Therapieversagen bei ambulant erworbener Pneumonie

Einleitung

Das Therapieversagen bei Patienten mit einer ambulant erworbenen Pneumonie (AEP) stellt häufig ein schwieriges und wenig verstandenes klinisches Problem dar. Das Spektrum möglicher inadäquater Vorgehensweisen umfasst eine ausgedehnte und wenig gezielte Diagnostik auf der einen sowie eine antimikrobielle Polypragmasie und Übertherapie unter Verzicht auf eine genaue diagnostische Evaluation auf der anderen Seite. Daraus resultieren häufig unnötige Belastungen und Risiken für den Patienten, in jedem Fall aber vermeidbare hohe Kosten. Die folgende Übersicht stellt den Versuch dar, eine klinisch brauchbare Systematik der Ursachen des Therapieversagens und auf diesem Hintergrund Maßgaben für das konkrete differenzialdiagnostische Vorgehen zu erstellen.

Literatur

• 1 American Thoracic Society . Guidelines for the initial management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, and initial antimicrobial therapy.  Am Rev Respir Dis. 1993;  148 1418-1426
• 2 Bartlett J G, Breiman R F, Mandell L A, File T MJ. Community-acquired pneumonia in adults: Guidelines for management.  Clin Infect Dis. 1998;  26 811-838
• 3 European study on community-acquired pneumonia (ESOCAP) committee . Guidelines for management of adult community-acquired lower respiratory tract infections.  Eur Respir J. 1998;  11 986-991
• 4 Schaberg T, Dalhoff K, Ewig S, Lorenz J, Wilkens H. (Deutsche Gesellschaft für Pneumologie) . Empfehlungen zur Therapie der ambulant erworbenen Pneumonie.  Pneumologie. 1998;  52 450-462
• 5 Halm E A, Fine M J, Marrie T J, Coley C M, Kapoor W N, Obrosky D S, Singer D E. Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines.  JAMA. 1998;  279 1452-1457
• 6 Clinton M, Irwin G, Niederman M, Fein A. Relationship of risk factors to the radiological progression of community acquired pneumonia.  Am Rev Respir Dis. 1992;  145 A551
• 7 Macfarlane J, Miller A, Smith W, Morris A H, Rose D E. Comparative radiographic features of community-acquired legionnaires' disease, pneumococcal pneumonia, mycoplasma pneumonia, and psittacosis.  Thorax. 1984;  39 28-33
• 8 Marrie T. Normal resolution of community-acquired pneumonia.  Semin Respir Infect. 1992;  7 289-293
• 9 Metlay J P, Fine M J, Schulz R, Marrie T J, Coley C M, Kapoor W N, Singer D E. Measuring symptomatic and functional recovery in patients with community-acquired pneumonia.  J Gen Intern Med. 1997;  12 423-430
• 10 Metlay J P, Atlas S J, Borowsky L H, Singer D E. Time course of symptom resolution in patients with community-acquired pneumonia.  Respir Med. 1998;  92 1137-1142
• 11 British Thoracic Society Research Commitee and The Public Health Laboratory Service . The aetiology, management and outcome of severe community acquired pneumonia on the intensive care unit.  Respir Med. 1992;  86 7-13
• 12 Fein A M, Feinsilver S H, Niederman M S, Fiel S, Pai P B. When pneumonia doesn't get better.  Clin Chest Med. 1987;  8 529-541
• 13 Fein A M, Feinsilver S H, Niederman M S. Nonresolving and slowly resolving pneumonia. Diagnosis and management in the elderly patient.  Clin Chest Med. 1993;  14 555-569
• 14 Feinsilver S H, Fein A M, Niederman M S, Schultz D E, Faegenburg D H. Utility of fiberoptic bronchoscopy in nonresolving pneumonia.  Chest. 1990;  98 1322-1326
• 15 Geppert E F. Chronic and recurrent pneumonia.  Semin Respir Infect. 1992;  7 282-288
• 16 Kirtland S H, Winterbauer R H. Slowly resolving, chronic, and recurrent pneumonia.  Clin Chest Med. 1991;  12 303-318
• 17 Ortqvist A, Kalin M, Lejdeborn L, Lundberg B. Diagnostic fiberoptic bronchoscopy and protected brush culture in patients with community-acquired pneumonia.  Chest. 1990;  97 576-582
