Rationale perioperative Antibiotikatherapie in der Thoraxchirurgie

Zusammenfassung

Hintergrund Infektiöse Komplikationen nach lungenresezierenden Eingriffen sind mit erheblicher perioperativer Morbidität und Mortalität verbunden. Neben anderen Faktoren beeinflusst sowohl die perioperative Antibiotikaprophylaxe als auch das Management der postoperativen Pneumonie das Behandlungsergebnis. Ein lokaler Behandlungspfad soll helfen, eine rationale perioperative Antibiotikatherapie zu realisieren.

Methoden Wir analysierten mikrobiologische Ergebnisse von 200 Patienten vor und nach lungenresezierenden Eingriffen von Oktober 2013 bis Oktober 2014. Unter Berücksichtigung der aktuellen Leitlinien, der lokalen Erreger- und Resistenzsituation sowie Prinzipien der Antibiotic Stewardship wurde ein Behandlungspfad für die perioperative Antibiotikatherapie entwickelt.

Ergebnisse Mehrheitlich wurden in der präoperativen (62%) und in der postoperativen Phase (78%) gramnegative Erreger nachgewiesen. Der Anteil der Erreger mit intrinsischer Resistenz gegenüber der gängigen perioperativen Antibiotikaprophylaxe war sowohl in der präoperativen (21%) als auch in der postoperativen Phase (39%) bedeutsam. Diese Erkenntnisse wurden in den lokalen Behandlungspfad integriert.

Schlussfolgerung Die gängige perioperative Antibiotikaprophylaxe erfasst nur teilweise das Erregerspektrum der präoperativen tracheobronchialen Besiedelung sowie der postoperativen Pneumonie. Sie sollte daher nicht über den Operationszeitpunkt hinaus fortgeführt werden. Eine postoperative Pneumonie sollte nach den Grundsätzen einer nosokomialen Pneumonie therapiert werden und die lokale Erreger- und Resistenzsituation berücksichtigen.

Abstract

Introduction Infectious complications after lung resections pose a high burden of perioperative morbidity and mortality. Among other factors, perioperative antibiotic prophylaxis and management of a postoperative pneumonia have an impact on patient outcome. We developed a local clinical pathway for adequate perioperative use of antibiotics.

Methods We analysed respiratory samples of 200 patients taken before and after lung resection performed in our lung clinic from October 2013 till October 2014. The clinical pathway was based on our local pathogen and resistance pattern as well as on current guidelines and on the principals of antibiotic stewardship.

Results Gram negative bacteria were the predominant pathogens that grew from the samples in the preoperative phase (62%), as well as in the postoperative phase (78%). A significant number of these bacteria showed intrinsic resistance against the commonly used antibiotics for perioperative prophylaxis. This was the case for both the preoperative phase (21%) and the postoperative phase (39%). These findings were integrated into the local clinical pathway.

Conclusion The commonly used antibiotics for perioperative prophylaxis in thoracic surgery cover only some of the pathogens responsible for preoperative airway colonisation and postoperative pneumonia. Therefore, perioperative antibiotic prophylaxis should be given as a single shot just before surgery and postoperative pneumonia should be treated as a hospital acquired pneumonia with respect to the local pathogen and resistance pattern.

Schlüsselwörter

Thoraxchirurgie - Antibiotikatherapie - Behandlungspfad - Antibiotikaprophylaxe

Key words

antibiotic treatment - antibiotic prophylaxis - thoracic surgery - clinical pathway

