Akute bakterielle Meningitis: Neues aus Forschung und Klinik

Zusammenfassung

Bis zur klinischen Einführung der Antibiotika in den 30er- und 40er-Jahren des vergangenen Jahrhunderts verliefen bakterielle Meningitiden meistens tödlich. Seither kann diese Erkrankung zwar geheilt werden, die Letalität und die Rate an dauerhaften neurologischen Schädigungen sind in Abhängigkeit von Erreger und betroffenem Patient aber weiterhin unerfreulich hoch. In den vergangenen 10 Jahren haben sich die Epidemiologie der Erkrankung, aber auch die Behandlungsmöglichkeiten entscheidend verändert. Die wichtigsten epidemiologischen Veränderungen sind (I) die „Beinahe-Ausrottung” der Haemophilus-influenzae-Typ-B-Meningitis sowie die Abnahme der Pneumokokken- und Meningokokkenmeningitisfälle in Ländern mit hoher Durchimpfungsrate und (II) die zunehmende Ausbreitung resistenter Meningitiserreger. Der entscheidende therapeutische Fortschritt ist, dass nun mit Dexamethason ein Medikament mit erwiesener Wirksamkeit – zumindest bei Erwachsenen mit einer Pneumokokkenmeningitis – für die adjuvante Therapie zur Verfügung steht. Darüber hinaus konnten klinische Studien belegen, dass der Zeitraum zwischen Krankenhausaufnahme und Beginn der Antibiotikatherapie den klinischen Verlauf entscheidend beeinflusst. In diesem Artikel werden zentrale epidemiologische Einflussgrößen wie soziokulturelle und individuelle Faktoren (z. B. Genpolymorphismen) vorgestellt. Zudem werden die aktuellen und die zu erwartenden Möglichkeiten der Impfprophylaxe (insbesondere neue Konjugatimpfstoffe) beschrieben. Ein weiterer Schwerpunkt liegt in der Darstellung des diagnostischen und therapeutischen Vorgehens bei der akuten bakteriellen Meningitis, unter Berücksichtigung der Behandlung meningitisassoziierter intrakranieller Komplikationen. Des Weiteren wird das gegenwärtig gültige Konzept zur Pathophysiologie der akuten bakteriellen Meningitis (am Beispiel der Pneumokokkenmeningitis) skizziert und daraus ableitbare innovative Therapieansätze (wie z. B. der Einsatz nicht lytischer bakterizider Antibiotika) vorgestellt.

Abstract

Until the introduction of antibiotics in the 1930 s and 1940 s, acute bacterial meningitis was fatal in the vast majority of cases. Since then it has become curable with a variable mortality and morbidity rate depending on individual pathogens and patients. During the past 20 years, we have witnessed significant changes in the epidemiology and treatment of acute bacterial meningitis. The most important epidemiological changes are (I) the near-eradication of meningitis due to Haemophilus influenzae type B as well as the decline in the incidence of pneumococcal and meningococcal meningitis in countries that have introduced the respective immunisation programmes, and (II) the emergence of antimicrobial resistance among meningeal pathogens which is of particular importance for the clinical management of the disease. The major therapeutic change is that adjuvant dexamethasone therapy has been demonstrated to be beneficial, particularly in adults with pneumococcal meningitis. It became also evident that time from arrival at the hospital to administration of the first dose of antibiotics is a crucial independent factor that influences outcome. Here we review (I) the epidemiological characteristics of acute bacterial meningitis, (II) the impact of vaccination programmes on the epidemiology, (III) the clinical and laboratory presentation of the disease and (IV) the antibiotic regimens and adjuvant treatment options that are currently recommended for its treatment. We further review (V) current concepts of the pathophysiology of the disease – using the example of pneumococcal meningitis – with an emphasis on promising targets for novel adjunctive therapy in acute bacterial meningitis.

Schlüsselwörter

Meningitis - Epidemiologie - Prophylaxe - Therapie - Pathophysiologie

Keywords

meningitis - epidemiology - prophylaxis - treatment - pathophysiology

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