Pilzinfektionen in der Intensivmedizin

Invasive Pilzinfektionen sind zunehmend bedeutsam – als primäre Infektion und im Rahmen komplexer Infektionsgeschehen bei kritisch kranken sowie immunsupprimierten oder organtransplantierten Patienten. Neben Candida-Infektionen liegt das Augenmerk v. a. auf der invasiven pulmonalen Aspergillose und den selteneren Schimmelpilzinfektionen, wie z. B. den Mukormykosen. Neben den bekannten, häufig verwendeten Antimykotika möchten wir auch die Rolle neuerer Therapien diskutieren und einen Ausblick in die Zukunft der Antimykotika wagen.

Kernaussagen

• Invasive Pilzinfektionen sind ein zunehmendes Problem in der modernen Intensivmedizin.

• Diagnose und Therapieentscheidung stellen im klinischen Alltag häufig ein Problem dar. Ein wichtiger Grund sind hier v. a. fehlende Routine und Unsicherheit.

• Relevante invasive fungale Infektionen (IFI) werden in der Intensivmedizin v. a. durch Candida spp., Aspergillus spp. und seltener Mucorales ausgelöst. Den Goldstandard der Diagnostik bildet weiterhin der kulturelle Nachweis.

• Bei der invasiven pulmonalen Aspergillose (IPA) ist die Galaktomannan-Bestimmung aus bronchoalveolärer Flüssigkeit sinnvoll und kann eine Therapieindikation nach sich ziehen.

• Fungale Pathogene zeigen intrinsische und erworbene Resistenzen. Daher ist die Erstellung eines Mykogramms nach kultureller Anzucht obligat. Die Therapie sollte, analog der bakteriellen Infektionen, an die Resistenztestung angepasst werden.

• Persistierende Fungämien (z. B. Candidämien) haben das Potenzial, septische Embolien zu bilden und eine Vielzahl an Organen (Auge, Herz, Hirn) in den Krankheitsprozess mit einzubeziehen.

• Hausinterne Verfahrensanweisungen helfen, Unsicherheiten in Diagnostik und Therapie zu reduzieren. Sie ermöglichen auch unerfahreneren Kollegen eine solide Entscheidungsfindung.

• Das Management von invasiven fungalen Infektion in der Intensivmedizin ist ein interdisziplinäres Unterfangen (Intensivmedizin, Mikrobiologie/Mykologie, Pharmazie/Phramakologie, Chirurgie, Radiologie u. a.). Die Organisation gemeinsamer Visiten (vgl. Infectious Diseases Stewardship, IDS) verbessert das Therapieergebnis.

Publikationsverlauf

Artikel online veröffentlicht:
22. Februar 2021

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