DGI:ZNS-Infektionen/Hirnabszess/Therapie: Difference between revisions

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==Therapie<ref><span style="color: #333333"><span style="box-sizing: inherit"> Nau R. Leitlinien für Diagnostik und Therapie in der Neurologie. Hirnabszess. AWMF-Registernummer: 030/108. https://dgn.org/leitlinien/ll-030-108-hirnabszess-2021</span></ref><ref><span style="color: #333333"><span style="box-sizing: inherit">Alvis Miranda H. et al. Brain abscess: Current management. J Neurosci Rural Pract 2013; 4(Suppl 1): p. S67-81.</span></ref><ref><span style="color: #333333">26. <span style="box-sizing: inherit">Brouwer MC et al. Brain abscess. N Engl J Med 2014; 371(5): p. 447-56.</span></ref><ref><span style="color: #333333">30. <span class="ve-pasteprotect"><span data-ve-attributes="{&quot;style&quot;:&quot;mso-tab-count:1&quot;}" style="box-sizing: inherit">Sonneville R et al. An update on bacterial brain abscess in immunocompetent patients. Clin Microbiol Infect 2017; 23(9): p. 614-620.</span></span>
<span data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:\nDE&quot;}" style="box-sizing: inherit"> </span></ref>==
=====<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Konservative Therapie</span>=====
=====<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Konservative Therapie</span>=====
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Voraussetzungen für ein rein konservatives Vorgehen sind</span>
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Voraussetzungen für ein rein konservatives Vorgehen sind</span>
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=====Antibiotikatherapie=====
=====Antibiotikatherapie=====
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Bei klinisch stabilen Patienten Abszessmaterial zur mikrobiologischen Diagnostik vor der ersten Antibiotikagabe</span>
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Bei klinisch stabilen Patient:innen Abszessmaterial zur mikrobiologischen Diagnostik vor der ersten Antibiotikagabe</span>


<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Wenn eine operative Sanierung nicht binnen weniger Stunden möglich ist, dann Entnahme von Blutkulturen und anschließend Beginn einer empirischen antibiotischen Therapie</span>
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Wenn eine operative Sanierung nicht binnen weniger Stunden möglich ist, dann Entnahme von Blutkulturen und anschließend Beginn einer empirischen antibiotischen Therapie</span>
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<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Dauer der antibiotischen Therapie mindestens 6 Wochen, anschließend Verlaufskontrolle mit cMRT</span>
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Dauer der antibiotischen Therapie mindestens 6 Wochen, anschließend Verlaufskontrolle mit cMRT</span>


{| class="wikitable  
{| class="wikitable "
|+<span id="Tabelle 5: Kalkulierte antibiotische Therapie">Tabelle 5: Kalkulierte antibiotische Therapie</span>
|+<span id="Tabelle 5: Kalkulierte antibiotische Therapie">Tabelle: Kalkulierte antibiotische Therapie</span>
!Klinische Situation
!Klinische Situation
!Präferenz
!Präferenz
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!Kommentar
!Kommentar
|-
|-
!Ohne Operation / Trauma
! rowspan="2" scope="row" |Ohne Operation / Trauma
|Therapie der Wahl
| rowspan="2" scope="row" |Therapie der Wahl
|
|
Ceftriaxon
Ceftriaxon
plus
plus
|2x2g i.v.  
|2x2g i.v.
|30d
|30d
| -
| -
|
|
|-
|-
!
|
|Metronidazol
|Metronidazol
|3x500mg i.v.
|3x500mg i.v.
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! rowspan="3" scope="row" |Nach Trauma / Operation
! rowspan="3" scope="row" |Nach Trauma / Operation
| rowspan="3" scope="row" |Therapie der Wahl
| rowspan="3" scope="row" |Therapie der Wahl
|  
|
Vancomycin
Vancomycin
plus
plus
|2x1g i.v.
|2x1g i.v.
|  
|
| rowspan="2" scope="row" |eGFR > 50ml/min
| rowspan="2" scope="row" |eGFR > 50ml/min
| rowspan="3" scope="row" |Spiegelkontrollen
| rowspan="3" scope="row" |Spiegelkontrollen
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<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Relativ kurzer Eingriff mit entsprechend niedriger Operationsletalität und –morbidität</span>
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Relativ kurzer Eingriff mit entsprechend niedriger Operationsletalität und –morbidität</span>


<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">GeringeTraumatisierung des Hirngewebes</span>
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Geringe Traumatisierung des Hirngewebes</span>


<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Nach Möglichkeit Einbringung einer Spüldrainage im Rahmen einer Punktion unter Navigation (sonographisch, stereotaktisch)</span>
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Nach Möglichkeit Einbringung einer Spüldrainage im Rahmen einer Punktion unter Navigation (sonographisch, stereotaktisch)</span>
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<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Bei Fisteln oder revisonsbedürftigen Frakturen</span>
<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Bei Fisteln oder revisonsbedürftigen Frakturen</span>
<br />
<references />

Latest revision as of 20:06, 9 August 2021

Konservative Therapie

Voraussetzungen für ein rein konservatives Vorgehen sind

·        Definitive Diagnose

·        Kalkulierbarkeit des Erregerspektrums

·        Liquorabfluss ist nicht behindert

·        Geringe raumfordernde Wirkung bzw. großes perifokales Ödem

Prinzipiell ist ein konservatives Vorgehen gerechtfertigt bei kleinen, multiplen oder sehr tief gelegenen Abszessen. Je weiter der entzündliche Prozess vom Ventrikelsystem entfernt ist, oder wenn sich (noch) keine Ringstruktur nach Kontrastmittel-Gabe zeigt, umso mehr ist ein konservatives Vorgehen angezeigt.

Antibiotikatherapie

·        Bei klinisch stabilen Patient:innen Abszessmaterial zur mikrobiologischen Diagnostik vor der ersten Antibiotikagabe

·        Wenn eine operative Sanierung nicht binnen weniger Stunden möglich ist, dann Entnahme von Blutkulturen und anschließend Beginn einer empirischen antibiotischen Therapie

·        Dauer der antibiotischen Therapie mindestens 6 Wochen, anschließend Verlaufskontrolle mit cMRT

Tabelle: Kalkulierte antibiotische Therapie
Klinische Situation Präferenz Substanz Dosierung Dauer Anpassungen Kommentar
Ohne Operation / Trauma Therapie der Wahl

Ceftriaxon plus

2x2g i.v. 30d -
Metronidazol 3x500mg i.v. 30d eGFR > 10ml/min
Nach Trauma / Operation Therapie der Wahl

Vancomycin plus

2x1g i.v. eGFR > 50ml/min Spiegelkontrollen

Ceftriaxon plus

2x2g i.v.
Metronidazol 3x500mg i.v. eGFR > 10ml/min


Abszessaspiration

·        Relativ kurzer Eingriff mit entsprechend niedriger Operationsletalität und –morbidität

·        Geringe Traumatisierung des Hirngewebes

·        Nach Möglichkeit Einbringung einer Spüldrainage im Rahmen einer Punktion unter Navigation (sonographisch, stereotaktisch)

Offene Kraniotomie mit Kapselexzision

·        Bei gekammertem Abszess

·        Wenn sich Fremdkörper im Abszess befinden

·        Bei Fisteln oder revisonsbedürftigen Frakturen

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