Verkürzte Therapiedauer bei bakteriellen Infektionen

Was ist neu?

Pyelonephritis Eine Therapiedauer von 7 Tagen ist bei Patienten mit Pyelonephritis nach neueren Studien sicher und in der Regel ausreichend – auch, wenn anstelle eines Fluorchinolons in der gezielten Behandlung Cotrimoxazol (bei nachgewiesener In-vitro-Aktivität) verwendet wird.

Bauchrauminfektionen Die Therapiedauer bei vielen intraabdominellen Infektionen kann bei entsprechenden Patienten postoperativ bzw. nach adäquater Drainage kurz sein. Vor allem bei Cholezystektomie braucht es in der Regel keine postoperative Antibiotikatherapie.

Gram-negative Bakteriämie/Sepsis Die Therapiedauer bei Gram-negativer Bakteriämie/Sepsis kann bei gutem Ansprechen individuell bis auf 7 Tage (ggf. bei z. B. erfolgter Herdsanierung/Drainage auch kürzer) verkürzt werden. Klinische Kriterien zur Therapiedauersteuerung reichen meist aus.

Ambulant erworbene Pneumonie Die Therapiedauer kann bei Patienten mit ambulant erworbener Pneumonie und gutem Ansprechen nach 3 – 5 Tagen entsprechend kurz sein.

Fieber (unklarer Ursache) und Neutropenie Daten aus einer randomisierten klinischen Studie und weitere Beobachtungen weisen darauf hin, dass bei Fieber unklarer Ursache im Falle von Ansprechen nach empirischer Antibiotikagabe Kurzzeittherapien auch bei Hochrisikopatienten mit Neutropenie adäquat sein können.

Abstract

The adequate duration of antibiotic therapy in the treatment of bacterial infections is often unclear. For many indications guidelines recommend intervals with ranges of several days instead of fixed courses of treatment, and physicians tend to choose longer rather than shorter durations. The emergence of infections due to multidrug-resistant bacteria and the valuation of avoidable side effects from antibiotic agents raised the question whether a shortened duration of therapy is appropriate in specific indications. Therefore clinical trials to investigate the effectiveness of shorter in comparison to prolonged antibiotic treatment have yet been of growing interest to current research. Recent studies have shown that, concerning clinical endpoints, shorter duration of antibiotic therapy is not inferior to longer treatment in the management of pyelonephritis, intraabdominal infections, community acquired pneumonia an also gramnegative bloodstream infections and febrile neutropenia.

