eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Pseudomonas Infection: Follow-up

Author: Selina SP Chen, MD, MPH, Assistant Professor of Pediatrics, Department of Internal Medicine, John A Burns School of Medicine, University of Hawaii; Internal Medicine and Pediatric Hospitalist, Kapiolani Medical Center for Women and Children; Internal Medicine Hospitalist, Straub Clinic and Hospital
Coauthor(s): Ralph Rudoy, MD, Chief, Division of Pediatric Infectious Disease, Acting Chair, Professor, Department of Pediatrics, John A Burns School of Medicine, University of Hawaii
Contributor Information and Disclosures

Updated: Oct 22, 2009

Follow-up

Further Inpatient Care

  • Admission is required for acute Pseudomonas infections that require intravenous (IV) antibiotic administration or possible surgical treatment.
  • Critically ill patients should be monitored in an ICU.
  • Most pseudomonal infections are nosocomial; thus, any hardware (eg, central lines, Foley catheters, endotracheal tubes) is a possible source of infection.

Further Outpatient Care

  • Closely monitor patients for adverse effects of medications.
  • Antibiotics (eg, aminoglycosides) may require drug level monitoring.
  • Relapses are common in malignant otitis externa, CNS infections, and endocarditis; patients may require repeated treatment.

Inpatient & Outpatient Medications

  • Double-coverage antibiotics may be prescribed on an inpatient or outpatient basis.
  • Otitis externa may require acidification with 2% acetic acid, with or without 1% hydrocortisone.

Transfer

  • Neonates who require workup for sepsis should be transferred to a neonatal intensive or intermediate care unit.
  • Patients may require transfer to a facility where ICU care is available.

Deterrence/Prevention

  • No vaccine is available to prevent infection by Pseudomonas organisms.
  • Hospital personnel should enforce universal precautions to prevent spread of infections.
  • Iatrogenic causes of nosocomial infections from central lines, Foley catheters, or endotracheal tubes can be prevented by avoiding such instrumentation, by limiting the time they are used, and by following CDC recommendations for inserting catheters. Prophylactic antibiotic administration is not recommended because of the emergence of resistant organisms;7 however, the effectiveness of antibiotic-treated catheters is under study.
  • To prevent folliculitis, CDC Health and Safety Guidelines for Public Spas and Hot Tubs recommend a free chlorine concentration of 1-3 mg/L and a pH of 7.2-7.8. Drain private hot tubs every 4-8 weeks, depending on the amount of use. Completely drain public hot tubs and whirlpools on a daily basis and clean interiors with an acidic solution. Bromine can be used as an alternative to chlorine.
  • If possible, avoid contact with animals infected by B mallei and B pseudomallei.

Complications

  • Complications depend on the site of infection.
    • Chronic glanders may lead to multiple abscesses within the muscles of the arms and legs or in the spleen or liver.
    • Chronic melioidosis can involve several organs (eg, joints, viscera, lymph nodes, skin, brain, liver, lung, bones, spleen).
    • Pseudomonal skin infections can be destructive and lead to necrotizing fasciitis, compartment syndrome, necrosis, gangrene, and loss of an extremity.
    • Septicemia may lead to septic shock and death.
  • CNS infections may lead to seizures, increased intracranial pressure, and the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
  • Pseudomonal ear infections may lead to sinusitis, mastoiditis, perichondritis, osteomyelitis of the temporal bones, and thrombosis. Cases of CNS involvement (especially seventh-cranial-nerve palsy) have been reported, although these cases are rare.
  • Pseudomonal eye infections can lead to corneal perforations and ulcerations, endophthalmitis, and orbital cellulitis.
  • GI infections may lead to cecal perforation, peritonitis, typhlitis, and severe electrolyte and fluid disturbances.
  • Untreated endocarditis may lead to congestive heart failure, conduction heart block, cerebritis, mycotic aneurysms, or brain abscess. Septic emboli to the lung and spleen also have been reported.
  • Pneumonia may require endotracheal intubation for respiratory support.
  • Prognosis varies based on the site of infection.
  • Always emphasize good hygiene, universal precautions, and safe sexual practices.

Prognosis

The site of infection determines the patient's prognosis.

