Update zur Tuberkulose im Kindesalter

Zusammenfassung

Die Tuberkulose ist eine der am längsten bekannten Infektionskrankheiten. Nichtsdestotrotz stellen Diagnostik und adäquate Therapie im Kindesalter immer noch eine Herausforderung dar. Aufgrund der speziellen immunologischen Situation sind Kinder, insbesondere Kleinkinder, in höherem Maße als Erwachsene gefährdet an Tuberkulose zu erkranken. Neue Diagnostikmethoden wie die Interferon Gamma Release Assays sind zwar spezifischer als der Tuberkulin-Hauttest, im Säuglingsalter und bei disseminierter Erkrankung sind jedoch beide Tests nicht immer ausreichend sensitiv. Eine resistogrammgerechte Therapie wird durch seltenen Erregernachweis bei meist paucibacillärer Erkrankung erschwert. Ein zunehmender Anteil resistenter Erreger bereitet zusätzliche Probleme. Aufgrund der im Vergleich zu Erwachsenen variablen Metabolisierung verschiedener Antituberkulotika in verschiedenen Altergruppen sind diese in der Therapie der Tuberkulose im Kindesalter häufig nicht ausreichend effizient. Außerdem können unerwünschte Nebenwirkungen die Therapie komplizieren. Neue Impfstoffe sind in der Erprobung, jedoch momentan noch nicht verfügbar.

Summary

Childhood tuberculosis has been described for centuries. Nevertheless correct and timely diagnosis as well as adequate treatment remain a challenge. Due to the special immunological conditions in childhood especially young children are at much higher risk of infection with tuberculosis than adults. New diagnostic tests like interferon release assays are more specific but show a lack of sensitivity in infants or miliary disease. Targeted therapeutic intervention is difficult due to often negative cultures in paucibacilliary disease. Increasing numbers of resistant strains cause multiple problems. In addition to this, children metabolize drugs differently and therefore require child specific dosages. Otherwise either sub therapeutic levels or increased side effects can occur. New vaccination strategies are under investigation but have not been approved for clinical use yet.

Schlüsselwörter

Tuberkulose - Resistenzen

Keywords

Tuberculosis - drug resistance

• Literatur

• 1 American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med. 2003; 167: 603-662.
• 2 Detjen AK, Magdorf K. Besonderheiten der Kindertuberkulose. Pneumologie 2009; 63: 207-218.
• 3 Diel R, Loytved G, Nienhaus A. et al New recommendations for contact tracing in tuberculosis. German Central Committee against Tuberculosis. Pneumologie 2011; 65: 359-378.
• 4 Dooley DP, Carpenter JL, Rademacher S. Adjunctive corticosteroid therapy for tuberculosis: a critical reappraisal of the literature. Clin Infect Dis 1997; 25: 872-888.
• 5 Graham S. Treatment of paediatric TB: revised WHO guidelines. Paediatric Respiratory Reviews 2011; 12: 22-26.
• 6 Magdorf K, Detjen AK. Proposed management of childhood tuberculosis in low-incidence countries. Eur J Pediatr 2008; 167: 927-938.
• 7 Mandalakas AM, Detjen AK, Hesseling AC. et al Interferon- gamma release assays and childhood tuberculosis: systematic review and meta-analysis. Int J Tuberc Lung Dis 2011; 15: 1018-1032.
• 8 Marais B, Gie R, Hesseling AC. et al A Refined Symptom-Based Approach to Diagnose Pulmonary Tuberculosis in Children. Pediatrics 2006; 118: e1350
• 9 Ozuah PO, Ozuah TP, Stein RE. et al Evaluation of a risk assessment questionnaire used to target tuberculin skin testing in children. JAMA 2001; 285: 451-453.
• 10 Robert Koch-Institut. Bericht zur Epidemiologie der Tuberkulose in Deutschland 2009. Berlin: Robert Koch-Institut; 2011: 19-37.
• 11 Rock RB, Olin M, Baker CA. et al Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin Microbiol Rev 2008; 21: 243-261.
• 12 Sandgren A. et al Childhood tuberculosis in the European Union - European Economic Area 2000-2009. http:www.eurosurveillance.org
• 13 Schaaf HS, Willemse M, Cilliers K. et al Rifampin pharmacokinetics in children, with and without human immunodeficiency virus infection, hospitalized for the management of severe forms of tuberculosis. BMC Med 2009; 7: 19
• 14 Sharma SK, Mohan A, Sharma A. et al Miliary Tuberculosis: New Insights Into an Old Disease. Lancet Infect Dis 2005; 5: 415-430.
• 15 Solovic I, Sester M, Gomez-Reino JJ. et al The risk of tuberculosis related totumour necrosis factor antagonist therapies: a TBNET consensus statement. Eur Respir J 2010; 36: 1185-1206.
• 16 Spyridis NP, Spyridis PG, Gelesme A. et al The effectiveness of a 9-month regimen of isoniazidalone versus 3- and 4-month regimens of isoniazid plus rifampin for treatment of latent tuberculosis infection in children: results of an 11-year randomized study. Clin Infect Dis 2007; 45: 715-722.
• 17 Ständige Impfkommission (STIKO). Impfempfehlungen der Ständigen Impfkommission (STIKO) am Robert Koch-Institut; Stand: Juli. 2011 13
• 18 Strang J, Nunn AJ. Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei: results at 10 years followup. Q J Med 2004; 97: 525-535.
• 19 Swaminathan S, Rekha B. Pediatric tuberculosis: global overview and challenges. Clin Infect Dis 2010; 50 (Suppl. 03) (Suppl) 184-194.
• 20 Thee S, Detjen AA, Wahn U, Magdorf K. Isoniazid pharmacokinetic studies of the 1960s: considering a higher isoniazid dose in childhood tuberculosis. Scand J Infect Dis 2010; 42: 294-298.
• 21 World Health Organisation. 2011/2012 Tuberculosis Global Facts; S. 1. www.who.int/tb
• 22 World Health Organisation, Geneva, Switzerland. Guidlelines for the programmatic management of drug-resistant tuberculosis - Emergency update. 2008 (WHO/HTM/TB/2008.402)
• 23 World Health Organization. Guidance for national tuberculosis programmes on the management of tuberculosis in children. 2006 (WHO/HTM/ TB/2006.371)