Latente tuberkulöse Infektion: Empfehlungen zur präventiven Therapie bei Erwachsenen in Deutschland

Zusammenfassung

Die immunologischen Vorgänge der latenten tuberkulösen Infektion sind komplex und bis heute nicht vollkommen verstanden. Das lebenslange Risiko eines mit Mycobacterium tuberculosis Infizierten, an einer behandlungsbedürftigen Tuberkulose zu erkranken, liegt für einen immunkompetenten Menschen bei etwa 5 - 10 %, es ist in den ersten beiden Jahren nach Infektion am höchsten. Verschiedene Faktoren, wie beispielsweise immunsuppressive Erkrankungen oder eine entsprechende Medikation, können das Erkrankungsrisiko erheblich steigern. Um die Entwicklung einer behandlungsbedürftigen Tuberkulose zu verhindern, besteht die Möglichkeit einer präventiven medikamentösen Therapie, das Vorgehen der Wahl ist die 9-monatige Einnahme von Isoniazid. In besonderen Fällen können auch alternative Therapieregime indiziert sein, deren Wirksamkeit jedoch bislang nicht abschließend beurteilt werden kann und deren Verträglichkeit der Isoniazid-Monotherapie wahrscheinlich unterlegen ist. Zur Erkennung einer latenten Infektion mit M. tuberculosis stellt zur Zeit immer noch der Tuberkulin-Hauttest das einzige belegte und in der Routine einsetzbare Verfahren dar. Er sollte heute ausschließlich nach der von Mendel und Mantoux beschriebenen Methode durchgeführt werden. Sensitivität und Spezifität sind abhängig von der Tuberkulose-Infektionsprävalenz, daher sollte er gezielt nur bei Personen angewendet werden, die ein erhöhtes Risiko einer latenten tuberkulösen Infektion haben. Die Interpretation des Tuberkulin-Hauttestes erfolgt unter Berücksichtigung der Zugehörigkeit zu definierten Risikogruppen bzw. entsprechend einer Gefährdungseinschätzung. Zu den Risikogruppen gehören Personen, bei denen die Möglichkeit einer kürzlichen Infektion mit M. tuberculosis gegeben ist (Kontaktpersonen zu ansteckungsfähigen Tuberkulosepatienten), oder bei denen Faktoren vorliegen, die mit einem erhöhten Risiko einhergehen, eine behandlungsbedürftige Tuberkulose zu entwickeln. Die Indikation zur Chemotherapie der latenten tuberkulösen Infektion ist individuell unter sorgfältiger Nutzen-Risikoabwägung zu stellen und setzt, neben der Patientenmitarbeit, eine intensive Aufklärung des Patienten sowie eine sorgfältige Kontrolle unter Therapie voraus. Vor Therapiebeginn ist eine behandlungsbedürftige Tuberkulose in jedem Fall mit geeigneten Methoden auszuschließen.

Abstract

The immunologic mechanisms of latent tuberculosis (TB) infection are complex and hitherto not completely understood. The lifelong risk of an immunocompetent individual of developing active TB after infection with M. tuberculosis is 5 - 10 % and highest during the first two years after infection. Various factors may considerably increase the risk of developing active TB, e. g., immunosuppressive disease or immunosuppressive medication. However, the development of active TB may be avoided by preventive chemotherapy, the therapy of choice being isoniazid over a 9-month period. Alternative treatment regimens may be indicated in special cases, but it must be borne in mind that the efficacy of these regimens has not been studied sufficiently while they seem to be less well tolerated than isoniazid monotherapy. The tuberculin skin test is still the only sufficiently documented method to detect latent infection with M. tuberculosis which is also suitable for routine application. This test today should be performed exclusively as described by Mendel and Mantoux. Its sensitivity and specificity depend on the prevalence of tuberculosis infection. It should therefore be restricted to individuals at increased risk of latent TB infection. When interpreting the tuberculin skin test, it is necessary to know whether an individual belongs to one of the defined risk groups or has an elevated risk of developing active TB. Among the risk groups are individuals who may have been infected recently with M. tuberculosis (contacts of contagious TB patients) or in whom other factors increase their risk of developing active TB. The indication for chemotherapy for latent TB infection must be based on a careful individual risk-benefit analysis and, besides patient compliance, requires full information of the patient and careful monitoring during therapy. Before initiating treatment, active TB must always be excluded by the proven methods.

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