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DOI: 10.1055/s-0029-1244836
© Georg Thieme Verlag KG Stuttgart · New York
Mikrobiologisches Monitoring bei Ventilator-assoziierten Pneumonien auf Intensivstationen
Microbiological monitoring of ventilator-associated pneumonia in an intensive care unitPublication History
eingereicht: 30.7.2009
akzeptiert: 22.10.2009
Publication Date:
26 January 2010 (online)

Zusammenfassung
Ventilator-assoziierte Pneumonien (VAP) sind die häufigste Manifestation von Infektionen auf Intensivstationen und bedingen den größten Teil des Antibiotikaverbrauchs. Für die Therapie der VAP ist es von entscheidender Bedeutung, dass die initale Antibiotikatherapie adäquat und so schnell wie möglich eingeleitet wird, da eine verzögerte und/oder inadäquate Therapie mit einer erhöhten Letalität einhergeht. Daher wird auf vielen Intensivstationen ein mikrobiologisches Monitoring in Form von regelmäßigen Überwachungskulturen der unteren Atemwege durchgeführt. Dies geschieht unter der Vorstellung, dass die Ergebnisse von Überwachungskulturen bei Auftreten einer Pneumonie eine gezieltere Antibiotikatherapie ermöglichen. Der vorliegende Artikel zeigt mögliche Vor- und Nachteile eines mikrobiologischen Monitorings auf und gibt einen kritischen Überblick über die aktuelle Literatur.
Die meisten Studien befürworten Überwachungskulturen, da diese in bis zu 85 % der Fälle mit den Pneumonie-verursachenden Erregern übereinstimmen und eine an den Ergebnissen von Überwachungskulturen orientierte Antibiotikatherapie häufiger adäquat ist als eine Leitlinien-basierte Therapie. Allerdings fehlen nach wie vor prospektive klinische Studien, die den Einfluss von Überwachungskulturen auf den klinischen Verlauf von VAP sowie ihre Kosteneffektivität untersuchen. Aus diesem Grund finden sich in den aktuellen Empfehlungen unterschiedlicher Fachgesellschaften bislang keine klaren Stellungnahmen zum mikrobiologischen Monitoring bei beatmeten Patienten.
Abstract
Ventilator-associated pneumonia is the most frequent nosocomial infection in intensive care units (ICU) and causes high mortality. Approximately 50% of all antibiotics in ICUs are administered for the treatment of respiratory tract infections. Prompt and appropriate antibiotic treatment is paramount for a favourable clinical outcome as any delay in diagnosis and treatment will result in increased mortality. Therefore it is common practice in many ICUs to perform routine surveillance cultures of lower respiratory tract samples so that when pneumonia occurs, the empiric antibiotic regime can be based on the pathogens previously identified in surveillance cultures. This article highlights the advantages and disadvantages of routine surveillance cultures and provides a critical review of the recent literature. The majority of published studies favour surveillance cultures, because these can often predict the pathogens responsible for pneumonia and lead to timely administration of adequate antimicrobial therapy. Although the rationale behind this approach appears evident, the impact of surveillance cultures on clinical outcome as well as their cost effectiveness remains to be determined. Therefore, at this point, national and international guidelines do not recommend the routine use of surveillance cultures in mechanically ventilated patients but stress the need for larger, well designed clinical studies.
Schlüsselwörter
Ventilator-assoziierte Pneumonie - Überwachungskultur - Mikrobiologisches Monitoring
Keywords
ventilator-associated pneumonia - surveillance cultures - microbiological monitoring
Literatur
- 1
A’Court C H, Garrard C S, Crook D. et al .
Microbiological
lung surveillance in mechanically ventilated patients, using non-directed
bronchial lavage and quantitative culture.
Q J Med.
1993;
86
635-648
Reference Ris Wihthout Link
- 2
American Thoracic Society
(ATS) .
Guidelines for the management of adults with
hospital-acquired, ventilator-associated, and healthcare-associated
pneumonia.
Am J Respir Crit Care Med.
2005;
171
388-416
Reference Ris Wihthout Link
- 3
Bagshaw S M, Laupland K B.
Epidemiology
of intensive care unit-acquired urinary tract infections.
Curr
Opin Infect Dis.
