DGI:ZNS-Infektionen/Nosokomiale Ventrikulitis und Meningitis/Therapie: Difference between revisions

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==Therapie==
Die Fokussanierung steht im Vordergrund, infizierte Kathetersysteme sollten entfernt werden. Begleitend erfolgt eine antibiotische Therapie, die zunächst hauptsächlich auf gram-positive Kokken zielt, begleitend sind Enterobacterales und ''Pseudomonas'' ''spp''. zu erfassen. Es sollte bei Erregernachweis eine Deeskalation nach Antibiogramm erfolgen. Die Therapiedauer beträgt i.d.R. 10-14 Tage.
Die Fokussanierung steht im Vordergrund, infizierte Kathetersysteme sollten entfernt werden. Begleitend erfolgt eine antibiotische Therapie, die zunächst hauptsächlich auf gram-positive Kokken zielt, begleitend sind Enterobacterales und Pseudomonas spp. zu erfassen. Es sollte bei Erregernachweis eine Deeskalation nach Antibiogramm erfolgen. Die Therapiedauer beträgt i.d.R. 10-14 Tage.
 
=====Dosierungsempfehlungen antibiotischer Therapien=====
<br /><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span>
 


=====Dosierungsempfehlungen antiinfektiver Therapien=====
<span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span>
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intravenöse Applikation <ref name=":0"><span style="color: #333333">28. <span class="ve-pasteprotect"><span data-ve-attributes="{&quot;style&quot;:&quot;mso-tab-count:1&quot;}" style="box-sizing: inherit">          <span style="box-sizing: inherit"> </span></span></span>Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Michael Scheld W, van de Beek D, Bleck TP, Garton HJ, Zunt JR: 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017; 64: e34–e65</span></ref><ref name=":1"><span class="ve-pasteprotect">31. <span data-ve-attributes="{&quot;style&quot;:&quot;mso-tab-count:1&quot;}" style="box-sizing: inherit">          <span style="box-sizing: inherit"> </span></span>Ambulant erworbene bakterielle (eitrige) Meningoenzephalitis im Erwachsenenalter, AWMF-Registernummer: 030/089 [</span><span style="color: #333333">https://www.awmf.org/leitlinien/detail/ll/030-089.html</span><span data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}" style="box-sizing: inherit"><span class="ve-pasteprotect"></span></span></ref>
Intravenöse Applikation <ref name=":b0"><span style="color: #333333">Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Michael Scheld W, van de Beek D, Bleck TP, Garton HJ, Zunt JR: 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017; 64: e34–e65</span></ref><ref name=":1"><span class="ve-pasteprotect">Ambulant erworbene bakterielle (eitrige) Meningoenzephalitis im Erwachsenenalter, AWMF-Registernummer: 030/089 [</span><span style="color: #333333">https://www.awmf.org/leitlinien/detail/ll/030-089.html</span><span data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}" style="box-sizing: inherit"><span class="ve-pasteprotect"></span></span></ref>
!Antibiotikum
!Antibiotikum
!Tagesdosis (Beispiel)
!Tagesdosis (Beispiel)
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|liposomales Amphotericin B
|Liposomales Amphotericin B
|2-5 mg/kg (1x tgl.)
|2-5 mg/kg (1x tgl.)
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|TDM
|TDM
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|}Legende:
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*CI: kontinuierliche Infusion (engl. continuous infusion)
*PI: prolongierte Infusion (engl. prolonged infusion)
*TDM: Therapeutisches Drug Monitoring (engl. therapeutic drug monitoring)
 


