Pseudomonas Infection Medication
- Author: Selina SP Chen, MD, MPH; Chief Editor: Russell W Steele, MD more...
Pseudomonas should be considered in the differential diagnoses in any probable Gram-negative infections. Often, the effect of this organism causes concern because it can cause severe hospital-acquired infection, especially in immunocompromised hosts. Furthermore, a concomitant antibiotic resistance is often present, which makes the choice of treatment difficult.
Often, treatment initially consists of empiric antibiotics. Therefore, when treating Pseudomonas organisms, one must consider some basic concepts. Indwelling catheters associated with any infections should be promptly removed. Delays in treatment are associated with high mortality. Combination therapy needs to be initiated in patients with severe infections and high-risk patients. Combination therapy requires 2 antipseudomonal antibiotics, each with different mechanisms of action. Often, treatment is achieved with a combination of an aminoglycoside or quinolone with another antipseudomonal antibiotic.
Combination therapy with antipseudomonal antibiotics is used to ensure treatment of resistant strains and to prevent selection of resistant mutants. Carbapenems (eg, imipenem, meropenem) and the monobactam antibiotic aztreonam are generally reserved for serious infections caused by organisms resistant to other beta-lactam antibiotics or in those with renal disease who are at risk for aminoglycoside-related nephrotoxicity.
Previous animal studies had brought concern of the use of quinolone in children. However, the use of quinolone is now being revisited. Discussion of these previous animal studies with
parents may be warranted.
Some exceptions to double-coverage antibiotics include the treatment of simple urinary infection (eg, cystitis) or local skin infection or empiric antibiotic coverage in the febrile patient with neutropenia. However, one of the most controversial topics in management involves combination versus monotherapy treatment. Well-designed studies are still needed to settle this controversy. If monotherapy is chosen, certain antibiotics (eg, aminoglycosides, aztreonam) should not be used as empiric monotherapy.
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting. Whenever feasible, select antibiotics based on culture sensitivity. Review of the institution's resistance is essential.
DOC for pseudomonal CNS infections and melioidosis. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Along with ceftazidime, DOC for CNS infections. Fourth-generation cephalosporin with good gram-negative coverage. Similar to third-generation cephalosporins but has better gram-positive coverage.
Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococcal and streptococcal organisms compared to imipenem.
Treats multiple organism infections when other agents do not have wide spectrum coverage or are contraindicated because of potential for toxicity.
Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
Inhibits biosynthesis of cell wall mucopeptide and is effective during active growth stage. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive, gram-negative, and anaerobic organisms.
Used in skin, bone, and skin structure infections, caused by S aureus, P aeruginosa, Proteus species, Escherichia coli, and Klebsiella and Enterobacter species.
Aminoglycoside antibiotic for gram-negative coverage, used in combination with agents against gram-positive organisms and anaerobes.
Often not DOC, yet consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, or in mixed infections caused by susceptible staphylococcal and gram-negative organisms. Base choice between tobramycin and gentamicin on the susceptibility of the area.
DOC for pediatric pseudomonal UTI.
Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM; once-a-day dosing is more effective.
Follow each regimen by at least a trough level drawn before the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after completion of 30-min infusion.
Fluoroquinolone with activity against pseudomonads, streptococcal, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. DOC for adult pseudomonal UTI and some skin infections.
Monobactam, not beta-lactam, antibiotic that inhibits cell wall synthesis during bacterial growth. Is active against gram-negative bacilli but has very limited gram-positive activity and is not useful for anaerobes. Lacks cross-sensitivity with beta-lactam antibiotics. May be used in patients allergic to penicillins or cephalosporins.
Duration of therapy depends on the severity of the infection; therapy is continued for at least 48 h after the patient is asymptomatic or evidence of bacterial eradication has been obtained. Doses smaller than indicated should not be used. Transient or persistent renal insufficiency may prolong serum levels. After initial loading dose of 1 or 2 g, reduce dose by one half for estimated ClCr of 10-30 mL/min/1.73 m2. When only serum creatinine concentration available, the following formula (based on sex, weight, age) can approximate ClCr. Serum creatinine should represent a steady state of renal function.
Males: ClCr = [(weight in kg)(140 - age)] / (72 X serum creatinine in mg/dL).
Females: 0.85 X above value. In patients with severe renal failure (ClCr < 10 mL/min/1.73 m2) and those supported by hemodialysis, the usual dose of 500 mg, 1 g, or 2 g is given initially.
Maintenance dose is one fourth of the usual initial dose given at the usual fixed interval of 6, 8, or 12 h.