2006;
19
67-71
Reference Ris Wihthout Link
- 4
Bouza E, Perez A, Munoz P. et
al .
Ventilator-associated pneumonia after heart surgery:
a prospective analysis and the value of surveillance.
Crit
Care Med.
2003;
31
1964-1970
Reference Ris Wihthout Link
- 5
Chastre J, Fagon J Y.
Ventilator-associated
pneumonia.
Am J Respir Crit Care Med.
2002;
165
867-903
Reference Ris Wihthout Link
- 6
Delclaux C, Roupie E, Blot F, Brochard L, Lemaire F, Brun-Buisson C.
Lower respiratory tract
colonization and infection during severe acute respiratory distress
syndrome: incidence and diagnosis.
Am J Respir Crit Care
Med.
1997;
156
1092-1098
Reference Ris Wihthout Link
- 7
Dennesen P J, van der Veen A J, Kessels A G, Ramsay G, Bonten M J.
Resolution of infectious parameters
after antimicrobial therapy in patients with ventilator-associated
pneumonia.
Am J Respir Crit Care Med.
2001;
163
1371-1375
Reference Ris Wihthout Link
- 8
Depuydt P, Benoit D, Vogelaers D. et al .
Systematic surveillance cultures as a tool
to predict involvement of multidrug antibiotic resistant bacteria
in ventilator-associated pneumonia.
Intensive Care Med.
2008;
34
675-682
Reference Ris Wihthout Link
- 9
Dupont H, Mentec H, Sollet J P, Bleichner G.
Impact of appropriateness of
initial antibiotic therapy on the outcome of ventilator-associated pneumonia.
Intensive Care Med.
2001;
27
355-362
Reference Ris Wihthout Link
- 10
Frere P, Hermanne J P, Debouge M H, de Moc P, Fillet G, Beguin Y.
Bacteremia
after hematopoietic stem cell transplantation: incidence and predictive
value of surveillance cultures.
Bone Marrow Transplant.
2004;
33
745-749
Reference Ris Wihthout Link
- 11
George D L, Falk P S, Wunderink R G. et al .
Epidemiology of ventilator-acquired
pneumonia based on protected bronchoscopic sampling.
Am
J Respir Crit Care Med.
1998;
158
1839-1847
Reference Ris Wihthout Link
- 12
Hayon J, Figliolini C, Combes A. et al .
Role of serial routine microbiologic culture
results in the initial management of ventilator-associated pneumonia.
Am J Respir Crit Care Med.
2002;
165
41-46
Reference Ris Wihthout Link
- 13
Hyllienmark P, Gardlund B, Persson J O, Ekdahl K.
Nosocomial pneumonia
in the ICU: a prospective cohort study.
Scand J Infect
Dis.
2007;
39
676-682
Reference Ris Wihthout Link
- 14
Iregui M, Ward S, Sherman G, Fraser V J, Kollef M H.
Clinical importance of delays in the initiation
of appropriate antibiotic treatment for ventilator-associated pneumonia.
Chest.
2002;
122
262-268
Reference Ris Wihthout Link
- 15
Jarvis W R.
Selected aspects of the socioeconomic impact of nosocomial infections:
morbidity, mortality, cost, and prevention.
Infect Control
Hosp Epidemiol.
1996;
17
552-557
Reference Ris Wihthout Link
- 16
Jung B, Sebbane M, Chanques G. et al .
Previous endotracheal aspirate allows guiding
the initial treatment of ventilator-associated pneumonia.
Intensive
Care Med.
2008;
35
101-107
Reference Ris Wihthout Link
- 17
Reinhart K, Brunkhorst FM, Bone H G. et al .
Diagnose und Therapie der Sepsis.
Der
Internist.
2006;
47
356-373
Reference Ris Wihthout Link
- 18
Kollef M H, Sherman G, Ward S, Fraser V J.
Inadequate antimicrobial treatment
of infections: a risk factor for hospital mortality among critically
ill patients.
Chest.
1999;
115
462-474
Reference Ris Wihthout Link
- 19
Lorenz J, Bodmann K F, Bauer T T, Ewig S, Trautmann M, Vogel F.
[Nosocomial
pneumonia: prevention, diagnosis, treatment].
Pneumologie.
2003;
57
532-545
Reference Ris Wihthout Link
- 20
Luna C M, Vujacich P, Niederman M S. et al .