<span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span>
<span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span>
{| class="wikitable "
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<span class="ve-pasteProtect" style="mso-ansi-language:
<span class="ve-pasteProtect" style="mso-ansi-language:
DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:\nDE&quot;}">intrathekale Applikation </span><ref name=":0" /><ref><span style="color: #333333">32. <span class="ve-pasteprotect"><span data-ve-attributes="{&quot;style&quot;:&quot;mso-tab-count:1&quot;}" style="box-sizing: inherit">          <span style="box-sizing: inherit"> </span></span></span>Nau R, Blei C, Eiffert H: Intrathecal Antibacterial and Antifungal Therapies. Clin Microbiol Rev 2020; 33(3)</span></ref>
DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:\nDE&quot;}">Intrathekale Applikation </span><ref name=":b0" /><ref><span style="color: #333333">Nau R, Blei C, Eiffert H: Intrathecal Antibacterial and Antifungal Therapies. Clin Microbiol Rev 2020; 33(3)</span></ref>
!Antibiotikum
!Antibiotikum
!Tagesdosis (1xtgl.)
!Tagesdosis (1xtgl.)
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===<span class="ve-pasteProtect" style="font-size:13.5pt; mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:Calibri; mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:13.5pt;\nmso-fareast-font-family:\&quot;Times New Roman\&quot;;mso-bidi-font-family:Calibri;\nmso-bidi-theme-font:minor-latin;mso-ansi-language:DE&quot;}">Kalkulierte Therapie</span><ref name=":0" /><ref name=":1" />===
<span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:13.5pt;mso-fareast-font-family:\&quot;Times New Roman\&quot;;mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:13.5pt;mso-fareast-font-family:\&quot;Times New Roman\&quot;;mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:13.5pt;mso-fareast-font-family:\&quot;Times New Roman\&quot;;mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span>Vancomycin PLUS Meropenem
Alternative zum Meropenem: Ceftazidim oder Cefepim (in Anlehnung an das lokale in-vitro-Resistenzmuster). Cephalosporine penetrieren nicht-entzündlich veränderte Meningen relativ schlecht, daher empfehlen die Autoren bei empirischer Anwendung dieser Substanzen: Anwendung einer höheren Loading dose und ein TDM.
(im Falle eines operativen Zugangs durch Schleimhäute PLUS Metronidazol)
Alternative Vancomycin: Linezolid (cave: bakteriostatisch)
===<span class="ve-pasteProtect" style="font-size:13.5pt; mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:Calibri; mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:13.5pt;\nmso-fareast-font-family:\&quot;Times New Roman\&quot;;mso-bidi-font-family:Calibri;\nmso-bidi-theme-font:minor-latin;mso-ansi-language:DE&quot;}">Erregerspezifische Therapie</span><ref name=":0" /><ref name=":1" />===
<br />
{| class="wikitable"
|+
!Erreger
!Standardtherapie
!Alternativtherapie
|-
|Enterobacterales (z.B. Klebsiella spp., E. coli)
|Cefotaxim/Ceftriaxon
|Cefepim, Meropenem, Ciprofloxacin
|-
|Enterobacterales mit induzierbaren AmpC-Betalactamasen (z.B. Enterobacter cloacae) oder ESBL-Bildner
|Meropenem
|Ciprofloxacin
|-
|Pseudomonas aeruginosa
|Ceftazidim, Meropenem, Cefepim, ggf. jeweils in Kombination mit FosfomycinColistin (nur bei nachgewiesener Multiresistenz, i.v.+i.t.)
|Aztreonam oder Ciprofloxacin
|-
|Acinetobacter baumanii
|Merope
|Colistin (i.v.+i.t.)
|-
|Staphylococcus spp. (Methicillin-empfindlich)
|Flucloxacillinggf. PLUS Fosfomycin, Rifampicin oder Linezolid
|Vancomycin
|-
|Staphylococcus spp. (Methicillin-resistent)
|Vancomycin ggf. PLUS Fosfomycin, Rifampicin oder Linezolid
|Linezolid
|-
|Candida spp.
|liposomales Amphotericin B ggf. PLUS Flucytosin
|Voriconazol, bei C. albicans: Fluconazol
|-
|Aspergillus spp.
|Voriconazol
|liposomales Amphotericin B, Posaconazol
|}
<span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:13.5pt;mso-fareast-font-family:\&quot;Times New Roman\&quot;;mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:13.5pt;mso-fareast-font-family:\&quot;Times New Roman\&quot;;mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:13.5pt;mso-fareast-font-family:\&quot;Times New Roman\&quot;;mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span>Legende: i.v. = intravenös, i.t. = intrathekal
Bei carbapenemresistenten gram-negativen Erregern sollte eine ergänzende intrathekale Therapie erfolgen. Für dieses Therapieregime konnte eine signifikante Reduktion der Sterblichkeit gezeigt werden <ref><span style="color: #333333">33. <span class="ve-pasteprotect"><span data-ve-attributes="{&quot;style&quot;:&quot;mso-tab-count:1&quot;}" style="box-sizing: inherit">          <span style="box-sizing: inherit"> </span></span></span>Karvouniaris M, Brotis AG, Tsiamalou P, Fountas KN: The Role of Intraventricular Antibiotics in the Treatment of Nosocomial Ventriculitis/Meningitis from Gram-Negative Pathogens: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 120:e637-e650</span></ref>. Diese Erkenntnisse konnten noch nicht in die aktuellen Leitlinien aufgenommen werden.
<br /><span class="ve-pasteProtect" style="font-size:12.0pt;line-height:107%;mso-ansi-language:DE" data-ve-attributes="{&quot;style&quot;:&quot;font-size:12.0pt;line-height:107%;mso-ansi-language:DE&quot;}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{&quot;style&quot;:&quot;mso-no-proof:yes&quot;}"></span></span>
<references />

