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Key Features

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Essentials of Diagnosis
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  • Opportunistic infection

  • Confirmed by cultures

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General Considerations
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  • Pseudomonas aeruginosa is an important cause of infection in children with cystic fibrosis, neoplastic disease, neutropenia, or extensive burns and in those receiving antibiotic therapy

  • Infections of the urinary and respiratory tracts, ears, mastoids, paranasal sinuses, eyes, skin, meninges, and bones are seen

  • Pseudomonas pneumonia is a common nosocomial infection in patients receiving assisted ventilation

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Clinical Findings

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  • Depend on the site of infection and the patient's underlying disease

  • Patients with cystic fibrosis

    • Have a persistent bronchitis that progresses to bronchiectasis and ultimately to respiratory failure

    • During exacerbations of illness, cough and sputum production increases with low-grade fever, malaise, and diminished energy

  • The purulent aural drainage without fever in patients with chronic suppurative otitis media is not distinguishable from that due to other causes

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Diagnosis

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  • Sepsis with these organisms resembles gram-negative sepsis with other organisms, although the presence of ecthyma gangrenosum suggests the etiologic diagnosis

  • Diagnosis is made by culture

  • Pseudomonas infection should be suspected in neonates and neutropenic patients with clinical sepsis

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Treatment

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  • Antibiotics effective against Pseudomonas include

    • Aminoglycosides

    • Ureidopenicillins (piperacillin)

    • β-Lactamase inhibitor with a ureidopenicillin (piperacillin-tazobactam)

    • Expanded-spectrum cephalosporins (ceftazidime and cefepime)

    • Imipenem, meropenem

    • Colistin has been used in some children with multidrug resistance

  • For serious infections

    • Gentamicin or tobramycin (5.0–7.5 mg/kg/d, given intramuscularly or intravenously in three divided doses)

    • Amikacin (15–22 mg/kg/d, given in two or three divided doses) in combination with piperacillin (240–300 mg/kg/d, given intravenously in four to six divided doses) or with another antipseudomonal β-lactam antibiotic

    • Ceftazidime (150–200 mg/kg/d, given in four divided doses) or cefepime (150 mg/kg/d, given in three divided doses) has activity against susceptible strains; treatment should be continued for 10–14 days

  • Aerosolized anti-pseudomonal antibiotics, tobramycin, and aztreonam have been very useful adjunctive therapy for patients with cystic fibrosis

  • Pseudomonas osteomyelitis due to punctures requires thorough surgical debridement and antimicrobial therapy for 2 week.

  • Chronic suppurative otitis media

    • Responds to intravenous ceftazidime (150–200 mg/kg/d in three or four divided doses) given until the drainage has ceased for 3 days

    • Twice-daily ceftazidime with aural debridement and cleaning given on an outpatient basis has also been successful

    • Swimmer's ear may be caused by P aeruginosa and responds well to topical drying agents (alcohol–vinegar mix) and cleansing

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Outcome

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Prevention
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  • Infections in burn patients can be inhibited by

    • Aggressive debridement

    • Topical treatment with 0.5% silver nitrate solution, 10% mafenide cream, or silver sulfadiazine

  • Nosocomial infections can be minimized by careful maintenance of equipment and enforcement of infection control procedures

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Prognosis
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  • Mortality rates in hospitalized patients exceed 50%, owing both to the severity of underlying illnesses in patients predisposed to Pseudomonas infection and to the limitations of therapy

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