Z Gastroenterol 2015; 53(05): 418-459
DOI: 10.1055/s-0034-1399337
Leitlinie
© Georg Thieme Verlag KG Stuttgart · New York

S2k-Leitlinie Gastrointestinale Infektionen und Morbus Whipple[1]

S2k-guideline gastrointestinal infectious diseases and Whipple’s disease
S. Hagel
1   Klinik für Innere Medizin IV, Zentrum für Infektionsmedizin und Krankenhaushygiene und IFB Sepsis und Sepsisfolgen, Universitätsklinikum Jena der Friedrich-Schiller-Universität Jena, Jena
,
H.-J. Epple
2   Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin
,
G. E. Feurle
3   DRK Krankenhaus Neuwied, Neuwied
,
W. V. Kern
4   Abteilung Infektiologie, Klinik für Innere Medizin II, Universitätsklinikum Freiburg, Freiburg
,
P. Lynen Jansen
5   Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten e.V. (DGVS), Berlin
,
P. Malfertheiner
6   Klinik für Gastroenterologie, Hepatologie und Infektiologie, Otto von Guericke Universität Magdeburg, Magdeburg
,
T. Marth
7   Abteilung für Innere Medizin, Krankenhaus Maria Hilf GmbH, Daun
,
E. Meyer
8   Krankenhaushygiene, Klinikum München, München
,
M. Mielke
9   Robert Koch-Institut, Berlin
,
V. Moos
10   Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin
,
L. von Müller
11   Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
,
J. Nattermann
12   Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Bonn
,
M. Nothacker
13   Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. (AWMF), Philipps-Universität, Marburg
,
C. Pox
14   Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum
,
E. Reisinger
15   Klinik und Poliklinik für Innere Medizin, Abteilung für Tropenmedizin und Infektionskrankheiten, Universitätsmedizin Rostock, Rostock
,
B. Salzberger
16   Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg, Regensburg
,
H. J. F. Salzer
17   I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg
,
M. Weber
18   Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena der Friedrich-Schiller-Universität Jena, Jena
,
T. Weinke
19   Klinik für Gastroenterologie und Infektiologie, Klinikum Ernst von Bergmann gGmbH, Potsdam
,
S. Suerbaum
20   Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Medizinische Hochschule Hannover, Hannover
,
A. W. Lohse*
17   I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg
,
A. Stallmach*#
18   Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena der Friedrich-Schiller-Universität Jena, Jena
,
Weitere Mitglieder der Leitlinienkommission in alphabetischer Reihenfolge einschließlich Affiliation:
› Institutsangaben
Weitere Informationen

Publikationsverlauf

20. Februar 2015

08. März 2015

Publikationsdatum:
12. Mai 2015 (online)

Einleitung und Methodik

E-1 Hintergrund

Akute gastrointestinale Infektionen werden durch eine tbVielzahl bakterieller, viraler und parasitärer Erreger hervorgerufen. Der Krankheitsverlauf wird durch die Virulenz des jeweiligen Erregers, die Wirtsantwort, durch den Ernährungs- und Immunstatus des Wirtes sowie mögliche Begleiterkrankungen beeinflusst. Meist ist eine infektiöse Gastroenteritis selbstlimitierend, eine symptomatische Behandlung ausreichend und eine ätiologische Abklärung aus klinischen Erwägungen nicht notwendig [1] .

