Lecture 5

Pseudomonus aeruginosa
Dr. Nazik M. Hussein
Pseudomonus aeruginosa
➢ P. aeruginosa is widely distributed in nature and is commonly present
in moist environments in hospitals.
➢ While not a part of the normal human microbiome, P. aeruginosa is
capable of colonization of various body sites (eg, mucous membrane,
respiratory tract, and GI tract).
➢ It is known to cause disease in humans, especially in people with
altered and decreased host defenses (eg, neutropenia, chemotherapy,
and burn wounds).
➢ The acquisition of the organism and subsequent infection can be either
endogenous or exogenous. Endogenous infection occurs after
colonization (eg, bacteremia after GI tract colonization); exogenous
infection typically occurs from an environmental reservoir via a
susceptible portal of entry (eg, burn wound infections or hot tub
folliculitis).
Morphology and Identification
Typical Organisms
➢ P. aeruginosa is motile and rod shaped, measuring about 0.6 × 2 μm.
It is Gram-negative and occurs as single bacteria, in pairs, and
occasionally in short chains.
Culture
➢ P. aeruginosa is an obligate aerobe that grows readily on many types
of culture media, sometimes producing a sweet or grape-like or corn
taco-like odor.
➢ Some strains hemolyze blood.
➢ P. aeruginosa forms smooth round colonies with a fluorescent
greenish color. Many strains of P. aeruginosa produce a non-
fluorescent bluish pigment, pyocyanin, which diffuses into the agar.
As all fluorescent pseudomonads, P. aeruginosa also produces the
fluorescent pigment pyoverdine, which gives a greenish color to the
agar when combined with pyocyanin.
➢ Some strains may also produce a dark red pigment (pyorubin) or a
brown black pigment (pyomelanin).
➢ P. aeruginosa in culture can produce multiple colony types; isolates
from different colony types may also have different biochemical and
enzymatic activities and different antimicrobial susceptibility patterns.
➢ Sometimes, it may not be clear if the colony types represent different
strains of P.aeruginosa or are variants of the same strain. Cultures
from patients with cystic fibrosis (CF) often yield P. aeruginosa
organisms that form mucoid colonies as a result of overproduction of
alginate, an exopolysaccharide. In CF patients, the exopolysaccharide
appears to provide the matrix for the organisms to live in a biofilm
Gram-stain of P. aeruginosa
P. aeruginosa on a Mueller-Hinton agar plate. The organism produces
pyocyanin, which is blue, and pyoverdine, which is green. Together these
pigments produce the blue-green color that is seen in the agar around the
pseudomonas growth.
Growth Characteristics
➢ P. aeruginosa grows well at 37°C to 42°C; its growth at 42°C helps
differentiate it from other Pseudomonas species that produce
fluorescent pigments.
➢ P. aeruginosa, like all pseudomonads, does not ferment
carbohydrates, but many strains oxidize glucose; these organisms are
therefore oxidase positive.
➢ Identification is usually based on colonial morphology, the presence
of characteristic pigments, oxidase positivity, and growth at 42°C.
Antigenic Structure and Toxins
➢ Pseudomonads, and P. aeruginosa specifically, produce a variety of
virulence factors, including adhesins, enzymes, and toxins.
➢ Pili (fimbriae) extend from the cell surface and promote attachment to
host epithelial cells.
➢ An exopolysaccharide, alginate, is responsible for the mucoid
colonies seen in cultures from patients with CF.
➢ Lipopolysaccharide, which exists in multiple immunotypes, is
responsible for many of the endotoxic properties of the organism.
➢ Most P. aeruginosa isolates from clinical infections produce
extracellular enzymes, including elastases, proteases, and two
hemolysins (a heat-labile phospholipase C and a heat-stable
glycolipid). In addition, pyocyanin produced by P. aeruginosa is
responsible for the production of hydrogen peroxide and superoxide,
and stimulates the release of interleukin IL-8.
