Update der S3-Leitlinie: Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie

Zusammenfassung

Hintergrund Die nosokomiale Pneumonie, die sowohl die im Krankenhaus erworbene (HAP) als auch die beatmungsassoziierte Pneumonie (VAP) umfasst, ist nach wie vor eine Hauptursache für Morbidität und Mortalität bei hospitalisierten Erwachsenen. Bei sich verändernden Erregerprofilen und aufkommenden Resistenzmustern bietet die vorliegende aktualisierte S3-Leitlinie (AWMF-Register-Nr. 020-013) eine evidenzbasierte Empfehlung zur Verbesserung der Diagnose, Risikostratifizierung und Behandlung der nosokomialen Pneumonie.

Methoden Die Aktualisierung der Leitlinie wurde von einem multidisziplinären Gremium entwickelt, in dem die wichtigsten deutschen Fachgesellschaften vertreten waren. Es wurde eine systematische Literaturrecherche mit anschließender kritischer Bewertung nach der GRADE-Methode durchgeführt. Strukturierte Konsensuskonferenzen stellten sicher, dass die Empfehlungen klinisch relevant und methodisch fundiert sind und den aktuellen Grundsätzen des Antibiotic Stewardship entsprechen.

Ergebnisse Bei der Behandlung nosokomialer Pneumonien sollten die Patienten in solche mit und solche ohne Risikofaktoren für multiresistente Erreger und/oder Pseudomonas aeruginosa unterteilt werden. Die bakterielle Multiplex-Polymerase-Kettenreaktion (PCR) sollte nicht routinemäßig eingesetzt werden. Die bronchoskopische Diagnose wird im Hinblick auf die wichtigsten Ergebnisse nicht als besser angesehen als die nicht bronchoskopische Probenahme. Eine Antibiotika-Kombinationstherapie ist Patienten mit septischem Schock und hohem Risiko für multiresistente Erreger vorbehalten, während die anderen Patienten mit einer Monotherapie (z. B. Meropenem) behandelt werden können. Bei klinisch stabilisierten Patienten sollte die Antibiotikatherapie deeskaliert und fokussiert sowie die Dauer auf 7–8 Tage verkürzt werden. Bei kritisch kranken Patienten sollte eine prolongierte Applikationsdauer geeigneter Betalaktam-Antibiotika bevorzugt werden. Bei Patienten auf der Intensivstation (ICU) besteht das Risiko einer invasiven pulmonalen Aspergillose (IPA). Die Diagnostik auf Aspergillus sollte mit einem Antigentest aus Bronchiallavageflüssigkeit erfolgen.

Schlussfolgerung Diese aktualisierte S3-Leitlinie bietet einen umfassenden, multidisziplinären Ansatz für die Behandlung der nosokomialen Pneumonie bei Erwachsenen. Durch die Integration neuer diagnostischer Verfahren und verfeinerter therapeutischer Strategien zielt sie darauf ab, die Behandlung zu standardisieren, die Ergebnisse für die Patienten sowie das antimikrobielle Stewardship zu verbessern, um das Auftreten resistenter Erreger einzudämmen.

Abstract

Background Nosocomial pneumonia, encompassing hospital-acquired (HAP) and ventilator-associated pneumonia (VAP), remains a major cause of morbidity and mortality in hospitalized adults. In response to evolving pathogen profiles and emerging resistance patterns, this updated S3 guideline (AWMF Register No. 020–013) provides an evidence-based framework to enhance the diagnosis, risk stratification, and treatment of nosocomial pneumonia.

Methods The guideline update was developed by a multidisciplinary panel representing key German professional societies. A systematic literature review was conducted with subsequent critical appraisal using the GRADE methodology. Structured consensus conferences and external reviews ensured that the recommendations were clinically relevant, methodologically sound, and aligned with current antimicrobial stewardship principles.

Results For the management of nosocomial pneumonia patients should be divided in those with and without risk factors for multidrug-resistant pathogens and/or Pseudomonas aeruginosa. Bacterial multiplex-polymerase chain reaction (PCR) should not be used routinely. Bronchoscopic diagnosis is not considered superior to non-bronchoscopic sampling in terms of main outcomes. Combination antibiotic therapy is now reserved for patients in septic shock and high risk for multidrug-resistant pathogens, while select patients may be managed with monotherapy (e. g., meropenem). In clinically stabilized patients, antibiotic therapy should be de-escalated and focused, as well as duration shortened to 7–8 days. In critically ill patients, prolonged application of suitable beta-lactam antibiotics should be preferred. Patients on the intensive care unit (ICU) are at risk for invasive pulmonary aspergillosis (IPA). Diagnostics for Aspergillus should be performed with an antigen test from bronchial lavage fluid.

Conclusion This updated S3 guideline offers a comprehensive, multidisciplinary approach to the management of nosocomial pneumonia in adults. By integrating novel diagnostic modalities and refined therapeutic strategies, it aims to standardize care, improve patient outcomes, and enhance antimicrobial stewardship to curb the emergence of resistant pathogens.

Schlüsselwörter

nosokomiale Pneumonie - beatmungsassoziierte Pneumonie - deutsche Leitlinie - Antibiotic Stewardship - sepsischer Schock

Keywords

nosocomial pneumonia - ventilator-associated pneumonia - german guideline - antimicrobial stewardship - septic shock

Publication History

Article published online:
01 April 2025

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