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Pseudomonas and Related Infections

By

Larry M. Bush

, MD, FACP, Charles E. Schmidt College of Medicine, Florida Atlantic University;


Maria T. Vazquez-Pertejo

, MD, FACP, Wellington Regional Medical Center

Last full review/revision Feb 2020| Content last modified Mar 2021
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Pseudomonas aeruginosa and other members of this group of gram-negative bacilli are opportunistic pathogens that frequently cause hospital-acquired infections, particularly in ventilator patients, burn patients, and patients with neutropenia or chronic debility. Many sites can be infected, and infection is usually severe. Diagnosis is by culture. Antibiotic choice varies with the pathogen and must be guided by susceptibility testing because resistance is common.

Epidemiology

Pseudomonas is ubiquitous and favors moist environments. In humans, P. aeruginosa is the most common pathogen, but infection may result from P. paucimobilis, P. putida, P. fluorescens, or P. acidovorans. Other important hospital-acquired pathogens formerly classified as Pseudomonas include Burkholderia cepacia and Stenotrophomonas maltophilia. B. pseudomallei causes a distinct disease known as melioidosis Melioidosis Melioidosis is an infection caused by the gram-negative bacterium Burkholderia (formerly Pseudomonas) pseudomallei. Manifestations include pneumonia, septicemia, and localized infection in various... read more that is limited mostly to the southeast Asia and northern Australia.

P. aeruginosa is present occasionally in the axilla and anogenital areas of normal skin but rarely in stool unless antibiotics are being given. In hospitals, the organism is frequently present in sinks, antiseptic solutions, and urine receptacles. Transmission to patients by health care practitioners may occur, especially in burn and neonatal intensive care units, unless infection control practices are meticulously followed.

Diseases Caused by Pseudomonas

Most P. aeruginosa infections occur in hospitalized patients, particularly those who have neutropenia or who are debilitated or immunocompromised. P. aeruginosa is a common cause of infections in intensive care units. HIV-infected patients, particularly those in advanced stages, and patients with cystic fibrosis Cystic Fibrosis Cystic fibrosis is an inherited disease of the exocrine glands affecting primarily the gastrointestinal and respiratory systems. It leads to chronic lung disease, exocrine pancreatic insufficiency... read more Cystic Fibrosis are at risk of community-acquired P. aeruginosa infections.

Pseudomonas infections can develop in many anatomic sites, including skin, subcutaneous tissue, bone, ears, eyes, urinary tract, lungs, and heart valves. The site varies with the portal of entry and the patient’s vulnerability. In hospitalized patients, the first sign may be overwhelming gram-negative sepsis Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more .

Skin and soft-tissue infections

In burns, the region below the eschar can become heavily infiltrated with organisms, serving as a focus for subsequent bacteremia—an often lethal complication.

Deep puncture wounds of the foot are often infected by P. aeruginosa. Draining sinuses, cellulitis, and osteomyelitis Osteomyelitis Osteomyelitis is inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. Common symptoms are localized bone pain and tenderness with constitutional symptoms (in acute... read more Osteomyelitis may result. Drainage from puncture wounds often has a sweet, fruity smell.

Ecthyma gangrenosum is a skin lesion that occurs in neutropenic patients and is usually caused by P. aeruginosa. It is characterized by erythematous, centrally ulcerated, purple-black areas about 1 cm in diameter occurring most often in moist areas such as the axillary, inguinal, or anogenital areas. Ecthyma gangrenosum typically occurs in patients with P. aeruginosa bacteremia.

Respiratory tract infections

Other infections

Pseudomonas is a common cause of nosocomial urinary tract infection Introduction to Urinary Tract Infections (UTIs) Urinary tract infections (UTIs) can be divided into upper tract infections, which involve the kidneys (pyelonephritis), and lower tract infections, which involve the bladder (cystitis), urethra... read more , especially in patients who have had urologic manipulation or obstructive uropathy. Pseudomonas commonly colonizes the urinary tract in catheterized patients, especially those who have received broad-spectrum antibiotics.

