Epidemiologie, Diagnostik, antimikrobielle Therapie und Management von erwachsenen Patienten mit ambulant erworbenen unteren Atemwegsinfektionen sowie ambulant erworbener Pneumonie – Update 2009

Inhalt 1. Struktur der Leitlinie e6 1.1.Vorwort e61.2. Ziele der Leitliniee6 1.3. Erstellung der Leitliniee71.3.1. Literaturrecherchee71.3.2. Formulierung der Empfehlungene71.4. Finanzierunge81.5. Implementierung/Publikatione81.6. Planmäßige Überarbeitunge81.7. Prozessqualität e8 2. Definitionen e8 3. Epidemiologie und sozialmedizinische Bedeutung e9 4. Erregerspektrum e9 5. Resistenzsituation e10 5.1. Resistenzsituation bei Streptococcus pneumoniae e105.1.1. Resistenz gegenüber Penicillin G e105.1.2. Resistenz gegenüber Makroliden e105.1.3. Resistenz gegenüber Fluorchinolonen e115.1.4. Resistenz gegenüber Tetracyclinen e115.2. Resistenzsituation bei Haemophilus influenzae e115.3. Resistenzsituation bei Moraxella catarrhalis e115.4. Resistenzsituation bei Enterobacteriaceae und Pseudomonas aeruginosa e115.5. Resistenzsituation bei Influenza-Viren und nicht primär respiratorischen Viren e12 6. Mikrobiologische Diagnostik e12 6.1. Diagnostik schnell wachsender Bakterien e126.2. Diagnostik spezieller Erreger e136.2.1. Diagnostik von Legionella pneumophila e136.2.2. Diagnostik von Mycoplasma pneumoniae e146.2.3. Diagnostik von Chlamydophila pneumoniae e156.2.4. Diagnostik respiratorischer Viren e15 7. Antiinfektiva zur Behandlung tiefer Atemwegsinfektionen e16 7.1. Betalaktamantibiotika e167.1.1. Orale Basispenicilline: Penicillin V und Amoxicillin e167.1.2. Parenterale Basispenicilline: Penicillin G und Ampicillin e167.1.3. Aminopenicillin-Betalaktamaseinhibitor-Kombinationen e167.1.4. Oralcephalosporine e167.1.5. Parenterale Cephalosporine e177.1.6. Ertapenem e177.1.7. Pseudomonaswirksame Betalaktame e187.2. Tetracycline: Doxycyclin e187.3. Makrolide und Azalide e187.4. Lincosamide: Clindamycin e197.5. Fluorchinolone e197.5.1. Levofloxacin und Moxifloxacin e197.5.2. Ciprofloxacin e207.6. Oxazolidinone: Linezolid e207.7. Influenzaviruswirksame Virustatika e207.8. Aciclovir e21 8. Symptomatik und Befunde bei unteren Atemwegsinfektionen e21 8.1. Symptomatik e218.2. Untersuchung e22 9. Behandlung Non-CAP: akute Bronchitis, Influenzainfektion, andere respiratorische Virusinfektionen e22 9.1. Akute Bronchitis e229.2. Influenzainfektion e239.3. Andere respiratorische Virusinfektionen e24 10. Akute Exazerbation der COPD (AECOPD) e24 10.1. Definition der AECOPD e2410.2. Ätiologie der AECOPD e2410.3. Klinische Symptomatik der AECOPD e2510.4. Mikrobiologische Diagnostik der AECOPD e2610.5. Indikation zur antimikrobiellen Therapie bei AECOPD e2610.5.1. Pathogenetische Überlegungen zur Therapieindikation bei AECOPD e2610.5.2. Begründung der Therapieempfehlung e2710.6. Auswahl der antimikrobiellen Therapie bei AECOPD e2810.7. Verlauf der antimikrobiellen Therapie bei AECOPD e29 11. Risikostratifizierung der CAP e30 11.1. Entscheidung zur stationären Einweisung e3011.2. Entscheidung zur Aufnahme auf