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SUMMARY AND RECOMMENDATIONS
The following general principles apply to the management of serious Pseudomonas
- Antibiotic resistance, both intrinsic and acquired, is important to consider when selecting empiric or directed therapy.
- Combination therapy may be indicated in certain high-risk patients and in severe infections.
- Antimicrobial therapy should be promptly initiated, as delayed therapy correlates with increased mortality.
- Source control is important. All infected catheters should be removed, and abscesses should be drained and obstructions relieved, whenever possible.
A limited number of antimicrobial agents have reliable activity against P.
Fluoroquinolones are the only class of antibiotics which has an oral formulation that is reliably active against P.
Aminoglycosides (gentamicin, tobramycin, amikacin) are active against P.
The use of combination antimicrobial therapy in patients with serious P.
We typically reserve combination therapy for empiric treatment of serious infections known or suspected to be caused by P.
Thus, for patients who have sepsis or septic shock, have neutropenia and bacteremia, have severe burns, or are in a setting where the incidence of resistance to the chosen antibiotic class is high (eg, >10 to 15
For patients without any of these additional risk factors for mortality or resistant organisms, we recommend empiric treatment with a single antipseudomonal
Once antimicrobial susceptibility data are available, we typically use a single active antipseudomonal agent. The rare exceptions when a combination regimen may be warranted include neutropenia and bacteremia, endocarditis, failure to improve on therapy, and multidrug resistance.
Multidrug resistance in many organisms, including P.
The general principles of antipseudomonal therapy in children are similar to those in adults with the main exception that antimicrobial dosing is weight-based. Use of a fluoroquinolone is a consideration for gram-negative infections caused by isolates susceptible to these agents, including infections caused by P.
Combination therapy for highly resistant infections
The difficulty in treating P. aeruginosa infections caused by strains that are resistant to all or all but one antibiotic has led investigators to use novel combinations of drugs that separately have little or no activity against the isolate. There are minimal clinical data to support such combination therapy, and most clinical studies did not analyze patient outcomes stratified by susceptibility profile. However, if combination therapy is used for
In a single clinical series of 64 patients with nosocomial pulmonary infections due to a highly resistant P.
Other combination regimens have been found to have enhanced activity against multidrug-resistant P.
The mechanisms for the enhanced activity are unknown for most combinations.