For serious or life-threatening infections, supplement maintenance doses with one eighth of the initial dose after each hemodialysis session.
Elderly persons may have diminished renal function. Renal status is a major determinant of dosage in these patients. Serum creatinine may not be an accurate determinant of renal status. Therefore, as with all antibiotics eliminated by kidneys, obtain estimates of ClCr and make appropriate dosage modifications. Insufficient data are available in regard to IM administration to pediatric patients or dosing in pediatric patients with renal impairment. Administered IV only to pediatric patients with normal renal function.
Aminoglycoside antibiotic recommended when less potentially hazardous therapeutic agents are ineffective or contraindicated. For treatment of susceptible infections and glanders infection.
DOC for B cepacia. Dihydrofolate reductase inhibitor that prevents tetrahydrofolic acid production in bacteria. Active in vitro against a broad range of gram-positive and gram-negative bacteria. Resistance is usually mediated by decreased cell permeability or alterations in amount or structure of dihydrofolate reductase. Demonstrates synergy with sulfonamides, potentiating inhibition of bacterial tetrahydrofolate production. Trimethoprim provides a synergistic effect when combined with sulfas.
Treats gram-positive and gram-negative organisms, as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunits; DOC in combination with streptomycin for glanders infection.
Effectively treats superficial bacterial infections of otitis externa.
Bendiak GN, Ratjen F. The approach to Pseudomonas aeruginosa in cystic fibrosis. Semin Respir Crit Care Med. 2009 Oct. 30(5):587-95. [Medline].
Pollack M. The Virulence of Pseudomonas aeruginosa. Rev Infect Dis. 1984. 6:S617-26.
Burkholder W. Sour skin, a bacterial rot of onion bulbs. Phytopathology. 1950. 40:115-8.
Werth BJ, Carreno JJ, Reveles KR. Shifting trends in the incidence of Pseudomonas aeruginosa septicemia in hospitalized adults in the United States from 1996-2010. Am J Infect Control. 2015 May 1. 43 (5):465-8. [Medline].
Reichert F, Piening B, Geffers C, Gastmeier P, Bührer C, Schwab F. Pathogen-Specific Clustering of Nosocomial Blood Stream Infections in Very Preterm Infants. Pediatrics. 2016 Mar 8. [Medline].
Rosenfeld M, Emerson J, McNamara S, et al. Risk factors for age at initial Pseudomonas acquisition in the cystic fibrosis epic observational cohort. J Cyst Fibros. 2012 May 1. [Medline].
Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug-resistant bacteria to healthcare workers' gloves and gowns after patient contact increases with environmental contamination. Crit Care Med. 2012 Apr. 40(4):1045-51. [Medline].
Kielhofner M, Atmar RL, Hamill RJ, Musher DM. Life-threatening Pseudomonas aeruginosa infections in patients with human immunodeficiency virus infection. Clin Infect Dis. 1992 Feb. 14(2):403-11. [Medline].
Giamarellou H, Antoniadou A. Antipseudomonal antibiotics. Med Clin North Am. 2001 Jan. 85(1):19-42, v. [Medline].
[Guideline] Committee on Infectious Diseases. The use of systemic fluoroquinolones. Pediatrics. 2006 Sep. 118(3):1287-92. [Medline].
Douidar SM, Snodgrass WR. Potential role of fluoroquinolones in pediatric infections. Rev Infect Dis. 1989 Nov-Dec. 11(6):878-89. [Medline].
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. 1999 Jun. 43(6):1379-82. [Medline].
Altemeier WA, Tonelli MR, Aitken ML. Pseudomonal pericarditis complicating cystic fibrosis. Pediatr Pulmonol. 1999 Jan. 27(1):62-4. [Medline].
Arbulu A, Holmes RJ, Asfaw I. Tricuspid valvulectomy without replacement. Twenty years' experience. J Thorac Cardiovasc Surg. 1991 Dec. 102(6):917-22. [Medline].
Ashdown LR, Guard RW. The prevalence of human melioidosis in Northern Queensland. Am J Trop Med Hyg. 1984 May. 33(3):474-8. [Medline].
Baltch AL, Griffin PE. Pseudomonas aeruginosa bacteremia: a clinical study of 75 patients. Am J Med Sci. 1977 Sep-Oct. 274(2):119-29. [Medline].
Baum J, Barza M. Topical vs subconjunctival treatment of bacterial corneal ulcers. Ophthalmology. 1983 Feb. 90(2):162-8. [Medline].
Brewer SC. Clinical Investigations in Critical Care: Ventilator-Associated Pneumonia due to Pseudomonas aeruginosa. Chest. 1996. 109:4:1020-30.