  • For patients with septicemia or bacteremia, the following factors are associated with an unfavorable outcome:
    • Persistent neutropenia
    • Presence of septic shock
    • Inappropriate antibiotic therapy
    • Persistent infection in lung, skin, or soft tissue
    • Unidentified source of infection
    • Renal failure
    • Metastatic foci
    • Rapidly progressing underlying disease
    • An absolute granulocyte count less than 100 cells/mcL.
  • For patients with cardiovascular (CV) infections, the following factors are associated with poor prognosis:
    • Delayed initiation of antibiotic therapy
    • Age older than 30 years
    • Presence of left-sided disease with persistent fever, despite 2 weeks' therapy
    • Mural vegetations
    • Systemic embolization
    • Mixed infections involving both P aeruginosa and S aureus.

Patient Education

  • Always emphasize good hygiene, universal precautions, and safe sexual practices.
  • Inform at-risk populations about areas in which glanders or melioidosis are endemic.
  • Inform patients about possible adverse effects of prescribed medications.

Miscellaneous

Medicolegal Pitfalls

  • Failure to determine early empiric antibiotic coverage for possible pseudomonal infections.
  • Failure to administer double-coverage antibiotics for life-threatening pseudomonal infections.
  • Failure to monitor adverse effects of treatment.

Special Concerns

  • Suspect pseudomonal infections in patients who have been hospitalized for extended periods and in patients with immunocompromise (eg, from cystic fibrosis [CF], HIV, diabetes).
  • Glanders and melioidosis can spread from animals to people and from person to person by contact with blood and body fluids. Two reported cases suggest sexual transmission of glanders, and several cases have been reported of glanders transmission to individuals caring for family members with glanders. Two documented cases of sexual transmission of melioidosis involved males with chronic prostate infection from the disease.
  • Persons with immunocompromise should avoid contact with animals, contaminated soil, or stagnant water in locales where glanders or melioidosis are endemic.
 


More on Pseudomonas Infection

Overview: Pseudomonas Infection
Differential Diagnoses & Workup: Pseudomonas Infection
Treatment & Medication: Pseudomonas Infection
Follow-up: Pseudomonas Infection
Multimedia: Pseudomonas Infection
References
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References

  1. Bendiak GN, Ratjen F. The approach to Pseudomonas aeruginosa in cystic fibrosis. Semin Respir Crit Care Med. Oct 2009;30(5):587-95. [Medline].

  2. Pollack M. The Virulence of Pseudomonas aeruginosa. Rev Infect Dis. 1984;6:S617-26.

  3. Burkholder W. Sour skin, a bacterial rot of onion bulbs. Phytopathology. 1950;40:115-8.

  4. Kielhofner M, Atmar RL, Hamill RJ, Musher DM. Life-threatening Pseudomonas aeruginosa infections in patients with human immunodeficiency virus infection. Clin Infect Dis. Feb 1992;14(2):403-11. [Medline].

  5. Giamarellou H, Antoniadou A. Antipseudomonal antibiotics. Med Clin North Am. Jan 2001;85(1):19-42, v. [Medline].

  6. Douidar SM, Snodgrass WR. Potential role of fluoroquinolones in pediatric infections. Rev Infect Dis. Nov-Dec 1989;11(6):878-89. [Medline].

  7. Carmeli Y, Troillet N, Eliopoulos GM, Samore MH. Emergence of antibiotic-resistant Pseudomonas aeruginosa: comparison of risks associated with different antipseudomonal agents. Antimicrob Agents Chemother. Jun 1999;43(6):1379-82. [Medline].

  8. Altemeier WA, Tonelli MR, Aitken ML. Pseudomonal pericarditis complicating cystic fibrosis. Pediatr Pulmonol. Jan 1999;27(1):62-4. [Medline].

  9. Arbulu A, Holmes RJ, Asfaw I. Tricuspid valvulectomy without replacement. Twenty years' experience. J Thorac Cardiovasc Surg. Dec 1991;102(6):917-22. [Medline].

  10. Ashdown LR, Guard RW. The prevalence of human melioidosis in Northern Queensland. Am J Trop Med Hyg. May 1984;33(3):474-8. [Medline].