Ocular involvement generally manifests as corneal ulceration, most often after trauma, but contamination of contact lenses or lens fluid has been implicated in some cases.

Bacteremia

Many Pseudomonas infections can cause bacteremia Bacteremia Bacteremia is the presence of bacteria in the bloodstream. It can occur spontaneously, during certain tissue infections, with use of indwelling genitourinary or IV catheters, or after dental... read more . In nonintubated patients without a detectable urinary focus, especially if infection is due to a species other than P. aeruginosa, bacteremia suggests contaminated IV fluids or drugs or antiseptics used in placing the IV catheter.

Diagnosis

  • Culture

Diagnosis of Pseudomonas infections depends on culturing the organism from the site of infection: blood, skin lesions, drainage fluid, urine, cerebrospinal fluid, or eye. Susceptibility testing is also done.

Localized infection may produce a fruity smell of newly mown grass, and pus may be greenish.

Treatment

  • Various antibiotics depending on site and severity of infection and susceptibility testing

Localized infection

Hot-tub folliculitis resolves spontaneously and does not require antibiotic therapy.

External otitis is treated with 1 to 2% acetic acid irrigations or topical drugs such as ciprofloxacin, polymyxin B, or colistin. More severe infection is treated with fluoroquinolones.

Focal soft-tissue infection may require early surgical debridement of necrotic tissue and drainage of abscesses in addition to antibiotics.

Small corneal ulcers are treated with ciprofloxacin 0.3% or levofloxacin 0.5%. Fortified (higher than stock concentration) antibiotic drops, such as tobramycin 15 mg/mL, are used for more significant ulcers. Frequent dosing (eg, every 1 hour around the clock) is necessary initially. Eye patching is contraindicated because it produces a dark warm environment that favors bacterial growth and prevents administration of topical drugs.

Asymptomatic bacteriuria is not treated with antibiotics, except during pregnancy and before urologic manipulation. Patients with symptomatic urinary tract infections can often be treated with oral levofloxacin 750 mg once a day or oral ciprofloxacin 500 mg 2 times a day.

Systemic infection

Parenteral therapy is required. Recently, single drug therapy with an active antipseudomonal beta-lactam (eg, ceftazidime) or a fluoroquinolone has been shown to produce outcomes equivalent to those of previously recommended combination therapy with an aminoglycoside plus an antipseudomonal beta-lactam, an antipseudomonal cephalosporin (eg, ceftazidime, cefepime, cefoperazone), a monobactam (eg, aztreonam), or a carbapenem (meropenem, imipenem, doripenem). Such single-drug therapy is also satisfactory for patients with neutropenia.

Right-sided endocarditis can be treated with antibiotics, but usually the infected valve must be removed to cure an infection involving the mitral, aortic, or prosthetic valve.

P. aeruginosa resistance may occur among patients treated with ceftazidime, cefepime, ciprofloxacin, gentamicin, meropenem, imipenem, or doripenem. Older antibiotics (eg, colistin) may be required to treat infections involving multidrug-resistant Pseudomonas species. Ceftolozane/tazobactam maintains activity against many multidrug-resistant strains of P. aeruginosa.

Key Points

  • Most P. aeruginosa infections occur in hospitalized patients, particularly those who are debilitated or immunocompromised, but patients with cystic fibrosis or advanced HIV may acquire the infection in the community.

  • Infection can develop in many sites, varying with the portal of entry (eg, skin in burn patients, lungs in patients on a ventilator, urinary tract in patients who have had urologic manipulation or obstructive uropathy); overwhelming gram-negative sepsis may occur.

  • Surface infections (eg, folliculitis, external otitis, corneal ulcers) may develop in healthy people.

  • Diagnose using cultures.

  • Treat systemic infection with parenteral therapy using a single drug (eg, an antipseudomonal beta-lactam, a fluoroquinolone).

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