• 18 Minogue M F, Coley C M, Fine M J, Marrie T J, Kapoor W N, Singer D E. Patients hospitalized after initial outpatient treatment for community-acquired pneumonia.  Ann Emerg Med. 1998;  31 376-380
• 19 Ewig S, Seifert K, Kleinfeld T, Göke N, Schäfer H. Management of patients with community-acquired pneumonia in a primary care hospital: a critical evaluation.  Respir Med. 2000;  94 556-563
• 20 Arancibia F, Ewig S, Martinez J M, Ruiz M, Bauer T, Mensa J, Torres A. Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications.  Am J Respir Crit Care Med. 2000;  162 154-160
• 21 Ewig S, Torres A. Severe community-acquired pneumonia.  Clin Chest Med. 1999;  20 575-587
• 22 Torres A, Serra-Battles J, Ferrer A, Jimenez P, Celis R, Cobo E, Rodriguez-Roisin R. Severe community-acquired pneumonia. Epidemiology and prognostic factors.  Am Rev Respir Dis. 1991;  144 312-318
• 23 Leroy O, Santre C, Beuscart C, Georges H, Guery B, Jacquier J M, Beaucaire G. A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit.  Intensive Care Med. 1995;  21 24-31
• 24 Ortqvist A, Hammers-Berggren S, Kalin M. Respiratory tract colonization and incidence of secondary infection during hospital treatment of community-acquired pneumonia.  Eur J Clin Microbiol Infect Dis. 1990;  9 725-731
• 25 Schaberg T. on behalf of the Wiesbaden Study Group . The clinical failure rate of first-line antibiotic treatment is the key cost driver in the treatment of patients with more severe community-acquired lower respiratory tract infections.  Eur Respir J. 1998;  12 (Suppl. 28) 143s
• 26 Ewig S. Community-acquired pneumonia - Definition, epidemiology, and outcome.  Semin Respir Infect. 1999;  14 94-102
• 27 Kuru T, Lynch J P III. Nonresolving or slowly resolving pneumonia.  Clin Chest Med. 1999;  20 623-651
• 28 Kresken M, Hafner D, Witte W, Reinert R R. Resistenzentwicklung bei Staphylokokken und anderen Gram-positiven Erregern gegenüber Chemotherapeutika im mitteleuropäischen Raum.  Chemother J. 2000;  9 (Suppl. 19) 5-14
• 29 Kresken M, Hafner D. und die Studiengruppe . Resistenzsituation bei klinisch wichtigen Infektionserregern gegenüber Chemotherapeutika in Mitteleuropa.  Chemother J. 2000;  7 51-86
• 30 Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia.  Am J Respir Crit Care Med. 1994;  150 251-253
• 31 Loeb M, McGeer A, McArthur M, Walter S, Simor A E. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.  Arch Intern Med. 1999;  159 2058-2064
• 32 Nakagawa T, Sekizawa K, Arai H, Kikuchi R, Manabe K, Sasaki H. High incidence of pneumonia in elderly patients with basal ganglia infarction.  Arch Intern Med. 1997;  157 321-324
• 33 Matthay R A, Arroliga A C. Resection of pulmonary metastases.  Am Rev Respir Dis. 1993;  148 1691-1696
• 34 Rodriguez J, Niederman M S, Fein A M, Pai P B. Nonresolving pneumonia in steroid-treated patients with obstructive lung disease.  Am J Med. 1992;  93 29-34
• 35 Mason C M, Nelson S. Normal host defences and impairments associated with delayed resolution of pneumonia.  Semin Respir Infect. 1992;  7 243-255
• 36 Jay S, Johanson W, Pierce A. The radiographic resolution of streptococcal pneumoniae pneumonia.  N Engl J Med. 1975;  293 798-801
• 37 Mittl R L, Schwab R J, Duchin J S, Goin J E, Albeida S M, Miller W T. Radiographic resolution of community acquired pneumonia.  Am J Respir Crit Care Med. 1994;  149 630-635
• 38 Lynch P III, Sitrin R G. Noninfectious mimics of community caquired pneumonia.  Semin Respir Infect. 1992;  7 282-288
• 39 Ewig S, Torres A. Flexible bronchoscopy for nosocomial pneumonia. As it stands today. Clin Chest Med 2000: (im Druck)
• 40 Niederman M S. Bronchoscopy in nonresolving nosocomial pneumonia.  Chest. 2000;  117 212S-218S
• 41 Dunn I J, Marrie T J, MacKeen A D, Bhan V, Janigan D T. The value of open lung biopsy in immunocompetent patients with community-acquired pneumonia requiring hospitalization.  Chest. 1994;  106 23-27