Akute gastrointestinale Infektionen sind häufig. Im Rahmen einer epidemiologischen Studie, bei der über 12 Monate 21 262 Erwachsene nach Symptomen einer gastrointestinalen Infektion in den vergangenen 4 Wochen telefonisch befragt wurden, wurde für Deutschland eine Inzidenz von 0,95 Episoden/Personenjahr ermittelt. Hochgerechnet bedeutet dies für Deutschland rund 65 Mio. Episoden einer akuten gastrointestinalen Erkrankung pro Jahr, von denen die überwiegende Mehrzahl infektiöser Genese ist. 78 % der Erkrankten gaben an, eine Diarrhö gehabt zu haben, 12 % der Erkrankten berichteten über Erbrechen, 10 % der Erkrankten wiesen beide Symptome auf. Die durchschnittliche Erkrankungsdauer betrug 3,7 Tage. Mehr als ein Drittel (37,8 %) der Erkrankten begaben sich in eine ambulante ärztliche Betreuung, weniger als 1 – 3 % der Patienten wurden hospitalisiert [2]. Die bei Weitem größte Gruppe der Patienten mit akuter Gastroenteritis wird somit ambulant betreut. Im Gegensatz zu diesen blanden, selbstlimitierenden Verläufen steht die Beobachtung, dass sich von 2001 – 2011 die Zahl der stationären Aufnahmen aufgrund einer akuten infektiösen Gastroenteritis von 127 867 auf 282 199 Fälle pro Jahr mehr als verdoppelt hat. Besonders stark war dieser Anstieg in der Gruppe der über 65-jährigen Patienten sowie bei Patienten mit Clostridium difficile-Infektionen (CDI) zu verzeichnen. Die Zahl der Sterbefälle aufgrund gastrointestinaler Infektionen stieg im gleichen Zeitraum um das 10fache an [3].

Entsprechend der nationalen und internationalen Literatur wurden – wie in [Tab. 1] angegeben – zentrale Bezeichnungen für den Leitlinientext definiert.

Tab. 1

Definitionen für den Leitlinientext

Definition

akute Diarrhö

≥ 3 Stuhlentleerungen sowie ein Stuhlgewicht > 250 g pro Tag bei verminderter Stuhlkonsistenz

Dysenterie

Diarrhö einhergehend mit Blut- und Schleimbeimengungen

chronische Diarrhö

Diarrhö länger als 4 Wochen anhaltend

Immundefizienz

  • angeborene Immundefizienz, z. B. im Rahmen von T- und B-Zell-Defekten

  • Patienten mit erworbener Immundefizienz, z. B. Z. n. Organ- oder Knochenmarktransplantation; Chemotherapie solider oder hämatologischer Neoplasien mit oder ohne Neutropenie; HIV-Infektion im Stadium AIDS; Immunsuppressive oder immunmodulierende Therapie bei Autoimmunopathien; Glukokortikoidtherapie über einen Zeitraum von mindestens vier Wochen mit einer Erhaltungsdosis ≥ 10 mg/d.


#

E-2 Ziele der Leitlinie

Vor dem Hintergrund der Häufigkeit, aber auch der Bandbreite vom blanden, selbstlimitierenden Verlauf, bis hin zur vital-bedrohlichen Infektion ist ein evidenzbasiertes Vorgehen in der Diagnostik und Therapie notwendig, um den Patientenbedürfnissen gerecht zu werden, aber auch um die zur Verfügung stehenden Ressourcen adäquat einzusetzen. Aufgrund dessen hat sich die Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselerkrankungen entschlossen, eine S2k-Leitlinie zu erstellen, die diesem wachsenden Problem Rechnung trägt. Die methodische Erstellung der Leitlinie folgt dem Regelwerk der AWMF und dem Leitlinienprogramm der DGVS [4]. Um der Vielfältigkeit und den Besonderheiten gastrointestinaler Infektionen bei Patienten in unterschiedlichen Situationen gerecht zu werden, wurden insgesamt 6 Arbeitsgruppen gebildet:

  • Diagnostik der ambulant erworbenen Gastroenteritis (AG 1)

  • Klinisches Bild und Therapie der ambulant erworbenen Gastroenteritis (AG 2)

  • Nosokomiale Diarrhö und Clostridium difficile (AG 3)

  • Diarrhö bei Immundefizienz (AG 4)

  • Akute Gastroenteritis bei Reiserückkehrern (AG 5)

  • Morbus Whipple (AG 6)

Obgleich ausgesprochen selten, stellt auch die Infektion mit Tropheryma whipplei eine gastrointestinale Infektion dar, die in dieser Leitlinie in einem eigenen Kapitel dargestellt wird. In dieser Arbeitsgruppe gab es zur Empfehlung 6.4 keinen Konsens; hier fand eine sehr kontroverse Diskussion statt. Da Vertreter beider Positionen aufgrund ihrer klinischen Erfahrungen und wissenschaftlichen Expertise als nationale und internationale Experten gelten, sogenannte Kompromissformulierungen zu wenig inhaltliche Aussagen enthalten und deshalb für die Praxis als nicht hilfreich erachtet wurden, entschlossen sich die Koordinatoren in Abstimmung mit dem Vertreter der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) (M. Nothacker), ein sog. Minderheitsvotum aufzunehmen. Ebenso wurde zur Empfehlung 1.4 eine Minderheitsmeinung der Vertreter des Robert Koch-Instituts aufgenommen, die auf eine regelhafte Diagnostik bez. Stx-Bildner bei Patienten mit blutigen Diarrhöen zum Ausschluss einer EHEC-Infektion hinwiesen.

