Chemoprophylaxe bakterieller Infektionskrankheiten in der pädiatrischen Onkologie

Zusammenfassung.

Die Prävention bakterieller Infektionen ist von vorrangiger Bedeutung für die Morbidität und Letalität immunsupprimierter Patienten in der pädiatrischen Onkologie. Mit unterschiedlicher Evidenz können für die antibakterielle Chemoprophylaxe (ABCP) folgende Empfehlungen für pädiatrischonkologische Patienten ausgesprochen werden: Bei Implantation eines ventrikuloperitonealen Shunts (oder eines ventrikulären Reservoirs) wird eine perioperative antimikrobielle Prophylaxe empfohlen (IB). Zur Prävention systemischer Infektionen mit Streptococcus viridans sollten bei Patienten nach einer Knochenmarktransplantation eine Prophylaxe mit Penicillin erwogen werden, wenn es sich bei den Isolaten häufiger und schweren Infektionen überwiegend um penicillinsensible S. viridans handelt (IIIC). Pädiatrisch-onkologische Abteilungen müssen ein zeitnahes Monitoring der bakteriellen Resistenzsituation nach dem Infektionsschutzgesetz durchführen (IB, IV). Das Risiko der Besiedlung und Infektion mit resistenten Bakterienstämmen muss gegen den objektiven Nutzen der ABCP abgewogen werden (IB). Nicht empfohlen werden die perioperative antibiotische Prophylaxe bei Implantation eines getunnelten oder vollständig subkutan gelegenen zentralen Venenkatheters (IIID) und die antibakterielle Prophylaxe ZVK-assoziierter Infektionen durch den Zusatz von Vancomycin zur Katheterspüllösung (IB). Ebenso kann eine orale antibakterielle Prophylaxe mit nicht resorbierbaren Antibiotika auf der Grundlage der bislang vorliegenden Studien auch für pädiatrische Patienten mit lang anhaltender, hochgradiger Granulozytopenie nicht empfohlen werden (IC). Die bisher verfügbaren Studien sprechen gegen den Nutzen einer antibakteriellen Chemoprohylaxe mit Trimethoprim-Sulfamethoxazol für neutropenische Patienten in der pädiatrischen Onkologie (die PCP-Prophylaxe bleibt davon unberührt) (ID). Für oder gegen die antibakterielle Chemoprophylaxe mit (den in der Pädiatrie bislang nicht zugelassenen) Fluorchinolonen kann keine Empfehlung abgegeben werden (IIIC).AbkürzungenABCP Antibakterielle Chemoprophylaxe
ARA-C Cytosin Arabinosid
CPX Ciprofloxacin
ESBL Betalaktamase mit erweitertem Spektrum
FCH Fluorchinolone
HWK Harnwegskatheter
KMT Knochenmarktransplantation
KNS Koagulase-negative Staphylokokken
MR-KNS Methicillin-resistente koagulasenegative Staphylokokken
MRSA Methicillinresistenter Staphylococcus aureus
MRSE Methicillinresistenter Staphylococcus epidermidis
PCP Pneumocystis-carinii-Pneumonie
RKI Robert-Koch-Institut, Berlin
TMS Trimethoprim-Sulfamethoxazol (Cotrimoxazol)
SDD Selektive Darmdekontamination
VAN Vancomycin
VRE Vancomycinresistente Enterokokken
ZVK Zentraler Venenkatheter

Bacterial infections are still a major challenge in the treatment of pediatric cancer patients. Considering the evidence in the literature and published consensus opinions of experts the following strategies of antibacterial chemoprophylaxis (ABCP) in pediatric cancer patients can be recommended (or not recommended): Accompanying the implantation of a ventriculoperitoneal shunt (or a Rickham-reservoir) ABCP is recommended, until prospective controlled studies including pediatric cancer patients have investigated this issue. In bone marrow or stem cell transplant recipients, the prophylactic administration of penicillin should be considered, if severe oral mucositis is a common adverse event in cancer departments with high rates of penicillin-susceptible strains of Streptococcus viridans. Prospective surveillance of resistant bacterial pathogens should be an indispensable tool of quality control in pediatric oncology departments. The risk of infection with antimicrobial-resistant isolates should be balanced against the real benefit of antimicrobial prophylaxis in every instance. ABCP should neither be given during implantation nor during prolonged usage to prevent bacterial infection of a central venous access device (unproven efficacy and potential hazards of Vancomycin-resistant gram-positive infections). The oral administration of non-absorbable ABCP or Trimetoprim-Sufomethoxazole is not recommended for the prevention of bacterial infections (unproven efficacy) and no recommendation can be given for the oral ABCP with chinolones (lacking data, risk of antimicrobial resistance).

Schlüsselwörter

Antibakterielle Chemoprophylaxe - pädiatrische Onkologie

Key words

Antibacterial chemoprophylaxis - pediatric oncology

Literatur

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