Pseudomonas Infection Workup

  • Author: Selina SP Chen, MD, MPH; Chief Editor: Russell W Steele, MD   more...
 
Updated: May 18, 2012
 

Laboratory Studies

Pseudomonas aeruginosa and other Pseudomonas organisms are aerobic, nonfermentative, nonenterobacterial gram-negative bacilli. Obtain 2 sets of blood cultures (ie, aerobic and anaerobic bottles) from different sites before starting empiric antibiotics. The following laboratory results are helpful to confirm a pseudomonal infection:

  • CBC counts revealing leukocytosis with a left shift and bandemia, which indicates possible presence of toxic granulations or vacuoles
  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, which may be elevated in infection
  • Metabolic profile revealing any electrolyte abnormalities, degree of dehydration, and worsening renal function

The following additional studies may be indicated, depending on the site of infection:

  • Culture of the purulent discharge helps diagnose suppurative otitis media or malignant otitis externa.
  • Corneal scrapings and culture may reveal pseudomonal involvement.
  • Culture of vegetations from patients with pseudomonal infectious endocarditis (IE) reveals high quantities of the organisms, although diagnosis is usually confirmed by a repeated blood culture.
  • Sputum Gram stain and culture may be indicated to evaluate for respiratory infection. This is especially recommended in children who may be predisposed to such infections.
  • Blood gas levels may reveal hypoxemia, with or without hypercarbia.
  • Wound and burn cultures can be helpful to identify pseudomonal infections.
  • Urinalysis with culture and sensitivity is helpful when evaluating for urinary tract infection (UTI). Although rare, sloughing of vesical membrane in the urine can indicate complications of pseudomonal infections.
  • Obtain stool cultures in patients with diarrhea. Note, however, that pseudomonal organisms produce no toxins.

Diagnosis of glanders can be confirmed by isolating B mallei from blood, sputum, urine, or skin lesions. No serologic tests are available. Diagnosis of melioidosis can be confirmed by isolating B pseudomallei from the blood, urine, sputum, or skin lesions. Detecting antibodies to the bacteria in the blood is another method.

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Imaging Studies

  • Chest radiography
    • Patients with cystic fibrosis (CF) may have a small heart, depressed diaphragm, and increased anteroposterior chest diameter. Chest radiography may also reveal cyst formation, mucus plugging of dilated bronchi, generalized bronchiectasis, patchy atelectasis, peribronchial thickening, overaeration, or extensive peribronchial infiltration.
    • The classic presentation of bacteremic pseudomonal pneumonia includes rapid progression of radiographic findings. Chest radiography performed within 48-72 hours after initial fever onset reveals parenchymal involvement with interstitial and alveolar infiltrates. Cavitation appears after 48 hours.
    • Typical findings include (1) poorly-defined, hemorrhagic, often subpleural, nodular areas with a small central area of necrosis and (2) multiple, 2-mm to 15-mm, necrotic, umbilicated nodules with hemorrhagic parenchyma, representing the pulmonary component of an ecthyma gangrenosum (EG) skin lesion.
    • The typical progression of disease is from pulmonary vascular congestion to pulmonary edema to necrotizing bronchopneumonia.
    • Radiographs of patients with primary nonbacteremic pneumonia are similar to those from patients whose pneumonia is caused by Staphylococcus aureus. Among the common features are a diffuse bronchopneumonia (usually bilateral with distinctive nodular infiltrates with small areas of radiolucency) and pleural effusions; empyema or lobar consolidation is occasionally observed.
  • CT scanning
    • A CT scan of the head may reveal a brain abscess. A CT scan of the surrounding soft tissue and osseous lesions is recommended in patients with malignant otitis externa to help define the intracranial and extracranial extent of disease.
    • Perform a CT scan of the abdomen as part of the workup for endocarditis, especially left-sided disease. Complications such as splenic abscesses require splenectomy before valvular replacement.
    • A CT scan of the chest is not usually indicated, except when respiratory failure requires better definition of chest involvement. With left-sided endocarditis, a CT scan of the chest also can reveal septic pulmonary emboli as a complication.
    • A CT scan of soft tissue and bone of skin infections may be required to exclude an abscess formation or osteomyelitis.
  • MRI
    • Consider MRI of the head to evaluate a patient with a brain abscess. MRI of the head in a patient with left-sided endocarditis may show cerebritis and mycotic aneurysm.
    • A CT scan or MRI of the surrounding tissue of the site of infection may be needed to delineate abscess formation.
  • Other studies
    • Echocardiography (ECHO) may reveal vegetations in endocarditis. However, because the yield is low, consider a transesophageal ECHO or repeat ECHO for highly suspicious cases.
    • Bone radiography or a nuclear study is helpful in diagnosing patients with suspected osteomyelitis.
    • Renal ultrasound may be helpful to evaluate patients with a suspected obstruction or abscess formation complicating a UTI.
    • A gallium WBC scan may help determine the extent of infection.
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Other Tests

  • To evaluate eye infections to determine the degree of corneal involvement, perform fluorescein staining and slit-lamp examination of the cornea.
  • Patients who develop septic pulmonary emboli as a complication may require a ventilation-perfusion scan.
  • A Wood light examination of a pseudomonal toe web reveals a green-white fluorescence from the elaboration of pyoverdin.
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Procedures

  • Needle biopsy or aspiration of the joint, possibly with fluoroscopic guidance, can be helpful in identifying the infectious organism. An open biopsy may be necessary, depending on disease extent.
  • Lumbar puncture is indicated when CNS involvement is suspected. Workup of neonatal sepsis should include lumbar puncture, if indicated.
  • Cardiac catheterization may reveal valvular involvement or vegetations.
  • Quantitative cultures from bronchoalveolar lavage obtained by bronchoscopy helps distinguish infection from colonization.
  • Thoracentesis may be indicated for patients who have pleural effusion.
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Histologic Findings

  • Histological findings of EG include edema, epidermal necrosis, and gram-negative rods on tissue gram stain.
  • Few neutrophils in the sparse inflammatory infiltrate can also be seen.
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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; Electronic Medical Record Physician Liaison and Trainer

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.

Specialty Editor Board

Leonard R Krilov, MD  Chief of Pediatric Infectious Diseases and International Adoption, 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

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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.

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: Novartis 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: Nothing to disclose.

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Erythematous papulopustules of pseudomonas folliculitis. Courtesy of Mark Welch, MD.
 
 
 
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