Beatmungsassoziierte Pneumonie und multiresistente bakterielle Erreger

Zusammenfassung

Die beatmungsassoziierte Pneumonie ist die bedeutendste nosokomiale Infektion in der Intensivmedizin. Eine frühzeitige adäquate Antibiotikatherapie hat höchste Priorität für das Outcome der Patienten; die Frage nach der optimalen diagnostischen Strategie steht dahinter zurück. Die initiale Antibiotikawahl richtet sich danach, ob multiresistente Erreger zu erwarten sind. Im Risikofall ist eine empirische Kombinationsbehandlung indiziert, die vorangegangene Antibiotikabehandlungen und lokale Resistenzmuster berücksichtigt. Die Reevaluation und Deeskalation der Therapie anhand der mikrobiologischen Befunde und die Begrenzung der Therapiedauer auf eine Woche sind entscheidend, um den Einsatz von Breit-spektrum-Antibiotika und die Selektion multiresistenter Erreger einzudämmen.

Summary

Ventilator-associated pneumonia remains the most serious nosocomial infection in critically ill patients. Providing appropriate antibiotic therapy promptly is crucial for successful treatment; whereas the diagnostic approach seems to play a minor role. The empirical antibiotic therapy should be guided by the risk for infections due to multiresistant bacteria. For patients at risk a combination therapy, considering local resistance data and formerly applied antibiotic substances, is recommended. Reevaluation and deescalation of antibiotic therapy based on microbiological culture results and discontinuation of antimicrobial treatment after one week is essential for the control of broadspectrum antibiotic use and antibiotic resistance.

Schlüsselwörter:

beatmungsassoziierte Pneumonie - multiresistente Erreger - Pseudomonas aeruginosa - methicillinresistenter Staphylococcus aureus (MRSA) - Acinetobacter ssp

Key words:

ventilator-associated pneumonia - multiresistant microorganisms - Pseudomonas aeruginosa - methicillin-resistant Staphylococcus aureus (MRSA) - Acinetobacter ssp

Kernaussagen

• Beatmete Patienten haben ein erheblich höheres Pneumonierisiko als spontan atmende Patienten; das Risiko steigt kumulativ mit der Beatmungsdauer.

• Das Auftreten einer beatmungsassoziierten Pneumonie wird in erster Linie durch die Intubation begünstigt; entsprechend kann die Pneumoniehäufigkeit durch noninvasive Beatmung gesenkt werden.

• Weitere sinnvolle Maßnahmen der Pneumonieprävention sind oropharyngeale Dekontamination, Oberkörperhochlagerung und subglottische Sekretabsaugung. Sedativa sollten restriktiv eingesetzt werden, um die Beatmungszeiten und das damit assoziierte Pneumonierisiko möglichst gering zu halten.

• Ein allgemein anerkannter Goldstandard für die Diagnostik der VAP existiert nicht. Anhand klinischer und radiologischer Zeichen kann die Diagnose nicht eindeutig gestellt werden.

• Durch bronchoskopische Gewinnung von Bronchialsekret in Kombination mit einer quantitativen mikrobiologischen Untersuchung kann die Diagnose mit hoher Spezifität gestellt werden; die Sensitivität ist allerdings - besonders bei bereits vorangegangener Antibiotikagabe - weit unter 100 %. Wichtig für den Erregernachweis ist, dass Blutkulturen und Proben von respiratorischen Sekreten vor Beginn der Antibiotikabehandlung gewonnen werden.

• Die mikroskopische Untersuchung von Trachealsekret oder BAL kann Anhaltspunkte für die Wahl der empirischen Antibiotikatherapie geben.

• Die häufigsten Erreger der VAP sind Pseudomonas aeruginosa, Staphylococcus aureus und Enterobacteriaceae. Wie weit mit multiresistenten Stämmen zu rechnen ist, hängt ab von der Dauer des Krankenhausaufenthalts, vorangegangenen Antibiotikabehandlungen sowie sog. Healthcare assoziierten Faktoren, wie z.B. Dialyse. Eine weitere wichtige Rolle spielt die lokale Prävalenz multiresistenter Isolate in der jeweiligen Intensivstation.

• Das Outcome der Patienten hängt von einer frühen und gleichzeitig adäquaten empirischen Antibiotikabehandlung ab.

• Um für einen möglichst hohen Anteil der Patienten noch vor Erhalt der mikrobiologischen Befunde eine wirksame Therapie sicherzustellen, sollte in Fällen, die resistente Erreger erwarten lassen, empirisch mit einer Kombination von zwei pseudomonaswirksamen Substanzen sowie einem MRSA-wirksamen Präparat begonnen werden.

• Nach Erhalt der mikrobiologischen Befunde sollte eine Reevaluation erfolgen, um die Behandlung entweder anhand des Antibiogramms nachgewiesener Erreger auf Antibiotika mit schmalerem Spektrum zu deeskalieren oder - falls sich der Verdacht auf eine Pneumonie nicht bestätigen lässt - die Therapie zu beenden.

• Bei gesicherter Pneumonie kann die Dauer der Antibiotikabehandlung auf acht Tage mit einer einzelnen Substanz begrenzt werden; bei Pneumonien mit Pseudomonas aeruginosa ist dieses Vorgehen allerdings umstritten.

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