Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie^[1]

Zusammenfassung

Die nosokomiale Pneumonie ist eine häufige Komplikation von Krankenhausaufenthalten. Die meisten Daten liegen zur beatmungsassoziierten Pneumonie vor, aber auch auf Normalstationen ist vermehrt mit dieser Erkrankung zu rechnen. Problematisch ist die Zunahme von Infektionen mit multiresistenten Erregern (MRE). Diese erschwert die adäquate Initialtherapie und kann zu unkritischem Einsatz von Breitspektrumantibiotika führen.

Die vorliegende S3-Leitlinie wurde von einer interdisziplinären Arbeitsgruppe auf der Basis einer systematischen Literaturrecherche erarbeitet. Die Empfehlungen zu Diagnostik und Therapie der nosokomialen Pneumonie wurden nach dem GRADE-System abgefasst. Sie berücksichtigen neben der Evidenzqualität auch Nutzen und Risiko bzw. Aufwand der empfohlenen Maßnahmen. Graduierung und Empfehlungsstärke entsprechen der Methodik der Nationalen Versorgungsleitlinien.

Die Leitlinie besteht aus zwei Teilen. Der allgemeine Teil vermittelt einen Überblick zu Epidemiologie, Erregerspektrum und Therapieoptionen der nosokomialen Pneumonie. Handlungsorientierte Empfehlungen werden im zweiten Teil zu zentralen Fragen der Diagnostik und Therapie abgegeben, die Hintergründe hierfür im Fließtext erklärt. Im Diagnostikteil wird besonderer Wert auf eine gezielte mikrobiologische Diagnostik gelegt, da diese die Voraussetzung für die Kenntnis des lokalen Erregerspektrums und der Resistenzraten bildet. Darüber hinaus stellt sie beim individuellen Patienten die beste Grundlage für die Deeskalation dar. Die Intensität der antiinfektiven Therapie ist vorwiegend davon abhängig, ob ein erhöhtes Risiko für Infektionen mit MRE besteht. Strukturierte Deeskalationskonzepte und konsequente Begrenzung der Therapiedauer dienen der Verminderung des Selektionsdrucks.

Abstract

Nosocomial pneumonia (HAP) is a frequent complication of hospital care. Most data are available on ventilator-associated pneumonia. However infections on general wards are also increasing. A central issue are infections with multi drug resistant (MDR) pathogens which are difficult to treat particularly in the empirical setting potentially leading to inappropriate use of antimicrobial therapy.

This guideline was compiled by an interdisciplinary group on the basis of a systematic literature review. Recommendations are made according to GRADE giving guidance for the diagnosis and therapy of HAP on the basis of quality of evidence and benefit/risk ratio.

The guideline has two parts. First an update on epidemiology, spectrum of pathogens and antiinfectives is provided. In the second part recommendations for the management of diagnosis and treatment are given. Proper microbiologic work up is emphasized for knowledge of the local patterns of microbiology and drug susceptibility. Moreover this is the optimal basis for deescalation in the individual patient. The intensity of antimicrobial therapy is guided by the risk of infections with MDR. Structured deescalation concepts and strict limitation of treatment duration should lead to reduced selection pressure.

¹ Unter Mitwirkung der folgenden wissenschaftlichen Fachgesellschaften und Institutionen:
Deutsche Gesellschaft für Chirurgie (D. S.)
Deutsche Gesellschaft für Innere Medizin e. V. (S. A.)
Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (T. W.)
Deutsche Sepsis-Gesellschaft e. V. (K. M.) und
Robert Koch-Institut
Verabschiedet von den Vorständen der beteiligten Fachgesellschaften am 1.10. 2012.

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