eine Intensivstation (ITS), Intermediärstation bzw. Station mit intensivierter Überwachung e3011.3 Einteilung der CAP e32 12. Ambulantes Management der CAP e32 12.1. CAP bei ambulanten Patienten ohne Risikofaktoren e3212.1.1. Erregerspektrum bei ambulanten CAP-Patienten ohne Risikofaktoren e3212.1.2. Diagnostik bei ambulanten Patienten ohne Risikofaktoren e3312.1.3. Therapie bei ambulanten CAP-Patienten ohne Risikofaktoren e3312.1.4. Verlauf bei ambulanten CAP-Patienten ohne Risikofaktoren e3312.2. CAP bei ambulanten Patienten mit Risikofaktoren e3412.2.1. Erregerspektrum bei ambulanten CAP-Patienten mit Risikofaktoren e3412.2.2. Diagnostik bei ambulanten CAP-Patienten mit Risikofaktoren e3412.2.3. Therapie bei ambulanten CAP-Patienten mit Risikofaktoren e3412.2.4. Verlauf bei ambulanten CAP-Patienten mit Risikofaktoren e35 13. Management bei hospitalisierten CAP-Patienten e35 13.1. Erregerspektrum bei hospitalisierten CAP-Patienten e3513.2. Diagnostik bei hospitalisierten CAP-Patienten e3613.3. Therapie bei hospitalisierten CAP-Patienten e3613.4. Verlauf bei hospitalisierten CAP-Patienten e39 14. Management der schweren ambulant erworbenen Pneumonie (schwere CAP) e40 14.1. Erregerspektrum der schweren ambulant erworbenen Pneumonie (sCAP) e4014.2. Diagnostik bei schwerer ambulant erworbener Pneumonie (sCAP) e4114.3. Therapie der schweren ambulant erworbenen Pneumonie (sCAP) e42 15.Therapieversagen bei CAP e45 15.1. Häufigkeit und Ursachen des Therapieversagens e4515.2. Diagnostisches Vorgehen e4515.3. Antibiotikatherapie bei Therapieversagen e46 16. Besondere Verlaufsformen der CAP e46 16.1. Pleuraerguss e4616.2. Aspirationspneumonie e4716.3. Retentionspneumonie e4716.4. Lungenabszess e4716.5. Pseudo-Therapieversager durch nichtinfektiöse Lungenerkrankungen, die initial wie eine Pneumonie imponieren e48 17. Besonderheiten der Therapie der CAP bei bekanntem Erreger e48 17.1. Legionellen e4817.2. Chlamydien und Mykoplasmen e4917.3. Ambulant erworbener methicillin-resistenter Staphylococcus aureus e4917.4. Pseudomonas aeruginosa e4917.5. Coxiella burnetii e50 18. Prävention der CAP e50 18.1. Influenzavirus-Impfung e5018.2. Pneumokokken-Impfung e5018.3. Sonstige präventive Maßnahmen e51 19. Pharmakoökonomische Bewertung der Evidenzlage zur CAP e51 20. CAP als terminales Ereignis bei hohem Lebensalter und/oder schwerer fortgeschrittener Komorbidität e52 21. Anhang e55 21.1. Autoren der Leitlinie e5521.2. Zur Konsensuskonferenz am 9. 12. 2008 eingeladene und vertretene Fachgesellschaften und Einrichtungen e5521.3. Teilnehmer der Konsensuskonferenz e5521.4. Erklärung über mögliche Interessenkonflikte e5621.5. Abkürzungsverzeichnis e56 22. Literaturverzeichnise57 Die nach der Literaturstelle in Klammern gesetzte Ziffer mit Buchstaben bezieht sich auf die Evidenzbewertung nach Oxford Centre of Evidence Based Medicine (1999).

22. Literaturverzeichnis

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1 Autorisierung der aktualisierten Leitlinie durch den Vorstand der Fachgesellschaft.