 Jul 26.
10:2379-86. [Medline].
10. Zhanel GG, Chung P, Adam H, Zelenitsky S, Denisuik A, Schweizer F, et al. Ceftolozane/tazobactam: a novel cephalosporin/β-
lactamase inhibitor combination with activity against multidrug-resistant gram-negative bacilli. Drugs. 2014 Jan. 74 (1):31-51.
[Medline].
11. Giancola SE, Mahoney MV, Bias TE, Hirsch EB. Critical evaluation of ceftolozane-tazobactam for complicated urinary tract and intra-
abdominal infections. Ther Clin Risk Manag. 2016 May 19. 12:787-97. [Medline].
12. Abuqaddom AI, Darwish RM, Muti H. The effects of some formulation factors used in ophthalmic preparations on thiomersal activity
against Pseudomonas aeruginosa and Staphylococcus aureus. J Appl Microbiol. 2003. 95(2):250-5. [Medline].
13. Bliziotis IA, Samonis G, Vardakas KZ, Chrysanthopoulou S, Falagas ME. Effect of aminoglycoside and beta-lactam combination
therapy versus beta-lactam monotherapy on the emergence of antimicrobial resistance: a meta-analysis of randomized, controlled
trials. Clin Infect Dis. 2005 Jul 15. 41(2):149-58. [Medline].
14. Chamot E, Boffi El Amari E, Rohner P, Van Delden C. Effectiveness of combination antimicrobial therapy for Pseudomonas
aeruginosa bacteremia. Antimicrob Agents Chemother. 2003 Sep. 47(9):2756-64. [Medline].
15. Crouch Brewer S, Wunderink RG, Jones CB, Leeper KV Jr. Ventilator-associated pneumonia due to Pseudomonas aeruginosa.
Chest. 1996 Apr. 109(4):1019-29. [Medline].
16. Cunha BA. Clinical relavance of penicillin resistant Streptococcus pneumoniae. Semin Respir Infect. 2002 Sep. 17(3):204-14.
[Medline].
17. Cunha BA. New uses for older antibiotics: nitrofurantoin, amikacin, colistin, polymyxin B, doxycycline, and minocycline revisited. Med
Clin North Am. 2006 Nov. 90(6):1089-107. [Medline].
18. Cunha BA. Ventilator associated pneumonia: monotherapy is optimal if chosen wisely. Crit Care. 2006. 10(2):141. [Medline].
19. Cunha BA. Multidrug resistant (MDR) Klebsiella, Acinetobacter, and Pseudomonas aeruginosa. Antibiotics for Clinicians. 2006.
10:354-355.
20. Cunha BA. Pseudomonas aeruginosa: resistance and therapy. Semin Respir Infect. 2002. 17:231-239. [Medline].
21. Edelstein MV, Skleenova EN, Shevchenko OV, D'souza JW, Tapalski DV, Azizov IS, et al. Spread of extensively resistant VIM-2-
positive ST235 Pseudomonas aeruginosa in Belarus, Kazakhstan, and Russia: a longitudinal epidemiological and clinical study.
Lancet Infect Dis. 2013 Jul 8. [Medline].
22. Edgeworth JD, Treacher DF, Eykyn SJ. A 25-year study of nosocomial bacteremia in an adult intensive care unit. Crit Care Med.
1999 Aug. 27(8):1421-8. [Medline].
23. Fiorillo L, Zucker M, Sawyer D, Lin AN. The pseudomonas hot-foot syndrome. N Engl J Med. 2001 Aug 2. 345(5):335-8. [Medline].
24. Garcia-Lechuz JM, Cuevas O, Castellares C, Perez-Fernandez C, Cercenado E, Bouza E. Streptococcus pneumoniae skin and soft
tissue infections: characterization of causative strains and clinical illness. Eur J Clin Microbiol Infect Dis. 2007 Apr. 26(4):247-53.
Epub. [Medline].
25. Gavin PJ, Suseno MT, Cook FV, Peterson LR, Thomson RB Jr. Left-sided endocarditis caused by Pseudomonas aeruginosa:
successful treatment with meropenem and tobramycin. Diagn Microbiol Infect Dis. 2003 Oct. 47(2):427-30. [Medline].
26. Heal CF, Buettner PG, Cruickshank R, Graham D, Browning S, Pendergast J, et al. Does single application of topical
chloramphenicol to high risk sutured wounds reduce incidence of wound infection after minor surgery? Prospective randomised
