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Dtsch Med Wochenschr 2019; 144(11): 724-728
DOI: 10.1055/a-0652-8351
Klinischer Fortschritt
Infektiologie
© Georg Thieme Verlag KG Stuttgart · New York

Nosokomiale Pneumonie – neue Leitlinien

Hospital-acquired pneumonia – new guidelines
Evelyn Kramme
1   Klinik für Infektiologie und Mikrobiologie, UKSH Campus Lübeck
,
Klaus Dalhoff
2   Medizinische Klinik III, UKSH Campus Lübeck
› Author Affiliations
Further Information

Publication History

Publication Date:
04 June 2019 (online)

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Was ist neu?

Erregerspektrum: Die Rolle multiresistenter Erreger Das nationale Referenzzentrum verzeichnet insgesamt eine Zunahme der Nachweise gramnegativer multiresistenter Erreger (MRE), was sich nach bisheriger Datenlage noch nicht auf das Erregerspektrum der HAP (hospital aquired pneumonia) ausgewirkt hat. Das individuelle Risikoprofil für das Auftreten von MRE bleibt entscheidend für die kalkulierte Therapie.

Diagnostik Als ergänzende diagnostische Maßnahme wurde die Thoraxsonografie in die Empfehlung aufgenommen. Besondere Bedeutung misst die Leitlinie der Messung von PCT und Laktat bei, um frühzeitig eine Sepsis/einen septischen Schock zu erkennen. Als Empfehlung zur virologischen Diagnostik kam die Durchführung einer PCR in der Influenza-Saison hinzu.

Kalkulierte Therapie: Initial Mono- oder Kombinationstherapie? Eine Kombinationstherapie wird nur noch bei sehr schwerer Erkrankung (invasive Beatmung, septischer Schock) und hohem Risiko für MRE empfohlen, da sie sich in zahlreichen Studien nur in diesen Konstellationen als überlegen erwiesen hat. Es wird eine deutliche Empfehlung zur zügigen Deeskalation nach klinischen und mikrobiologischen Kriterien ausgesprochen.

Aufgrund pharmakokinetischer/pharmakodynamischer Erwägungen sollte bei Patienten mit Sepsis/septischem Schock in der Initialphase eine prolongierte Infusion von hierfür geeigneten Betalaktam-Antibiotika nach initialer Kurzinfusion erwogen werden.

Inhalative Therapie Eine adjunktive aerosolierte Therapie sollte nur in erfahrenen Zentren bei Nachweis von Erregern mit multiplen Resistenzen durchgeführt werden, wenn der Therapieerfolg einer systemischen Therapie fraglich ist.

Abstract

Etiology The role of multidrug-resistant (MDR) pathogens in nosocomial infections is increasing. However national data in Germany do not show significant changes in the spectrum of pathogens in hospital-acquired pneumonia (HAP). The assessment of individual risk factors for MDR pathogens remains central for the selection of empiric antimicrobial therapy.

Diagnostics Thoracic ultrasound may be added as part of the diagnostic work-up and for the detection of complications. Procalcitonin and lactate testing are recommended for the diagnosis of sepsis/septic shock in addition to sepsis scores. Detection of influenza virus by PCR from respiratory samples is recommended during influenza season.

Antimicrobial treatment Empiric combination therapy is only recommended for patients with severe HAP (invasive ventilation, septic shock) and high risk of infection with MDR pathogens, since combination therapy has only been shown to be superior in this situation. Deescalation according to clinical and microbiological criteria is highly recommended. In patients with septic organ dysfunction/septic shock antibiotic dosing of adequately choosen betalactams according to Pk/Pd criteria is endorsed.

Aerosolised antibiotics adjunctive aerosolised therapy should only be performed in experienced centres. This remains an option for patients with detection of MDR pathogens, who are not deemed successfully treatable with systemic therapy alone.

Schlüsselwörter

nosokomiale Pneumonie - Leitlinien - antimikrobielle Therapie - multiresistente Erreger

Key words

nosocomial pneumonia - guidelines - antimicrobial treatment - multidrug resistant pathogens
 

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