Pseudomonas Infection Follow-up

Updated: Jul 25, 2017
  • Author: Selina SP Chen, MD, MPH; Chief Editor: Russell W Steele, MD  more...
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Follow-up

Further Outpatient Care

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  • 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.
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Further Inpatient Care

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  • 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.
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Inpatient & Outpatient Medications

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  • 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.
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Transfer

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  • 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.
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Deterrence/Prevention

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  • 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; [13] 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.
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Complications

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  • 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.
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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.
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Patient Education

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  • 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.
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