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Pseudomonas aeruginosa Infections Treatment & Management

  • Author: Marcus Friedrich, MD, MBA, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
Updated: Dec 17, 2015

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.


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.


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.


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.


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.


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.



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.



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.



Patients require no specific limitations on activity.

Contributor Information and Disclosures

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.


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.

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.

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

Disclosure: Nothing to disclose.

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 Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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

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.

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