Latest revision as of 08:34, 14 September 2021

Die Fokussanierung steht im Vordergrund, infizierte Kathetersysteme sollten entfernt werden. Begleitend erfolgt eine antibiotische Therapie, die zunächst hauptsächlich auf gram-positive Kokken zielt, begleitend sind Enterobacterales und Pseudomonas spp. zu erfassen. Es sollte bei Erregernachweis eine Deeskalation nach Antibiogramm erfolgen. Die Therapiedauer beträgt i.d.R. 10-14 Tage.

Dosierungsempfehlungen antiinfektiver Therapien

Intravenöse Applikation [1][2]
Antibiotikum Tagesdosis (Beispiel) Bemerkung Anpassung
Aztreonam 6-8g (3-4x 2g)
Cefepim 6g (3x 2g) CI, PI
Cefotaxim 12g (6x 2g)
Ceftazidim 6g (3x 2g) CI, PI, TDM
Ceftriaxon 4g (2x 2g)
Ciprofloxacin 1200mg (3x 400mg)
Flucloxacillin 12g (6x 2g) TDM
Fluconazol 800mg (1x tgl.)
Fosfomycin 24g (3x 8g)
Linezolid 1200mg (2x 600mg) CI, TDM
Liposomales Amphotericin B 2-5 mg/kg (1x tgl.)
Meropenem 6g (3x 2g) CI, PI, TDM
Posaconazol 800mg (2x 400mg) TDM
Rifampicin 600-1200mg (1-2x tgl.)
Vancomycin 30-60 mg/kg (2-4x tgl.) CI, TDM
Voriconazol 8 mg/kg (2x tgl.) TDM

Intrathekale Applikation [1][3]
Antibiotikum Tagesdosis (1xtgl.) Bemerkung
Gentamicin 4-10mg
Tobramycin 5-10mg
Amikacin 30mg
Colistin 10mg
Daptomycin 5-10mg
Vancomycin 10-20mg
Tigecyclin 1-10mg
Caspofungin 5-10mg
  1. ↑ 1.0 1.1 Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Michael Scheld W, van de Beek D, Bleck TP, Garton HJ, Zunt JR: 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017; 64: e34–e65
  2. ↑ Ambulant erworbene bakterielle (eitrige) Meningoenzephalitis im Erwachsenenalter, AWMF-Registernummer: 030/089 [https://www.awmf.org/leitlinien/detail/ll/030-089.html
  3. ↑ Nau R, Blei C, Eiffert H: Intrathecal Antibacterial and Antifungal Therapies. Clin Microbiol Rev 2020; 33(3)
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