placebo controlled double blind trial. BMJ. 2009 Jan 15. 338:a2812. [Medline]. [Full Text].
27. Hoban DJ, Zhanel GG. Clinical implications of macrolide resistance in community-acquired respiratory tract infections. Expert Rev
Anti Infect Ther. 2006 Dec. 4(6):973-80. [Medline].
28. Ibrahim EH, Ward S, Sherman G, Kollef MH. A comparative analysis of patients with early-onset vs late-onset nosocomial
pneumonia in the ICU setting. Chest. 2000 May. 117(5):1434-42. [Medline].
29. Janeczko L. Study Finds Rapid Spread of Extensively Drug-Resistant P. aeruginosa. Medscape Medical News. Available at
http://www.medscape.com/viewarticle/808645. Accessed: August 4, 2013.
30. Karlowsky JA, Draghi DC, Jones ME, Thornsberry C, Friedland IR, et al. Surveillance for antimicrobial susceptibility among clinical
isolates of Pseudomonas aeruginosa and Acinetobacter baumannii from hospitalized patients in the United States, 1998 to 2001.
Antimicrob Agents Chemother. 2003 May. 47(5):1681-8. [Medline].
31. Klibanov OM, Raasch RH, Rublein JC. Single versus combined antibiotic therapy for gram-negative infections. Ann Pharmacother.
2004 Feb. 38(2):332-7. [Medline].
32. Micek ST, Lloyd AE, Ritchie DJ, Reichley RM, Fraser VJ, Kollef MH. Pseudomonas aeruginosa bloodstream infection: importance of
appropriate initial antimicrobial treatment. Antimicrob Agents Chemother. 2005 Apr. 49(4):1306-11. [Medline].
33. Muramatsu H, Horii T, Morita M, Hashimoto H, Kanno T, Maekawa M. Effect of basic amino acids on susceptibility to carbapenems in
clinical Pseudomonas aeruginosa isolates. Int J Med Microbiol. 2003 Jun. 293(2-3):191-7. [Medline].
34. Paul M, Silbiger I, Grozinsky S, Soares-Weiser K, Leibovici L. Beta lactam antibiotic monotherapy versus beta lactam-
aminoglycoside antibiotic combination therapy for sepsis. Cochrane Database Syst Rev. 2006. (1):CD003344. [Medline].
35. Quittner AL, Modi AC, Wainwright C, Otto K, Kirihara J, Montgomery AB. Determination of the minimal clinically important difference
scores for the Cystic Fibrosis Questionnaire-Revised respiratory symptom scale in two populations of patients with cystic fibrosis and
chronic Pseudomonas aeruginosa airway infection. Chest. 2009 Jun. 135(6):1610-8. [Medline]. [Full Text].
36. Retsch-Bogart GZ, Quittner AL, Gibson RL, Oermann CM, McCoy KS, Montgomery AB, et al. Efficacy and safety of inhaled
aztreonam lysine for airway pseudomonas in cystic fibrosis. Chest. 2009 May. 135(5):1223-32. [Medline]. [Full Text].
37. Schoni MH. Macrolide antibiotic therapy in patients with cystic fibrosis. Swiss Med Wkly. 2003 May 31. 133(21-22):297-301.
[Medline].
38. Shorr AF. Review of studies of the impact on Gram-negative bacterial resistance on outcomes in the intensive care unit. Crit Care
Med. 2009 Apr. 37(4):1463-9. [Medline].
39. van Delden C. Pseudomonas aeruginosa bloodstream infections: how should we treat them?. Int J Antimicrob Agents. 2007 Nov. 30
Suppl 1:S71-5. [Medline].
40. Veesenmeyer JL, Hauser AR, Lisboa T, Rello J. Pseudomonas aeruginosa virulence and therapy: evolving translational strategies.
Crit Care Med. 2009 May. 37(5):1777-86. [Medline]. [Full Text].
41. Vonberg RP, Gastmeier P. Isolation of infectious cystic fibrosis patients: results of a systematic review. Infect Control Hosp
Epidemiol. 2005 Apr. 26(4):401-9. [Medline].
42. Wang S, Kwok M, McNamara JK, Cunha BA. Colistin for multi-drug resistant (MDR) gram-negative bacillary infections. Antibiotics for
Clinicians. 2007. 11:389-396.

