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

Revision as of 11:34, 17 June 2021

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.

Dosierungsempfehlungen antibiotischer Therapien

intravenöse Applikation ^[1]^[2]


Antibiotikum	Tagesdosis (Beispiel)	Bemerkung
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

Legende:

CI: kontinuierliche Infusion (engl. continuous infusion)

PI: prolongierte Infusion (engl. prolonged infusion)

TDM: Therapeutisches Drug Monitoring (engl. therapeutic drug monitoring)

intrathekale Applikation ^[1], 32^[3]]


Antibiotikum	Tagesdosis (1x tgl.)	Bemerkung
Gentamicin	4-10mg
Tobramycin	5-10mg
Amikacin	30mg
Colistin	10mg
Daptomycin	5-10mg
Vancomycin	10-20mg
Tigecyclin	1-10mg
Caspofungin	5-10mg

Kalkulierte Therapie

^[1]^[2]]

Vancomycin PLUS Meropenem

Alternative Meropenem: Ceftazidim oder Cefepim (im Falle eines operativen Zugangs durch Schleimhäute PLUS Metronidazol)

Alternative Vancomycin: Linezolid (cave: bakteriostatisch)

Erregerspezifische Therapie

^[1]^[2]]


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	Meropenem	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

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 [33^[4]]. Diese Erkenntnisse konnten noch nicht in die aktuellen Leitlinien aufgenommen werden.

↑ ^1.0 ^1.1 ^1.2 ^1.3 28. 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
↑ ^2.0 ^2.1 ^2.2 31. Ambulant erworbene bakterielle (eitrige) Meningoenzephalitis im Erwachsenenalter, AWMF-Registernummer: 030/089 [https://www.awmf.org/leitlinien/detail/ll/030-089.html
↑ 32. Nau R, Blei C, Eiffert H: Intrathecal Antibacterial and Antifungal Therapies. Clin Microbiol Rev 2020; 33(3)
↑ 33. 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

[:0-1] 1.0 ^1.1 ^1.2 ^1.3 28. 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

[:1-2] 2.0 ^2.1 ^2.2 31. Ambulant erworbene bakterielle (eitrige) Meningoenzephalitis im Erwachsenenalter, AWMF-Registernummer: 030/089 [https://www.awmf.org/leitlinien/detail/ll/030-089.html

[3] 32. Nau R, Blei C, Eiffert H: Intrathecal Antibacterial and Antifungal Therapies. Clin Microbiol Rev 2020; 33(3)

[4] 33. 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

[1]

[2]

[3]

[4]

@@ Line 1: / Line 1: @@
-f==Therapie==
+==Therapie==
 <span class="ve-pasteProtect" style="font-size:12.0pt;
 mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:Calibri;
@@ Line 6: / Line 6: @@
 =====<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;}">Dosierungsempfehlungen antibiotischer Therapien</span>=====
 <span class="ve-pasteProtect" style="mso-ansi-language:
-DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:\nDE&quot;}">intravenöse Applikation </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;}">, 31</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><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>
+DE" data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:\nDE&quot;}">intravenöse Applikation </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><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>
 {| class="wikitable sortable bs-exportable MsoTable15List1Light" border="0" cellspacing="0" cellpadding="0" style="border-collapse:collapse;mso-yfti-tbllook:1184;mso-padding-alt:5.65pt 5.4pt 5.65pt 5.4pt" data-ve-attributes="{&quot;style&quot;:&quot;border-collapse:collapse;mso-yfti-tbllook:1184;mso-padding-alt:5.65pt 5.4pt 5.65pt 5.4pt&quot;}"
 |+