Pseudomonas aeruginosa Infections
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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.
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
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.
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.
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:
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.
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.
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.
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.
P aeruginosa is common in immunocompromised patients with diabetes.
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]
P aeruginosa endocarditis in individuals who abuse intravenous drugs is observed mainly among young black males.
Cases of endocarditis and vertebral osteomyelitis have been observed in young males who use intravenous drugs.
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.
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]
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.
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.
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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.
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
Disclosure: Nothing to disclose.
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
Disclosure: Nothing to disclose.
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
Disclosure: Nothing to disclose.
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
Disclosure: Nothing to disclose.
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; Fellow of the Royal College of Physicians, London
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
Disclosure: Nothing to disclose.
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
Disclosure: Nothing to disclose.
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
Disclosure: Nothing to disclose.
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
Disclosure: Nothing to disclose.
Pseudomonas aeruginosa Infections
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