Impact of BAL data on the therapy
and outcome of ventilator-associated pneumonia.
Chest.
1997;
111
676-685
Reference Ris Wihthout Link
- 21
Masterton R G, Galloway A, French G. et al .
Guidelines for the management of hospital-acquired
pneumonia in the UK: report of the working party on hospital-acquired
pneumonia of the British Society for Antimicrobial Chemotherapy.
J Antimicrob Chemother.
2008;
62
5-34
Reference Ris Wihthout Link
- 22
Michel F, Franceschini B, Berger P. et al .
Early antibiotic treatment for BAL-confirmed
ventilator-associated pneumonia: a role for routine endotracheal
aspirate cultures.
Chest.
2005;
127
589-597
Reference Ris Wihthout Link
- 23 Nationales Referenzzentrum
für die Surveillance von nosokomialen Infektionen (NRZ).
Modul ITS KISS Referenzdaten. 2009
Reference Ris Wihthout Link
- 24
Pugin J, Auckenthaler R, Mili N, Janssens J P, Lew P D, Suter P M.
Diagnosis
of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic
and nonbronchoscopic „blind” bronchoalveolar lavage
fluid.
Am Rev Respir Dis.
1991;
143
1121-1129
Reference Ris Wihthout Link
- 25
Rello J, Ausina V, Ricart M, Castella J, Prats G.
Impact of previous antimicrobial therapy on the etiology and
outcome of ventilator-associated pneumonia.
Chest.
1993;
104
1230-1235
Reference Ris Wihthout Link
- 26
Sanders K M, Adhikari N K, Friedrich J O, Day A, Jiang X, Heyland D.
Previous
cultures are not clinically useful for guiding empiric antibiotics in
suspected ventilator-associated pneumonia: secondary analysis from
a randomized trial.
J Crit Care.
2008;
23
58-63
Reference Ris Wihthout Link
- 27
Sintchenko V, Iredell J R, Gilbert G L.
Antibiotic therapy of ventilator-associated
pneumonia--a reappraisal of rationale in the era of bacterial resistance.
Int J Antimicrob Agents.
2001;
18
223-229
Reference Ris Wihthout Link
- 28
Strassburg A, Rupp J, Herth F J, Magnussen H, Zabel P, Lange C.
[Infection diagnostics
in pneumology. Part 1. Survey and methods].
Pneumologie.
2008;
62
730-743
Reference Ris Wihthout Link
- 29
Tablan O C, Anderson L J, Besser R, Bridges C, Hajjeh R.
Guidelines for preventing health-care--associated pneumonia,
2003: recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee.
MMWR Recomm Rep.
2004;
53
1-36
Reference Ris Wihthout Link
- 30
Torres A, Ewig S, Lode H, Carlet J.
Defining, treating and preventing hospital
acquired pneumonia: European perspective.
Intensive Care Med.
2008;
35
9-29
Reference Ris Wihthout Link
- 31
Trouillet J L, Chastre J, Vuagnat A. et al .
Ventilator-associated pneumonia caused
by potentially drug-resistant bacteria.
Am J Respir Crit Care
Med.
1998;
157
531-539
Reference Ris Wihthout Link
- 32
Valles J, Artigas A, Rello J. et al .
Continuous aspiration of subglottic secretions
in preventing ventilator-associated pneumonia.
Ann Intern Med.
1995;
122
179-186
Reference Ris Wihthout Link
- 33
Valles J, Pobo A, Garcia-Esquirol O, Mariscal D, Real J, Fernandez R.
Excess ICU mortality
attributable to ventilator-associated pneumonia: the role of early
vs late onset.
Intensive Care Med.
2007;
33
1363-1368
Reference Ris Wihthout Link
- 34
Zuschneid I, Geffers C, Sohr D. et al .
Validation of surveillance in the intensive
care unit component of the German nosocomial infections surveillance
system.
Infect Control Hosp Epidemiol.
2007;
28
496-499
Reference Ris Wihthout Link
Prof. Dr. med. Harald Seifert
Institut für Medizinische Mikrobiologie,
Immunologie und Hygiene, Universitätsklinikum Köln
Goldenfelsstr.19-21
50935 Köln
Phone: 0221/478-32009
Email: harald.seifert@uni-koeln.de