  11. Baltch AL, Griffin PE. Pseudomonas aeruginosa bacteremia: a clinical study of 75 patients. Am J Med Sci. Sep-Oct 1977;274(2):119-29. [Medline].

  12. Baum J, Barza M. Topical vs subconjunctival treatment of bacterial corneal ulcers. Ophthalmology. Feb 1983;90(2):162-8. [Medline].

  13. Brewer SC. Clinical Investigations in Critical Care: Ventilator-Associated Pneumonia due to Pseudomonas aeruginosa. Chest. 1996;109:4:1020-30.

  14. Byrne S, Maddison J, Connor P, et al. Clinical evaluation of meropenem versus ceftazidime for the treatment of Pseudomonas spp. infections in cystic fibrosis patients. J Antimicrob Chemother. Jul 1995;36 Suppl A:135-43. [Medline].

  15. Cleveland RP, Hazlett LD, Leon MA, Berk RS. Role of complement in murine corneal infection caused by Pseudomonas aeruginosa. Invest Ophthalmol Vis Sci. Feb 1983;24(2):237-42. [Medline].

  16. Cunha BA. Antibiotic resistance. Med Clin North Am. Nov 2000;84(6):1407-29. [Medline].

  17. Davis SD, Sarff LD, Hyndiuk RA. Comparison of therapeutic routes in experimental Pseudomonas keratitis. Am J Ophthalmol. May 1979;87(5):710-6. [Medline].

  18. Edgeworth JD, Treacher DF, Eykyn SJ. A 25-year study of nosocomial bacteremia in an adult intensive care unit. Crit Care Med. Aug 1999;27(8):1421-8. [Medline].

  19. EORTC International Antimicrobial Therapy Cooperative Group. Ceftazidime combined with a short or long course of amikacin for empirical therapy of gram-negative bacteremia in cancer patients with granulocytopenia. N Engl J Med. Dec 31 1987;317(27):1692-8. [Medline].

  20. Fagon JY, Chastre J, Domart Y, et al. Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis. Apr 1989;139(4):877-84. [Medline].

  21. Germiller JA, El-Kashlan HK, Shah UK. Chronic Pseudomonas infections of cochlear implants. Otol Neurotol. Mar 2005;26(2):196-201. [Medline].

  22. Giamarellou H. Empiric therapy for infections in the febrile, neutropenic, compromised host. Med Clin North Am. May 1995;79(3):559-80. [Medline].

  23. Giamarellou H. Malignant otitis externa: the therapeutic evolution of a lethal infection. J Antimicrob Chemother. Dec 1992;30(6):745-51. [Medline].

  24. Gitterman B. In Brief: Aminoglycosides. Pediatrics in Review. Aug 1998;19(8):285.

  25. Griffiths AL, Jamsen K, Carlin JB, et al. Effects of segregation on an epidemic Pseudomonas aeruginosa strain in a cystic fibrosis clinic. Am J Respir Crit Care Med. May 1 2005;171(9):1020-5. [Medline].

  26. Harris A, Torres-Viera C, Venkataraman L, et al. Epidemiology and clinical outcomes of patients with multiresistant Pseudomonas aeruginosa. Clin Infect Dis. May 1999;28(5):1128-33. [Medline].

  27. Highsmith AK, Le PN, Khabbaz RF, Munn VP. Characteristics of Pseudomonas aeruginosa isolated from whirlpools and bathers. Infect Control. Oct 1985;6(10):407-12. [Medline].

  28. Ho PL, Chan KN, Ip MS, et al. The effect of Pseudomonas aeruginosa infection on clinical parameters in steady-state bronchiectasis. Chest. Dec 1998;114(6):1594-8. [Medline].

  29. Husson MO, Richet H, Aubert A, et al. In vitro comparative activity of meropenem with 15 other antimicrobial agents against 1798 Pseudomonas aeruginosa isolates in a French multicenter study. Clin Microbiol Infect. Aug 1999;5(8):499-503. [Medline].

  30. Isles A, Maclusky I, Corey M, et al. Pseudomonas cepacia infection in cystic fibrosis: an emerging problem. J Pediatr. Feb 1984;104(2):206-10. [Medline].