Das Ziel der S2k-Leitlinie „Gastrointestinale Infektionen und Morbus Whipple“ ist es, den aktuellen Kenntnisstand zu klinischem Bild, Diagnostik und Therapie gastrointestinaler Infektionen bei Erwachsenen auf Basis der wissenschaftlichen Evidenz zusammenzufassen, im Expertenkonsens zu bewerten und daraus praxisrelevante Empfehlungen abzuleiten. Sie soll einen Handlungskorridor für häufige Entscheidungen liefern und der evidenzbasierten Fort- und Weiterbildung dienen, um somit eine Verbesserung der medizinischen Versorgung betroffener Personen zu erreichen. Für die Therapie und die Besonderheiten bei Kindern und Jugendlichen sei auf die AWMF-Leitlinie „Akute infektiöse Gastroenteritis“ der Gesellschaft für Pädiatrische Gastroenterologie und Ernährung (GPGE) hingewiesen (AWMF Leitlinien Register; Nr. 068/003). Für die Diagnostik und Therapie der Helicobacter pylori-Infektion wird auf die entsprechende, aktuell in Revision befindliche, AWMF-Leitlinie „Helicobacter pylori und gastroduodenale Ulkuskrankheit” der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und auf die Mikrobiologisch-infektiologischen Qualitätsstandards (MIQ): Gastrointestinale Infektionen verwiesen [5] [6]. Da Besonderheiten hinsichtlich Diagnostik, Therapie und Verlauf bei immundefizienten Patienten beachtet werden müssen, widmet sich diesem Thema detailliert das Kapitel 4. In der Gruppe immundefizienter Patienten werden einerseits Patienten mit angeborener Immundefizienz z. B. im Rahmen von T- und B-Zell-Defekten als auch Patienten mit erworbener Immundefizienz im Rahmen einer fortgeschrittenen HIV-Erkrankung, einer Immunsuppression bei Chemotherapie oder medikamentös bedingt nach Transplantationen oder unter der Therapie einer Autoimmunerkrankung verstanden. Auf Besonderheiten bei der Therapie älterer Patienten über 65 Jahre wird, sofern die Evidenz dies zulässt, in den entsprechenden Kapiteln zu Diagnostik und Therapie gesondert hingewiesen.

Gültigkeit der Empfehlungen

Die Diagnose- und Therapieempfehlungen gelten nicht für Säuglinge und Kleinkinder; hier sei auf die entsprechenden Leitlinien der Fachgesellschaften verwiesen.

Die Gültigkeit dieser Leitlinie beträgt 5 Jahre. Eine Revision ist für 2018/2019 geplant. Ansprechpartner für die Aktualisierung ist Frau PD. Dr. med. Petra Lynen Jansen, lynen@dgvs.de.


#

1 Ergebnisse einer S2k-Konsensuskonferenz der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselerkrankungen (DGVS) gemeinsam mit der Deutschen Gesellschaft für Innere Medizin (DGIM), der Deutschen Gesellschaft für Hygiene und Mikrobiologie (DGHM), der Deutschen Gesellschaft für Infektiologie (DGI), der Deutschen Gesellschaft für Krankenhaushygiene e. V. (DGKH), der Deutschen Gesellschaft für Pathologie (DGP), der Deutschen Gesellschaft für Tropenmedizin und Internationale Gesundheit (DTG), dem Robert Koch-Institut (RKI) und der Paul-Ehrlich Gesellschaft für Chemotherapie e. V. (PEG).


* Gleichberechtigte durch die DGVS mandatierte Koordinatoren der Leitlinie


# für die Mitglieder der Leitlinienkommission „Gastrointestinale Infektion und Morbus Whipple“


 
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