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. 1995 Jul. 36 Suppl A:135-43. [Medline].
Cleveland RP, Hazlett LD, Leon MA, Berk RS. Role of complement in murine corneal infection caused by Pseudomonas aeruginosa. Invest Ophthalmol Vis Sci. 1983 Feb. 24(2):237-42. [Medline].
Cunha BA. Antibiotic resistance. Med Clin North Am. 2000 Nov. 84(6):1407-29. [Medline].
Davis SD, Sarff LD, Hyndiuk RA. Comparison of therapeutic routes in experimental Pseudomonas keratitis. Am J Ophthalmol. 1979 May. 87(5):710-6. [Medline].
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].
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. 1987 Dec 31. 317(27):1692-8. [Medline].
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. 1989 Apr. 139(4):877-84. [Medline].
Germiller JA, El-Kashlan HK, Shah UK. Chronic Pseudomonas infections of cochlear implants. Otol Neurotol. 2005 Mar. 26(2):196-201. [Medline].
Giamarellou H. Empiric therapy for infections in the febrile, neutropenic, compromised host. Med Clin North Am. 1995 May. 79(3):559-80. [Medline].
Giamarellou H. Malignant otitis externa: the therapeutic evolution of a lethal infection. J Antimicrob Chemother. 1992 Dec. 30(6):745-51. [Medline].
Gitterman B. In Brief: Aminoglycosides. Pediatrics in Review. 1998 Aug. 19(8):285.
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. 2005 May 1. 171(9):1020-5. [Medline].
Harris A, Torres-Viera C, Venkataraman L, et al. Epidemiology and clinical outcomes of patients with multiresistant Pseudomonas aeruginosa. Clin Infect Dis. 1999 May. 28(5):1128-33. [Medline].
Highsmith AK, Le PN, Khabbaz RF, Munn VP. Characteristics of Pseudomonas aeruginosa isolated from whirlpools and bathers. Infect Control. 1985 Oct. 6(10):407-12. [Medline].
Ho PL, Chan KN, Ip MS, et al. The effect of Pseudomonas aeruginosa infection on clinical parameters in steady-state bronchiectasis. Chest. 1998 Dec. 114(6):1594-8. [Medline].
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. 1999 Aug. 5(8):499-503. [Medline].
Isles A, Maclusky I, Corey M, et al. Pseudomonas cepacia infection in cystic fibrosis: an emerging problem. J Pediatr. 1984 Feb. 104(2):206-10. [Medline].
Kang CI, Kim SH, Park WB, et al. Clinical features and outcome of patients with community-acquired Pseudomonas aeruginosa bacteraemia. Clin Microbiol Infect. 2005 May. 11(5):415-8. [Medline].
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. 2000 Dec. 106(6):1387-90. [Medline].
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.
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. 1990 Jul-Aug. 12(4):693-702. [Medline].
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. 2005 Oct. 17(5):470-6. [Medline].
Lahiri T. Approaches to the treatment of initial Pseudomonas aeruginosa infection in children who have cystic fibrosis. Clin Chest Med. 2007 Jun. 28(2):307-18. [Medline].
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. 2005 Jan. 132(1):25-9. [Medline].
Malaty J, Lee JC, Zhang M, et al. Hearing loss and extent of labyrinthine injury in Pseudomonas otitis media. Otolaryngol Head Neck Surg. 2005 Jan. 132(1):25-9. [Medline].
Marchetti F, Bua J. More evidence is needed in the antibiotic treatment of Pseudomonas aeruginosa colonisation. Arch Dis Child. 2005 Nov. 90(11):1204. [Medline].
Medical Letter. Drugs for sexually transmitted infections. Med Lett Drugs Ther. 1999 Sep 24. 41(1062):85-90. [Medline].
Medical Letter. The choice of antibacterial drugs. Med Lett Drugs Ther. 1999 Oct 22. 41(1064):95-104. [Medline].
Milner SM. Acetic acid to treat Pseudomonas aeruginosa in superficial wounds and burns. Lancet. 1992 Jul 4. 340(8810):61. [Medline].
Morrison AJ Jr, Wenzel RP. Epidemiology of infections due to Pseudomonas aeruginosa. Rev Infect Dis. 1984 Sep-Oct. 6 Suppl 3:S627-42. [Medline].
Mukhopedhyay S, Singh M, Cater JI. Nebulized antipseudomonal antibiotic therapy in cystic fibrosis: A meta-analysis of benefits and risks. Thorax. 1996. 51:364.