Schlüsselwörter

Bakterielle Infektionen - Antibiotika - Therapiedauer

Key words

bacterial infection - antibiotics - duration of therapy

• Literatur

• 1 Llewelyn MJ, Fitzpatrick JM, Darwin E. et al. The antibiotic course has had its day. BMJ 2017; 358: j3418
• 2 Tebano G, Dyar OJ, Beovic B. et al. Defensive medicine among antibiotic stewards: the international ESCMID AntibioLegalMap survey. J Antimicrob Chemother 2018; DOI: 10.1093/jac/dky098.
• 3 Spellberg B. The maturing antibiotic mantra: shorter is still better. J Hosp Med 2018; 13: 361-362
• 4 Sandberg T, Skoog G, Hermansson AB. et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet 2012; 380: 484-490
• 5 Dinh A, Davido B, Etienne M. et al. Is 5 days of oral fluoroquinolone enough for acute uncomplicated pyelonephritis? The DTP randomized trial. Eur J Clin Microbiol Infect Dis 2017; 36: 1443-1448
• 6 van Nieuwkoop C, van der Starre WE, Stalenhoef JE. et al. Treatment duration of febrile urinary tract infection: a pragmatic randomized, double-blind, placebo-controlled non-inferiority trial in men and women. BMC Med 2017; 15: 70
• 7 Fox MT, Melia MT, Same RG. et al. A seven-day course of TMP-SMX may be as effective as a seven-day course of ciprofloxacin for the treatment of pyelonephritis. Am J Med 2017; 130: 842-845
• 8 Regimbeau JM, Fuks D, Pautrat K. et al. Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis: a randomized clinical trial. JAMA 2014; 312: 145-154
• 9 Sawyer RG, Claridge JA, Nathens AB. et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med 2015; 372: 1996-2005
• 10 Rattan R, Allen CJ, Sawyer RG. et al. Patients with complicated intra-abdominal infection presenting with sepsis do not require longer duration of antimicrobial therapy. J Am Coll Surg 2016; 222: 440-466
• 11 Doi A, Morimoto T, Iwata K. Shorter duration of antibiotic treatment for acute bacteraemic cholangitis with successful biliary drainage: a retrospective cohort study. Clin Microbiol Infect 2018; DOI: 10.1016/j.cmi.2018.01.021.
• 12 Loozen CS, Kortram K, Kornmann VN. et al. Randomized clinical trial of extended versus single-dose perioperative antibiotic prophylaxis for acute calculous cholecystitis. Br J Surg 2017; 104: e151-e157
• 13 de Santibañes M, Glinka J, Pelegrini P. et al. Extended antibiotic therapy versus placebo after laparoscopic cholecystectomy for mild and moderate acute calculous cholecystitis: a randomized double-blind clinical trial. Surgery 2018; DOI: 10.1016/j.surg.2018.01.014.
• 14 Montravers P, Tubach F, Lescot T. et al. Short-course antibiotic therapy for critically ill patients treated for postoperative intra-abdominal infection: the DURAPOP randomised clinical trial. Intensive Care Med 2018; 44: 300-310
• 15 Chotiprasitsakul D, Han JH, Cosgrove SE. et al. Comparing the outcomes of adults with Enterobacteriaceae bacteremia receiving short-course versus prolonged-course antibiotic therapy in a multicenter, propensity score–matched cohort. Clin Infect Dis 2018; 66: 172-177
• 16 Nelson AN, Justo JA, Bookstaver PB. et al. Optimal duration of antimicrobial therapy for uncomplicated Gram-negative bloodstream infections. Infection 2017; 45: 613-620
• 17 Giannella M, Pascale R, Toschi A. et al. Treatment duration for Escherichia coli bloodstream infection and outcomes: retrospective single-centre study. Clin Microbiol Infect 2018; DOI: 10.1016/j.cmi.2018.01.013.
• 18 Yahav D, Turjeman A, Babitch T. et al. Seven versus 14 antibiotic days for the treatment of Gram-negative bacteraemia: non-inferiority randomized controlled trial. ECCMID 2018 abstract #O1120
• 19 el Moussaoui R, de Borgie CA, van den Broek P. et al. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. BMJ 2006; 332: 135
• 20 Uranga A, España PP, Bilbao A. et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med 2016; 176: 1257-1265
• 21 Dinh A, Benjamin D, Duran C. et al. Effectiveness of three days of beta-lactam antibiotics for hospitalized community-acquired pneumonia: a randomized non-inferiority double-blind trial. ECCMID 2018 abstract #O1126
• 22 Foolad F, Huang AM, Nguyen CT. et al. A multicentre stewardship initiative to decrease excessive duration of antibiotic therapy for the treatment of community-acquired pneumonia. J Antimicrob Chemother 2018; 73: 1402-1407
• 23 Heinz WJ, Buchheidt D, Christopeit M. et al. Diagnosis and empirical treatment of fever of unknown origin (FUO) in adult neutropenic patients: guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2017; 96: 1775-1792
• 24 Aguilar-Guisado M, Espigado I, Martín-Peña A. et al. Optimisation of empirical antimicrobial therapy in patients with haematological malignancies and febrile neutropenia (How Long study): an open-label, randomised, controlled phase 4 trial. Lancet Haematol 2017; 4: e573-e583
• 25 Le Clech L, Talarmin JP, Couturier MA. et al. Early discontinuation of empirical antibacterial therapy in febrile neutropenia: the ANTIBIOSTOP study. Infect Dis (Lond) 2018; 16: 1-11