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Anästhesiol Intensivmed Notfallmed Schmerzther 2011; 46(10): 674-682
DOI: 10.1055/s-0031-1291946
Fachwissen
Anästhesie-Topthema: Perioperative Prophylaxe und Therapie von Infektionen
© Georg Thieme Verlag Stuttgart · New York

Perioperative Prophylaxe und Therapie von Infektionen – Perioperative Antibiotikaprophylaxe

Perioperative antimicrobial prophylaxis
Ina Tammer
,
Gernot Geginat
,
Dirk Schlüter
Further Information

Publication History

Publication Date:
21 October 2011 (online)

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Zusammenfassung

Die perioperative Antibiotikaprophylaxe (PAP) stellt eine wichtige, jedoch nicht die alleinige Maßnahme zur Prävention postoperativer Wundinfektionen dar. Ihre Wirksamkeit wurde in einer Vielzahl von Studien belegt und in nationalen und internationalen Leitlinien umgesetzt. Neben der Auswahl des Antibiotikums sind Art, Dauer und Zeitpunkt der Applikation wichtige Kriterien für den Erfolg der Prophylaxe. Der Artikel gibt einen Überblick über die zur PAP empfohlenen Antibiotika und deren Einfluss auf das normalerweise zu erwartende Erregerspektrum bei elektiven Eingriffen. Darüber hinaus werden die häufigsten Problemkeime postoperativer Wundinfektionen und der derzeitige Stellenwert alternativer Antibiotika diskutiert.

Abstract

Perioperative antimicrobial prophylaxis (AMP) is an important but not the only procedure to prevent surgical site infections. The effectiveness of AMP to prevent surgical site infections has been proven in numerous studies during the last decades and is part of national and international guidelines. The choice of the antibiotic as well as the duration, time point and mode of application strongly impact on the effectiveness of the prophylaxis. This article provides an overview on recommended antibiotics for AMP and their activity against the expected bacterial pathogens in elective surgery. Furthermore, the current spectrum of microorganisms most frequently isolated from surgical site infections and alternative antibiotic strategies are discussed.

Kernaussagen

  • Nach wie vor ist die perioperative Antibiotikaprophylaxe mit Amino- / Azylaminopenizilline/BLI oder Cephalosporinen der 1./2. Generation ausreichend effektiv, was sich an den in Deutschland niedrigen postoperativen Wundinfektionsraten zeigt.

  • Bei Patienten mit nachgewiesenen Allergien gegen Beta-Lactam-Antibiotika muss auf alternative Substanzen wie Clindamycin oder Fluorochinolone (oder Vancomycin) zurückgegriffen werden.

  • Bei Hochrisikopatienten, antibiotisch vorbehandelten Patienten und Patienten mit Ableitungen muss man von einer Selektion resistenter Spezies ausgehen. Hier sollten Substanzen mit einem erweiterten Wirkspektrum gewählt werden.

  • Patienten mit einem erhöhten Risiko für eine MRSA-Kolonisation sollten vor elektiven Eingriffen auf MRSA gescreent und nach Möglichkeit präoperativ saniert werden. Ist eine Sanierung vorher nicht möglich, sollte die Dekolonisationsbehandlung perioperativ weitergeführt werden.

  • In operativen Einrichtungen mit niedriger MRSA-Prävalenz sollten weiterhin Amino- / Azylaminopenizilline/BLI-Kombinationen oder Cephalosporine der 1./2. Generation eingesetzt werden.

  • In operativen Einrichtungen mit hoher Prävalenz Methicillin-resistenter Staphylokokken und vorgesehener Implantation von Fremdmaterial kann eine zusätzliche perioperative Prophylaxe mit Vancomycin erwogen werden.

  • Das Antibiotikum sollte intravenös appliziert werden, um in kurzer Zeit ausreichend hohe Serum- und Gewebespiegel zu erreichen.

  • Optimal ist ein Zeitintervall von 1 h vor bis 2 h nach der Inzision, spätestens jedoch vor Wundverschluss. Sollen intraoperativ Materialien für die kulturelle mikrobiologische Diagnostik gewonnen werden, so darf das Antibiotikum erst nach Materialentnahme gegeben werden.

  • Bei Operationen, die länger als 2 h dauern, sollte eine Wiederholungsdosis gegeben werden.

  • Eine Verlängerung der perioperativen Prophylaxe über die Dauer der Operation hinaus reduziert postoperative Wundinfektionen nicht, sondern erhöht das Risiko für die Selektion resistenter Spezies. Außerdem steigt das Risiko für die Entstehung C. difficile-assoziierter Diarrhoen.

Schlüsselwörter:

perioperative Antibiotikaprophylaxe - Prävention - postoperative Wundinfektion - MRSA

Key words:

perioperative antimicrobial prophylaxis - prevention - surgical site infections - MRSA

Ergänzendes Material

 

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