• Literatur

• 1 Schussler O, Alifano M, Dermine H. et al. Postoperative pneumonia after major lung resection. Am J Respir Crit Care Med 2006; 173: 1161-1169 doi:10.1164/rccm.200510-1556OC
• 2 Imperatori A, Nardecchia E, Dominioni L. et al. Surgical site infections after lung resection: a prospective study of risk factors in 1,091 consecutive patients. J Thorac Dis 2017; 9: 3222-3231 doi:10.21037/jtd.2017.08.122
• 3 Simonsen DF, Søgaard M, Bozi I. et al. Risk factors for postoperative pneumonia after lung cancer surgery and impact of pneumonia on survival. Respir Med 2015; 109: 1340-1346 doi:10.1016/j.rmed.2015.07.008
• 4 Belda J, Cavalcanti M, Ferrer M. et al. Bronchial colonization and postoperative respiratory infections in patients undergoing lung cancer surgery. Chest 2005; 128: 1571-1579 doi:10.1378/chest.128.3.1571
• 5 DʼJourno XB, Rolain JM, Doddoli C. et al. Airways colonizations in patients undergoing lung cancer surgery. Eur J Cardiothorac Surg 2011; 40: 309-319 doi:10.1016/j.ejcts.2010.11.036
• 6 Aznar R, Mateu M, Miró JM. et al. Antibiotic prophylaxis in non-cardiac thoracic surgery: cefazolin versus placebo. Eur J Cardiothorac Surg 1991; 5: 515-518
• 7 Edwards FH, Engelman RM, Houck P. et al. The Society of Thoracic Surgeons Practice Guideline Series: antibiotic prophylaxis in cardiac surgery, part I: duration. Ann Thorac Surg 2006; 81: 397-404 doi:10.1016/j.athoracsur.2005.06.034
• 8 Engelman R, Shahian D, Shemin R. et al. The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part II: antibiotic choice. Ann Thorac Surg 2007; 83: 1569-1576 doi:10.1016/j.athoracsur.2006.09.046
• 9 Chang SH, Krupnick AS. Perioperative antibiotics in thoracic surgery. Thorac Surg Clin 2012; 22: 35-45 vi doi:10.1016/j.thorsurg.2011.08.012
• 10 Wacha H, Hoyme U, Isenmann R. et al. Perioperative Antibiotika-Prophylaxe. Empfehlungen einer Expertenkommission der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. Chemother J 2010; 19: 70-84
• 11 Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60: 27-40
• 12 Berríos-Torres SI, Umscheid CA, Bratzler DW. et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017; 152: 784-791 doi:10.1001/jamasurg.2017.0904
• 13 Dalhoff K, Abele-Horn M, Andreas S. et al. [Epidemiology, diagnosis and treatment of adult patients with nosocomial pneumonia – update 2017 – S3 guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy, the German Radiological Society and the Society for Virology]. Pneumologie 2018; 72: 15-63 doi:10.1055/s-0043-121734
• 14 Podbielski A, Herrmann M, Kniehl E, Mauch H, Rüssmann H. Hrsg. MIQ 07: Infektionen der tiefen Atemwege. Teil I + II. 2. Aufl.. Amsterdam: Elsevier; 2010
• 15 Du Rand IA, Blaikley J, Booton R. et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax 2013; 68 (Suppl. 01) i1-i44 doi:10.1136/thoraxjnl-2013-203618
• 16 Hautmann H, Eberhardt R, Heine R. et al. Recommendations for sedation during flexible bronchoscopy. Pneumologie 2011; 65: 647-652 doi:10.1055/s-0031-1291395
• 17 EUCAST. Breakpoint tables for interpretation of MICs and zone diameters Version 8.1. Im Internet: http://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Breakpoint_tables/v_8.1_Breakpoint_Tables.pdf Stand: 31.05.2018
• 18 Leclercq R, Cantón R, Brown DF. et al. EUCAST expert rules in antimicrobial susceptibility testing. Clin Microbiol Infect 2013; 19: 141-160 doi:10.1111/j.1469-0691.2011.03703.x
• 19 de With K, Allerberger F, Amann S. et al. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2016; 44: 395-439 doi:10.1007/s15010-016-0885-z
• 20 Schussler O, Dermine H, Alifano M. et al. Should we change antibiotic prophylaxis for lung surgery? Postoperative pneumonia is the critical issue. Ann Thorac Surg 2008; 86: 1727-1733 doi:10.1016/j.athoracsur.2008.08.005
• 21 Turna A, Kutlu CA, Ozalp T. et al. Antibiotic prophylaxis in elective thoracic surgery: cefuroxime versus cefepime. Thorac Cardiovasc Surg 2003; 51: 84-88 doi:10.1055/s-2003-38991
• 22 Bodmann KF, Grabein B, Kresken M. et al. S2k-Leitlinie „Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen – Update 2018“. Im Internet: https://www.awmf.org/uploads/tx_szleitlinien/082-006l_S2k_Parenterale_Antibiotika_2019-01_1.pdf Stand: 21.05.2018
• 23 Chastre J, Wolff M, Fagon JY. et al. Comparison of 8 vs. 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA 2003; 290: 2588-2598 doi:10.1001/jama.290.19.2588
• 24 Yamada Y, Sekine Y, Suzuki H. et al. Trends of bacterial colonisation and the risk of postoperative pneumonia in lung cancer patients with chronic obstructive pulmonary disease. Eur J Cardiothorac Surg 2010; 37: 752-757 doi:10.1016/j.ejcts.2009.05.039
• 25 Radu DM, Jauréguy F, Seguin A. et al. Postoperative pneumonia after major pulmonary resections: an unsolved problem in thoracic surgery. Ann Thorac Surg 2007; 84: 1669-1673 doi:10.1016/j.athoracsur.2007.05.059