DGI:ZNS-Infektionen/Tuberkulose Meningitis/Therapie: Difference between revisions

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<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;}">Zusätzlich zur antituberkulösen Chemotherapie <span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">[1</span></span><ref><span style="color: rgb(51, 51, 51)">Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K, EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009; 2;302(21):2323-9</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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 2</span></span><ref><span style="color: rgb(51, 51, 51)">Kumta N, Roberts JA, Lipman J et al. Antibiotic distribution into cerebrospinal fluid: Can dosing safely account for drug and disease factors in the treatment of ventriculostomy-associated infections? Clin Pharmacokinet 2018; 57: 439–454</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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 5</span></span><ref><span style="color: rgb(51, 51, 51)">Nau R et al. S1-Leitlinie Hirnabszess. 2016. In: Deutsche Gesellschaft für Neurologie, Hrsg. Leitlinien für Diagnostik und Therapie in der Neurologie. Online:</span> [http://www.dgn.org/leitlinien www.dgn.org/leitlinien]<br /></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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 7</span></span><ref><span style="color: rgb(51, 51, 51)">Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen - Update 2018. <nowiki>https://www.awmf.org/leitlinien/detail/ll/082-006.html</nowiki></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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">]</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;}">sollte Dexamethason oder Prednisolon verabreicht werden. Für Deutschland wird in Übereinstimmung mit den NICE-Empfehlungen beim Erwachsenen (> 15 Jahre) eine Prednisolon-Dosis von 40 mg/Tag (ohne RMP-Gabe: 20 mg/Tag) empfohlen, welche nach 2-3 Wochen um jeweils 10 mg/Woche reduziert und dann beendet werden kann <span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">[10</span></span><ref><span style="color: rgb(51, 51, 51)">Ducomble T, et al., The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009. Euro Surveill, 2013;</span> '''18'''<span style="color: rgb(51, 51, 51)">(12)</span><br /></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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 11</span></span><ref><span style="color: rgb(51, 51, 51)">in Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. 2011; London</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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">]</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;}">Zusätzlich zur antituberkulösen Chemotherapie <span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}"></span></span><ref><span style="color: rgb(51, 51, 51)">Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K, EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009; 2;302(21):2323-9</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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 2</span></span><ref><span style="color: rgb(51, 51, 51)">Kumta N, Roberts JA, Lipman J et al. Antibiotic distribution into cerebrospinal fluid: Can dosing safely account for drug and disease factors in the treatment of ventriculostomy-associated infections? Clin Pharmacokinet 2018; 57: 439–454</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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 5</span></span><ref><span style="color: rgb(51, 51, 51)">Nau R et al. S1-Leitlinie Hirnabszess. 2016. In: Deutsche Gesellschaft für Neurologie, Hrsg. Leitlinien für Diagnostik und Therapie in der Neurologie. Online:</span> [http://www.dgn.org/leitlinien www.dgn.org/leitlinien]<br /></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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 7</span></span><ref><span style="color: rgb(51, 51, 51)">Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen - Update 2018. <nowiki>https://www.awmf.org/leitlinien/detail/ll/082-006.html</nowiki></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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}"></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;}">sollte Dexamethason oder Prednisolon verabreicht werden. Für Deutschland wird in Übereinstimmung mit den NICE-Empfehlungen beim Erwachsenen (> 15 Jahre) eine Prednisolon-Dosis von 40 mg/Tag (ohne RMP-Gabe: 20 mg/Tag) empfohlen, welche nach 2-3 Wochen um jeweils 10 mg/Woche reduziert und dann beendet werden kann <span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}"></span></span><ref><span style="color: rgb(51, 51, 51)">Ducomble T, et al., The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009. Euro Surveill, 2013;</span> '''18'''<span style="color: rgb(51, 51, 51)">(12)</span><br /></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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 11</span></span><ref><span style="color: rgb(51, 51, 51)">in Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. 2011; London</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;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}"></span>.</span>


MDR = multi-drug resistance, RMP = Rifampicin
MDR = multi-drug resistance, RMP = Rifampicin

Revision as of 09:47, 17 June 2021

Therapie

Tabelle 2: First line Medikamente zur Behandlung der Tbc
Klinische Situation Präferenz Substanz Dosierung Dauer Liquor Gängigkeit
Tuberkulöse Meningitis Therapie der Wahl Rifampicin 10 mg/kg KG, max 600 mg 12 Monate 10-20%
Isoniazid 5 mg/kg KG 12 Monate 80-90%
Pyrazinamid 25 mg/kg KG Ersten 2 Monate 90-100%
Ethamutolb *15 mg/kg KG Ersten 2 Monate 20-30%
Zusatz Vitamin B6 [1] 40 mg/d mit INH -


Tabelle 3: Core second-line Medikamente zur Therapie der MDR-Tbc
Klinische Situation Substanz Dosierung Dauer Liquor Gängigkeit
Tuberkulöse Meningitis Second line Levofloxacin 10-15 mg/kg durchgängig 70-80%
Moxifloxacin 400mg durchgängig 70-80%
Amikacin 15 mg/kg, max 1g i.v. Intensivphase 10-20%
Kanamycin 15 mg/kg, max 1g i.v. Intensivphase 10-20%
Capreomycin 15 mg/kg, max 1g i.v. Intensivphase Keine Daten
Ethionamid 15-20 mg/kg, max 1g i.v. durchgängig 80-90%
Cycloserin 10-20 mg/kg, max 1g i.v. durchgängig 80-90%
Linezolid 600 mg durchgängig 30-70%

Zusätzlich zur antituberkulösen Chemotherapie [2], 2[3], 5[4], 7[5] sollte Dexamethason oder Prednisolon verabreicht werden. Für Deutschland wird in Übereinstimmung mit den NICE-Empfehlungen beim Erwachsenen (> 15 Jahre) eine Prednisolon-Dosis von 40 mg/Tag (ohne RMP-Gabe: 20 mg/Tag) empfohlen, welche nach 2-3 Wochen um jeweils 10 mg/Woche reduziert und dann beendet werden kann [6], 11[7].

MDR = multi-drug resistance, RMP = Rifampicin

  1. ↑ Amagon KI, Awodele O, Akindele AJ. Methionine and vitamin B-complex ameliorate antitubercular drugs-induced toxicity in exposed patients. Pharmacol Res Perspect 2017; 5(5)
  2. ↑ Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K, EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009; 2;302(21):2323-9
  3. ↑ Kumta N, Roberts JA, Lipman J et al. Antibiotic distribution into cerebrospinal fluid: Can dosing safely account for drug and disease factors in the treatment of ventriculostomy-associated infections? Clin Pharmacokinet 2018; 57: 439–454
  4. ↑ Nau R et al. S1-Leitlinie Hirnabszess. 2016. In: Deutsche Gesellschaft für Neurologie, Hrsg. Leitlinien für Diagnostik und Therapie in der Neurologie. Online: www.dgn.org/leitlinien
  5. ↑ Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen - Update 2018. https://www.awmf.org/leitlinien/detail/ll/082-006.html
  6. ↑ Ducomble T, et al., The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009. Euro Surveill, 2013; 18(12)
  7. ↑ in Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. 2011; London
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