  31. Kang CI, Kim SH, Park WB, et al. Clinical features and outcome of patients with community-acquired Pseudomonas aeruginosa bacteraemia. Clin Microbiol Infect. May 2005;11(5):415-8. [Medline].

  32. Karlowicz MG, Buescher ES, Surka AE. Fulminant late-onset sepsis in a neonatal intensive care unit, 1988- 1997, and the impact of avoiding empiric vancomycin therapy. Pediatrics. Dec 2000;106(6):1387-90. [Medline].

  33. Kerem E. The Role of Pseudomonas aeruginosa in the Pathogenesis of Lung Disease in Cystic Fibrosis: More Questions than Answers. Pediatric Pulmonology- Supplement. 1997;14:403-11.

  34. Komshian SV, Tablan OC, Palutke W, Reyes MP. Characteristics of left-sided endocarditis due to Pseudomonas aeruginosa in the Detroit Medical Center. Rev Infect Dis. Jul-Aug 1990;12(4):693-702. [Medline].

  35. Koprnova J, Beno P, Korcova J, et al. Bacteremia due to Pseudomonas aeruginosa: results from a 3-year national study in the Slovak Republic. J Chemother. Oct 2005;17(5):470-6. [Medline].

  36. Malaty J, Lee JC, Zhang M, et al. Click here to read Hearing loss and extent of labyrinthine injury in Pseudomonas otitis media. Malaty J, Lee JC, Zhang M, Stevens G, Antonelli PJ. Department of Otolaryngology, University of Florida, Gainesville 32610-0264, USA. Otolaryngol Head Neck Surg. Jan 2005;132(1):25-9. [Medline].

  37. Malaty J, Lee JC, Zhang M, et al. Hearing loss and extent of labyrinthine injury in Pseudomonas otitis media. Otolaryngol Head Neck Surg. Jan 2005;132(1):25-9. [Medline].

  38. Marchetti F, Bua J. More evidence is needed in the antibiotic treatment of Pseudomonas aeruginosa colonisation. Arch Dis Child. Nov 2005;90(11):1204. [Medline].

  39. Medical Letter. Drugs for sexually transmitted infections. Med Lett Drugs Ther. Sep 24 1999;41(1062):85-90. [Medline].

  40. Medical Letter. The choice of antibacterial drugs. Med Lett Drugs Ther. Oct 22 1999;41(1064):95-104. [Medline].

  41. Milner SM. Acetic acid to treat Pseudomonas aeruginosa in superficial wounds and burns. Lancet. Jul 4 1992;340(8810):61. [Medline].

  42. Morrison AJ Jr, Wenzel RP. Epidemiology of infections due to Pseudomonas aeruginosa. Rev Infect Dis. Sep-Oct 1984;6 Suppl 3:S627-42. [Medline].

  43. Mukhopedhyay S, Singh M, Cater JI. Nebulized antipseudomonal antibiotic therapy in cystic fibrosis: A meta-analysis of benefits and risks. Thorax. 1996;51:364.

  44. Mull, CC. Case Report: Ecthyma gangrenosum as a Manifestation of Pseudomonas Sepsis in a Previously Healthy Child. Annals Emerg Med. Oct 2000;36:4.

  45. Nagaki M, Shimura S, Tanno Y, et al. Role of chronic Pseudomonas aeruginosa infection in the development of bronchiectasis. Chest. Nov 1992;102(5):1464-9. [Medline].

  46. Neo EN, Haritharan T, Thambidorai CR, Suresh V. Pseudomonas necrotizing fasciitis in an immunocompetent infant. Pediatr Infect Dis J. Oct 2005;24 (10):942-3. [Medline].

  47. Obritsch MD, Fish DN, MacLaren R, Jung R. Nosocomial infections due to multidrug-resistant Pseudomonas aeruginosa: epidemiology and treatment options. Pharmacotherapy. Oct 2005;25(10):1353-64. [Medline].

  48. Pandey A, Malenie R, Asthana AK. Beta-lactamase producing Pseudomonas aeruginosa in hospitalised patients. Indian J Pathol Microbiol. Oct 2005;48(4):530-3. [Medline].

