Pneumokokkeninfektionen – was gibt es Neues?^[*]

Zusammenfassung

Pneumokokken sind weiterhin der wichtigste Erreger der ambulant erworbenen Pneumonie. Die Transmission der Erkrankung findet über die Kolonisierung des Nasopharynx vor allem von Kindern statt. Die Impfung mit der Pneumokokkenkonjugatvakzine senkt diese Kolonisationsrate und führt sekundär zu herdprotektiven Effekten. Außer im Kindesalter tritt die Erkrankung vor allem bei älteren, komorbiden Menschen auf und hat bei diesem Kollektiv eine konstant hohe Sterblichkeit. Das höchste Erkrankungsrisiko haben Menschen mit HIV/AIDS und hämatologischen und soliden Neoplasien. Für eine rasche Deeskalation einer empirischen Therapie bei Pneumokokkeninfektionen auf ein Schmalspektrumpenicillin wäre eine schnellere Erregerdiagnose wünschenswert. Leider fehlt dem Pneumokokken-Antigentest im Urin für die Routinediagnostik die nötige Sensitivität. Einen Fortschritt stellt dagegen der direkte Erregernachweis aus der Blutkultur mittels MALDI-TOF dar. In mehreren Kohortenstudien konnte gezeigt werden, dass eine Kombinationstherapie von einem Makrolid plus Betalaktam die Mortalität von invasiven Pneumokokkeninfektionen senkt. Bisher ist es jedoch nicht hinreichend geklärt, ob diese Beobachtung auf günstige Effekte der Kombinationstherapie oder auf Verzerrungen, bedingt durch das Studiendesign, beruht.

Abstract

Pneumococci remain the most important cause for community-acquired pneumonia. The colonization of the nasopharynx is prerequisite for their transmission and the colonization of toddlers are an important reservoir also for infections in the elderly. Since pneumococcal conjugate vaccines reduce the colonization rate of children its widespread use has also resulted in a reduction of invasive pneumococcal disease in adults. Advanced age and comorbidity are the most important risk factors for pneumococcal pneumonia and the mortality in this risk group is still very high. The strongest risk factor for invasive pneumococcal infections, however, is HIV/AIDS and solid or hematologic malignancies. A more rapid identification could aid de-escalation of empiric antibiotic therapy. The pneumococcal urinary antigen test, however lacks sensitivity for this purpose. In contrast, the direct identification of pathogens from positive blood culture bottles by MALDI-TOF is a very encouraging development in diagnostic microbiology. In several cohort studies patients treated with a combination of a betalactam plus macrolide had a lower mortality than patients treated with betalactam monotherapy. If these observations reflect a truly beneficial effect of combination therapy or rather confounding of the studies remains unclear and evidence from interventional studies is needed.

^* Professor Hartmut Lode zum 75. Geburtstag gewidmet.

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