➢ Many strains of P. aeruginosa produce exotoxin A, which causes
tissue necrosis. The toxin blocks protein synthesis by a mechanism of
action identical to that of diphtheria toxin, although the structures of
the two toxins are not identical.
Pathogenesis
➢ P. aeruginosa is pathogenic only when introduced into areas devoid
of normal defenses, such as when mucous membranes and skin are
disrupted by direct tissue damage as in the case of burn wounds; when
intravenous or urinary catheters are used; or when neutropenia is
present, as in cancer chemotherapy.
➢ The bacterium attaches to and colonizes the mucous membranes or
skin, invades locally, and subsequently produces systemic disease (eg,
bloodstream infections).
➢ These processes are promoted by the pili, enzymes, and toxins.
Lipopolysaccharide plays a direct role in causing fever, shock,
oliguria, disseminated intravascular coagulation, and adult respiratory
distress syndrome.
➢ The propensity to form biofilms by P. aeruginosa in the lumen of
catheters and in the lungs of CF patients greatly contributes to the
virulence of this organism.
Clinical Findings
➢ P. aeruginosa produces infection of wounds and burns, often giving
rise to blue-green pus; meningitis when introduced by lumbar
puncture or during a neurosurgical procedure; and urinary tract
infection when introduced by catheters and instruments or in irrigating
solutions.
➢ Involvement of the respiratory tract, especially from contaminated
respirators, results in necrotizing pneumonia.
➢ In CF patients, P. aeruginosa causes a chronic pneumonia, a
significant cause of morbidity and mortality in this population.
➢ The bacterium is often found in mild otitis externa in swimmers. It
may cause invasive otitis externa in patients with diabetes.
➢ Infection of the eye, which may lead to rapid destruction of the eye,
occurs most commonly after injury or surgical procedures.
➢ In infants or debilitated persons, P. aeruginosa may invade the
bloodstream and result in fatal sepsis; this occurs commonly in
patients with leukemia or lymphoma who have received antineoplastic
drugs or radiation therapy and in patients with severe burns.
➢ Hemorrhagic necrosis of skin occurs often in sepsis caused by P.
aeruginosa; the lesions, called ecthyma gangrenosum, are surrounded
by erythema and often do not contain pus.
Ecthyma gangrenosum. Necrotic skin lesion
caused by Pseudomonas aeruginosa
Diagnostic Laboratory Tests
Specimens
➢ Specimens from skin lesions, pus, urine, blood, spinal fluid, sputum,
and other material should be obtained as indicated by the type of
infection.
Smears
➢ Gram-negative rods are often seen in smears. No specific morphologic
characteristics differentiate pseudomonads in specimens from enteric
or other Gram-negative rods.
Culture
➢ Specimens are plated on blood agar and the differential media
commonly used to grow the enteric Gram-negative rods.
➢ Pseudomonads grow readily on most of these media, but they may
grow more slowly than the enterics. P. aeruginosa does not ferment
carbohydrates, including lactose, and is easily differentiated from the
lactose-fermenting bacteria. Culture is the specific test for diagnosis
of P. aeruginosa infection.
Treatment
➢ A combination antimicrobial therapy is usually required to
successfully treat significant infections. An extended-spectrum
penicillin, such as piperacillin active against P. aeruginosa, is
typically used in combination with an aminoglycoside, usually
tobramycin.
➢ Other drugs active against P. aeruginosa include aztreonam;
carbapenems; and the fluoroquinolones, including ciprofloxacin.
➢ P. aeruginosa is intrinsically resistant to many antimicrobial agents,
and can acquire additional resistance to many other antimicrobial
agents via horizontal gene transfer and/or mutations.
Epidemiology and Control
➢ P. aeruginosa is primarily a nosocomial, opportunistic pathogen, and
the methods for control of infection are similar to those for other
nosocomial pathogens.
➢ Effective infection-control prevention measures should focus on
preventing the contamination of medical equipment, potential cross-
contamination between patients, and selection of appropriate
antibiotic therapy guidelines to prevent emergence of drug resistance.