Mull, CC. Case Report: Ecthyma gangrenosum as a Manifestation of Pseudomonas Sepsis in a Previously Healthy Child. Annals Emerg Med. 2000 Oct. 36:4.
Nagaki M, Shimura S, Tanno Y, et al. Role of chronic Pseudomonas aeruginosa infection in the development of bronchiectasis. Chest. 1992 Nov. 102(5):1464-9. [Medline].
Neo EN, Haritharan T, Thambidorai CR, Suresh V. Pseudomonas necrotizing fasciitis in an immunocompetent infant. Pediatr Infect Dis J. 2005 Oct. 24 (10):942-3. [Medline].
Obritsch MD, Fish DN, MacLaren R, Jung R. Nosocomial infections due to multidrug-resistant Pseudomonas aeruginosa: epidemiology and treatment options. Pharmacotherapy. 2005 Oct. 25(10):1353-64. [Medline].
Pandey A, Malenie R, Asthana AK. Beta-lactamase producing Pseudomonas aeruginosa in hospitalised patients. Indian J Pathol Microbiol. 2005 Oct. 48(4):530-3. [Medline].
Paul M, Leibovici L. Combination antibiotic therapy for Pseudomonas aeruginosa bacteraemia. Lancet Infect Dis. 2004 Aug. 4(8):519-27. [Medline].
Radford R, Brahma A, Armstrong M, Tullo AB. Severe sclerokeratitis due to Pseudomonas aeruginosa in noncontact-lens wearers. Eye. 2000 Feb. 14 (Pt 1):3-7. [Medline].
Rajashekaraiah KR, Rice TW, Kallick CA. Recovery of Pseudomonas aeruginosa from syringes of drug addicts with endocarditis. J Infect Dis. 1981 Nov. 144(5):482. [Medline].
Roilides E, Butler KM, et al. Pseudomonas Infections in Children with Human Immunodeficiency Virus Infection. Pediatric Infect Dis J. 1992. 11:547-53.
Saiman L. The use of macrolide antibiotics in patients with cystic fibrosis. Curr Opin Pulm Med. 2004 Nov. 10(6):515-23. [Medline].
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].
Tabbara KF, El-Sheikh HF, Aabed B. Extended wear contact lens related bacterial keratitis. Br J Ophthalmol. 2000 Mar. 84(3):327-8. [Medline].
Tablan OC, Chorba TL, Schidlow DV, et al. Pseudomonas cepacia colonization in patients with cystic fibrosis: risk factors and clinical outcome. J Pediatr. 1985 Sep. 107(3):382-7. [Medline].
Taneja N, Meharwal SK, Sharma SK, Sharma M. Significance and characterisation of pseudomonads from urinary tract specimens. J Commun Dis. 2004 Mar. 36(1):27-34. [Medline].
Tsekouras AA, Johnson A, Miller G, Orton HI. Pseudomonas aeruginosa necrotizing fasciitis: a case report. J Infect. 1998 Sep. 37(2):188-90. [Medline].
Tumaliuan JA, Stambouly JJ, Schiff RJ, et al. Pseudomonas pericarditis and tamponade in an infant with human immunodeficency virus infection. Arch Pediatr Adolesc Med. 1997 Feb. 151(2):207-8. [Medline].
Whitehead B, Helms P, Goodwin M, et al. Heart-lung transplantation for cystic fibrosis. 2: Outcome. Arch Dis Child. 1991 Sep. 66(9):1022-6; discussion 1016-7. [Medline].
Wu BY, Peng CT, Tsai CH, Chiu HH. Community-acquired Pseudomonas aeruginosa bacteremia and sepsis in previously healthy infants. Acta Paediatr Taiwan. 1999 Jul-Aug. 40(4):233-6. [Medline].
Yeung CK, Lee KH. Community acquired fulminant Pseudomonas infection of the gastrointestinal tract in previously healthy infants. J Paediatr Child Health. 1998 Dec. 34(6):584-7. [Medline].
Over-the-Counter Topical Antiseptic Products: Drug Safety Communication - FDA Requests Label Changes and Single-Use Packaging to Decrease Risk of Infection. FDA. 11/13/2013. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm374892.htm.
Zegans ME, DiGiandomenico A, Ray K, Naimie A, Keller AE, Stover CK, et al. Association of Biofilm Formation, Psl Exopolysaccharide Expression, and Clinical Outcomes in Pseudomonas aeruginosa Keratitis: Analysis of Isolates in the Steroids for Corneal Ulcers Trial. JAMA Ophthalmol. 2016 Feb 4. [Medline].