  49. Paul M, Leibovici L. Combination antibiotic therapy for Pseudomonas aeruginosa bacteraemia. Lancet Infect Dis. Aug 2004;4(8):519-27. [Medline].

  50. Radford R, Brahma A, Armstrong M, Tullo AB. Severe sclerokeratitis due to Pseudomonas aeruginosa in noncontact-lens wearers. Eye. Feb 2000;14 (Pt 1):3-7. [Medline].

  51. Rajashekaraiah KR, Rice TW, Kallick CA. Recovery of Pseudomonas aeruginosa from syringes of drug addicts with endocarditis. J Infect Dis. Nov 1981;144(5):482. [Medline].

  52. Roilides E, Butler KM, et al. Pseudomonas Infections in Children with Human Immunodeficiency Virus Infection. Pediatric Infect Dis J. 1992;11:547-53.

  53. Saiman L. The use of macrolide antibiotics in patients with cystic fibrosis. Curr Opin Pulm Med. Nov 2004;10(6):515-23. [Medline].

  54. Schimpff SC, Moody M, Young VM. Relationship of colonization with Pseudomonas aeruginosa to development of Pseudomonas bacteremia in cancer patients. Antimicrobial Agents Chemother. 1970;10:240-4. [Medline].

  55. Tabbara KF, El-Sheikh HF, Aabed B. Extended wear contact lens related bacterial keratitis. Br J Ophthalmol. Mar 2000;84(3):327-8. [Medline].

  56. Tablan OC, Chorba TL, Schidlow DV, et al. Pseudomonas cepacia colonization in patients with cystic fibrosis: risk factors and clinical outcome. J Pediatr. Sep 1985;107(3):382-7. [Medline].

  57. Taneja N, Meharwal SK, Sharma SK, Sharma M. Significance and characterisation of pseudomonads from urinary tract specimens. J Commun Dis. Mar 2004;36(1):27-34. [Medline].

  58. Tsekouras AA, Johnson A, Miller G, Orton HI. Pseudomonas aeruginosa necrotizing fasciitis: a case report. J Infect. Sep 1998;37(2):188-90. [Medline].

  59. Tumaliuan JA, Stambouly JJ, Schiff RJ, et al. Pseudomonas pericarditis and tamponade in an infant with human immunodeficency virus infection. Arch Pediatr Adolesc Med. Feb 1997;151(2):207-8. [Medline].

  60. Whitehead B, Helms P, Goodwin M, et al. Heart-lung transplantation for cystic fibrosis. 2: Outcome. Arch Dis Child. Sep 1991;66(9):1022-6; discussion 1016-7. [Medline].

  61. Wu BY, Peng CT, Tsai CH, Chiu HH. Community-acquired Pseudomonas aeruginosa bacteremia and sepsis in previously healthy infants. Acta Paediatr Taiwan. Jul-Aug 1999;40(4):233-6. [Medline].

  62. Yeung CK, Lee KH. Community acquired fulminant Pseudomonas infection of the gastrointestinal tract in previously healthy infants. J Paediatr Child Health. Dec 1998;34(6):584-7. [Medline].

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Further Reading

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Keywords

infection, pseudomonal infection, glanders, melioidosis, Whitmore disease, cepacia syndrome, treatment, diagnosis

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Contributor Information and Disclosures

Author

Selina SP Chen, MD, MPH, Assistant Professor of Pediatrics, Department of Internal Medicine, John A Burns School of Medicine, University of Hawaii; Internal Medicine and Pediatric Hospitalist, Kapiolani Medical Center for Women and Children; Internal Medicine Hospitalist, Straub Clinic and Hospital
Selina SP Chen, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Physicians-American Society of Internal Medicine, and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Ralph Rudoy, MD, Chief, Division of Pediatric Infectious Disease, Acting Chair, Professor, Department of Pediatrics, John A Burns School of Medicine, University of Hawaii
Ralph Rudoy, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Leonard R Krilov, MD, Chief of Pediatric Infectious Diseases, Vice Chair, Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital
Leonard R Krilov, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Medimmune Grant/research funds Cliinical trials; Medimmune Honoraria Speaking and teaching; Medimmune Consulting fee Consulting

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

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