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Signs and symptoms

Respiratory tract (eg, pneumonia)

CNS (eg, meningitis, brain abscess)

Ear (eg, otitis externa and media)

Eye (eg, bacterial keratitis, endophthalmitis)

Bones and joints (eg, osteomyelitis)

GI tract (eg, diarrhea, enteritis, enterocolitis)

Skin (eg, ecthyma gangrenosum)

Bacteremia: Fever, tachypnea, and tachycardia; hypotension and shock; jaundice

See Clinical Presentation for more detail.

Laboratory studies that may be helpful include the following:

Complete blood count (CBC)

In urinary tract infection (UTI), urinalysis

Gram stain and culture of CSF if meningitis is suspected

Imaging studies that may be warranted include the following:

Brain CT or MRI of the brain for suspected pseudomonal brain abscess

Renal ultrasonography for suspected of perinephric abscess complicating UTI

Echocardiography for suspected endocarditis with positive blood culture findings

Fluorescein staining and slit-lamp examination of the cornea for keratitis

Flexible fiberoptic bronchoscopy with bronchoalveolar lavage or bronchial brushing

Lumbar puncture with cell count and cultures

See Workup for more detail.

Endocarditis: Give a high-dose aminoglycoside plus an extended-spectrum penicillin or antipseudomonal cephalosporin

Surgical debridement should be aggressive. Principles of surgical care are as follows:

Diabetic foot ulcers may require surgical debridement of necrotic tissue

See Treatment and Medication for more detail.

P aeruginosa is common in immunocompromised patients with diabetes.

Signs and symptoms depend on the primary site of infection.

Right-sided and left-sided valve infections may occur.

Central nervous system

P aeruginosa infection can cause meningitis and brain abscess.

Bones and joints

Urinary tract infections

Pseudomonal bacteremia produces distinctive skin lesions known as ecthyma gangrenosum.

Patients have rales, rhonchi, fever, cyanosis, retractions, and hypoxia.

Shock may develop in patients with bacteremic pneumonia.

Skin and soft tissue infections

Vertebral osteomyelitis manifests as local tenderness and a decreased range of motion.

Osteomyelitis may complicate puncture wounds.

Neurological deficits, when present, suggest spinal cord involvement.

Malignant otitis externa

Local lymphadenopathy may be present.

Patients have fever, tachypnea, and tachycardia.

Hypotension and shock may develop.

Jaundice may occur.

Skin shows characteristic skin lesions called ecthyma gangrenosum.

Diabetes - Malignant otitis externa

Cancer - Pneumonia, sepsis

Intensive care unit (ICU) stay

Aspiration Pneumonitis and Pneumonia

Community-Acquired Pneumonia (CAP)

Pneumococcal Infections (Streptococcus pneumoniae)

Pneumocystis jiroveci Pneumonia (PJP)

Obtain Gram stain and culture of cerebrospinal fluid if meningitis is suspected.

Brain CT scan or MRI

Gram stain of respiratory secretions and cerebrospinal fluid

Fluorescein staining and slit-lamp examination of the cornea for keratitis

Renal function and aminoglycoside level should be monitored.

See also Complicated P aeruginosa infections (below).

Antibiotic therapy is instituted before a specific diagnosis is made.

External otitis is treated locally with antibiotics and steroids.

Malignant otitis requires aggressive treatment with 2 antibiotics and surgery.