Pseudomonas Infection Treatment & Management

Antimicrobial agents are needed to treat Pseudomonas infections. Two antipseudomonal drug combination therapy (eg, a beta-lactam antibiotic with an aminoglycoside) is usually recommended for the initial empiric treatment of a pseudomonal infection, especially for patients with neutropenia, bacteremia, sepsis, severe upper respiratory infections (URIs), or abscess formation. The choice of antibiotic also depends on the site and extent of infection and on local resistance patterns. ^[10] Reports of more resistant strains of Pseudomonas organisms to the currently used antimicrobials are causing much concern.

B cepacia has grown resistant to aminoglycosides, antipseudomonal penicillins, and most beta-lactam agents. Some strains are variably susceptible to third-generation cephalosporins, ciprofloxacin, trimethoprim-sulfamethoxazole, ampicillin-sulbactam, chloramphenicol, or meropenem.

Because human cases of glanders are rare, limited information is available about antibiotic treatment of the organism in humans. Sulfadiazine has been effective in experimental treatments of animals and humans. B mallei organisms are usually sensitive to tetracyclines, ciprofloxacin, streptomycin, novobiocin, gentamicin, imipenem, ceftazidime, and sulfonamides. Resistance to chloramphenicol has been reported. Treatment duration is often prolonged, from 1-2 months, often combined with surgical drainage.

Ceftazidime alone or in combination with either trimethoprim-sulfamethoxazole or amoxicillin clavulanate is the therapy of choice for B pseudomallei. The organism is usually sensitive to imipenem, penicillin, doxycycline, azlocillin, ceftazidime, ticarcillin-clavulanic acid, and ceftriaxone. Initiate treatment early in the course of the disease. The organism is resistant to ciprofloxacin and aztreonam. Treatment is often prolonged, from 3-12 months, with the longest duration of therapy used for chronic extrapulmonary disease.

Pseudomonas vaccines are also currently used to reduce infection risks in patients with cystic fibrosis (CF) and are still under investigation. Pseudomonas aeruginosa infections include the following:

• Bacteremia

  • Empiric antibiotics are often started before the organism is identified.

  • Whether single-drug or combination therapy is most effective in patients who have bacteremia and neutropenia is debated. The author is unaware of any prospective randomized comparison between monotherapy and combination drug therapy for patients with pseudomonal bacteremia. Duration of treatment is at least 2 weeks.

• Bone and skin infections

  • A 4-week course of aminoglycoside antibiotics is often successful for managing vertebral osteomyelitis.

  • Sternoarticular pyarthrosis has been managed effectively with aminoglycoside and antipseudomonal penicillin if administered for at least 6 weeks.

  • Patients with osteomyelitis of the pubic symphysis require treatment for at least 4 weeks with an antipseudomonal penicillin and aminoglycoside combination. Surgical intervention is not usually indicated.

  • Patients with osteochondritis require medical and surgical treatment. Parenteral administration of 1-2 antipseudomonal agents is recommended before surgical debridement. The recommended regimen continues postsurgical treatment for 1-2 additional weeks with oral (PO) ciprofloxacin.

  • Chronic contiguous pseudomonal osteomyelitis requires 4-6 weeks of combination therapy, in addition to surgical debridement.

  • Burn wound sepsis management requires early intervention with daily wound inspection and systemic antibiotic combination regimens. Monotherapy is not indicated.

  • Management of pseudomonal cellulitis includes the use of PO antibiotic for 7-10 days; this often resolves a localized infection.

  • Pseudomonal toe web infections require initial debridement with applications of silver nitrate or 5% acetic acid to the toe webs and the dorsal and planter areas. Following this initial treatment, apply a topical antibiotic, silver sulfadiazine cream, or Castellani paint until infection resolves. PO quinolone effectively reduces the duration of infection.

  • Pseudomonal folliculitis is often self-limited; treatment may require only application of silver sulfadiazine cream or 5% acetic acid wet compresses for 20 minutes 2-4 times daily with topical antibiotics.

• CNS infections

  • Ceftazidime, cefepime, or meropenem are the antibiotics of choice because of their high CNS penetration. Initially, consider double coverage with an aminoglycoside for patients with adequate renal function. Aztreonam, ciprofloxacin, or levofloxacin are indicated for patients with renal failure and those allergic to beta-lactam. Imipenem-cilastatin should be avoided because of the risk of seizures. Intrathecal treatment should also be considered. Treatment duration should be at least 2 weeks.

  • Antibiotics can be used in the initial treatment of brain abscesses that are multiple, small (ie, < 2 cm), poorly distributed, or relatively difficult to access. Antibiotic therapy duration depends on the speed of abscess shrinkage, but therapy usually lasts 2-6 weeks.

• Ear and eye infections

  • Otitis media in at-risk populations should be treated with antipseudomonal agents for at least 10 days.

  • Chronic suppurative otitis media requires daily aural toilet and treatment with antibiotics (eg, ceftazidime, mezlocillin, ciprofloxacin), and often surgical treatment.

  • Otitis externa can be treated with local care using an acetic acid compress and daily aural cleaning.

  • Management of malignant externa otitis should be aggressive and involve both medical and surgical therapies. The conventional therapy (ie, an aminoglycoside and a beta-lactam agent with antipseudomonal activity) is needed for at least 4 weeks to treat localized infections and 6-8 weeks or longer to treat extensive disease. Monotherapy using ceftazidime intravenously (IV), cefepime IV, or ciprofloxacin PO for 6 weeks has been reported effective.

  • If gram-negative rods are isolated from the Gram stain of an eye infection, immediately start a combined topical and subconjunctival (or subtenon) therapy of aminoglycoside antibiotics. Aminoglycoside solution (not ointment) must be applied to the affected eye every 30-60 minutes. Subconjunctival therapy is needed for the first 3 days of treatment. Total duration of therapy is at least 1 week. An alternative therapy uses a quinolone antibiotic solution. The addition of parental or PO antipseudomonal antibiotics also has been beneficial.

  • Pseudomonal endophthalmitis requires immediate antibiotic therapy, using aminoglycoside and antipseudomonal penicillin administered via a parenteral and subconjunctival, topical, or intraocular route. Therapy duration depends on the clinical improvement.

• GI and GU infections

  • Treat GI manifestations of pseudomonal infection with antibiotic therapy for patients with severe localized or systemic infections.

  • The treatment modality for urinary tract infection (UTI) depends on the presence of sepsis, degree of chronicity, potential sites of persistent infection, and local antibiotic susceptibility. Ideally, indwelling urinary catheters should be removed. If the catheter cannot be removed, consider treating only symptomatic episodes or exacerbations because it is not feasible to totally eradicate the organism. Aminoglycosides and quinolones remain the agents of choice.

• Cardiovascular (CV) and respiratory infections

  • To treat endocarditis, administer an antipseudomonal beta-lactam with high-dose aminoglycoside for approximately 6 weeks.

  • According to the criteria used in France to select antibiotics to treat VAP, the following 2 risk factors must be considered: (1) administration of broad-spectrum antibiotics in the previous 15 days and (2) mechanical ventilation for fewer than 7 days or for 7 or more days. The extended factors predict the involvement of multiresistant nosocomial P aeruginosa, suggesting administration of carbapenems to those who have undergone mechanical ventilation of 7 or more days and who have been exposed to antibiotics in the prior 15 days.

  • The role of antibiotic prophylaxis or chronic suppression of respiratory pseudomonal infections in patients with CF is controversial. Among the promising treatment plans are intermittent aerosolization of antibiotics to patients with CF who have established pseudomonal lung infections.

  • Choices for empiric antibiotic treatment in patients with a history of Pseudomonas infection requires review of previous culture sensitivity.

  • More widely accepted is the treatment of children with pseudomonal infections by using fluoroquinolone, especially children with previous therapeutic failure or resistance to multiple other antibiotics. ^[11] Treatment often continues until symptoms resolve (ie, 1-2 wk).

  • Inhalation of mucolytic and hydrating agents, postural drainage, and chest physiotherapy often are therapies used together. Bronchial lavage also has been used to remove respiratory secretions.

  • A Cochrane review looked at 60 clinical trials to examine the effectiveness of antibiotic treatment in cystic fibrosis patients with early Pseudomonas aeruginosa infection. The study concluded that nebulized antibiotics by themselves or along with oral antibiotics were better than no treatment at all and that infection may be eradicated for up to two years. However, there is insufficient evidence that antibiotic treatment decreases mortality and morbidity or improves quality of life. ^[12]

See the list below:

• Brain abscesses usually require surgical drainage, followed by a prolonged course of antibiotic therapy.

• Sternoarticular pyarthrosis often requires surgical debridement.

• Patients with osteochondritis or chronic contiguous osteomyelitis require surgical debridement of necrotic bone, foreign bodies, or possible prosthetic materials.

• Tympanomastoid surgery is no longer considered standard management for chronic suppurative otitis media, unless a cholesteatoma is present.

• Patients with malignant externa otitis usually require surgical treatment (eg, ear canal debridement, bone or cartilage debridement, mastoidectomy, facial nerve decompression).

• Surgical intervention is indicated for bowel necrosis, perforation, obstruction, or undrained pus, although intervention for anorectal infections of patients with malignancies and neutropenia is controversial.

• Patients with endocarditis require aggressive antibiotic therapy and surgery. If bacteremia persists 2 weeks after antimicrobial therapy, a valvulectomy is indicated. Patients with left-sided endocarditis that is refractory to antibiotic treatment and is hemodynamically unstable require early valve replacement.

• Bilateral lung and heart-lung transplants are options offering moderate success rates for children and young adults in whom end-stage CF lung disease is associated with chronic pseudomonal lower respiratory tract infections.

• Over-the-counter topical antiseptic drugs for use prior to surgery or injections have reported outcomes that range from localized infections at injection sites to systemic infections that resulted in death. Organisms implicated in the outbreaks included P aeruginosa. The FDA recommends single-use packaging and to follow label instructions to reduce the number of bacteria on the skin.

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• Consultation with an infectious disease specialist is suggested for complicated cases, such as persistent or resistant infections.

• Consultation with an orthopedic surgeon may be needed for possible open biopsy or surgical intervention for patients whose infections involve the joint.

• A podiatrist can assist in foot care by performing debridement and nail care.

• A neurologist and neurosurgeon are needed for patients with neurological infections (eg, a brain abscess).

• Consult an otolaryngologist for cases of malignant otitis media that may require surgery.

• Consult an ophthalmologist for pseudomonal eye infections.

• A cardiologist or cardiac surgeon often becomes involved in the care of patients with pseudomonal endocarditis (especially left-sided endocarditis).

• Pulmonologists are often involved with patients who have CF. Pulmonologists may also be consulted for patients who require bronchoscopy.

• Critical care specialists are often involved in the treatment of patients who require intensive care, such as those in septic shock or with severe burns.

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• The main goal regarding diet, as it relates to patients with pseudomonal infections, is to provide adequate nutrition, prevent malnutrition, and avoid complications related to dietary delivery.

• Patients with CF who require increased energy intake should receive a higher proportion of fat to nonprotein energy value. Avoid diets with increased amounts of carbohydrates because the increased carbon dioxide production causes difficulty in breathing and ventilation support.

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• Restrictions depend on the area of infection.

• Localized infections rarely require activity limitations.