DGI:ZNS-Infektionen/Hirnabszess/Therapie: Difference between revisions
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==Therapie== | ==Therapie== | ||
'''<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{"style":"box-sizing: inherit;"}"> | <span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{"style":"box-sizing: inherit;"}">[24</span></span><ref><span style="color: rgb(51, 51, 51)">Xu XX, et al., Can diffusion-weighted imaging be used to differentiate brain abscess from other ring-enhancing brain lesions? A meta-analysis. Clin Radiol, 2014;</span> '''69'''<span style="color: rgb(51, 51, 51)">(9): 909-15</span><br /></ref><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{"style":"box-sizing: inherit;"}">-26</span></span><ref><span style="color: rgb(51, 51, 51)">Mishra AK, et al., Molecular revolution in the diagnosis of microbial brain abscesses</span>''.'' <span style="color: rgb(51, 51, 51)">Eur J Clin Microbiol Infect Dis, 2014;</span> '''33'''<span style="color: rgb(51, 51, 51)">(12): 2083-93</span><br /></ref><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{"style":"box-sizing: inherit;"}">, 30</span></span><ref><span style="color: rgb(51, 51, 51)">Beer R, Lackner P, Pfausler B, Schmutzhard E: Nosocomial ventriculitis and meningitis in neurocritical care patients.</span> <span class="ve-pasteProtect" style="color: rgb(51, 51, 51)" data-ve-attributes="{"style":"mso-ansi-language:DE"}">J Neurol 2008; 255(11):1617-1624</span><br /></ref><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{"style":"box-sizing: inherit;"}">]</span>:</span> | ||
=====<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}">Konservative Therapie</span>===== | =====<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}">Konservative Therapie</span>===== | ||
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|+ | |+ | ||
! class="col-grey-light-bg | ! style="width:63.8pt;" class="col-grey-light-bg" width="85" valign="top" data-ve-attributes="{"style":"width:63.8pt;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">'''Klinische Situation'''</span> | ||
! class="col-grey-light-bg | ! style="width:63.8pt;" class="col-grey-light-bg" width="85" valign="top" data-ve-attributes="{"style":"width:63.8pt;"}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{"style":"color: black"}">'''Präferenz'''</span> | ||
! class="col-grey-light-bg | ! style="width:77.95pt;" class="col-grey-light-bg" width="104" valign="top" data-ve-attributes="{"style":"width:77.95pt;"}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{"style":"color: black"}">'''Substanz'''</span> | ||
! class="col-grey-light-bg | ! style="width:3cm;" class="col-grey-light-bg" width="113" valign="top" data-ve-attributes="{"style":"width:3cm;"}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{"style":"color: black"}">'''Dosierung'''</span> | ||
! class="col-grey-light-bg | ! style="width:42.55pt;" class="col-grey-light-bg" width="57" valign="top" data-ve-attributes="{"style":"width:42.55pt;"}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{"style":"color: black"}">'''Dauer'''</span> | ||
! class="col-grey-light-bg | ! style="width:2cm;" class="col-grey-light-bg" width="76" valign="top" data-ve-attributes="{"style":"width:2cm;"}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{"style":"color: black"}">'''Anpas-sungen'''</span> | ||
! class="col-grey-light-bg | ! style="width:82.1pt;" class="col-grey-light-bg" width="109" valign="top" data-ve-attributes="{"style":"width:82.1pt;"}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{"style":"color: black"}">'''Kommentar'''</span> | ||
|- style="box-sizing: inherit;" data-ve-attributes="{"style":"box-sizing: inherit;"}" | |- style="box-sizing: inherit;" data-ve-attributes="{"style":"box-sizing: inherit;"}" | ||
| style="" data-ve-attributes="{"style":""}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">Ohne Operation/ Trauma</span> | | style="" data-ve-attributes="{"style":""}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">Ohne Operation/ Trauma</span> | ||
| style="" data-ve-attributes="{"style":""}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">Therapie der Wahl</span> | | style="" data-ve-attributes="{"style":""}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">Therapie der Wahl</span> | ||
| style="width:77.95pt;" width="104" valign="top" data-ve-attributes="{"style":"width:77.95pt;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">Ceftriaxon</span> | | style="width:77.95pt;" width="104" valign="top" data-ve-attributes="{"style":"width:77.95pt;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">Ceftriaxon</span> | ||
plus | |||
| style="width:3cm;" width="113" valign="top" data-ve-attributes="{"style":"width:3cm;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">2 x 2 g i.v.</span> | | style="width:3cm;" width="113" valign="top" data-ve-attributes="{"style":"width:3cm;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">2 x 2 g i.v.</span> | ||
| style="width:42.55pt;" width="57" valign="top" data-ve-attributes="{"style":"width:42.55pt;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">30 d</span> | | style="width:42.55pt;" width="57" valign="top" data-ve-attributes="{"style":"width:42.55pt;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">30 d</span> | ||
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| style="width:63.8pt;" width="85" valign="top" data-ve-attributes="{"style":"width:63.8pt;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">Therapie der Wahl</span> | | style="width:63.8pt;" width="85" valign="top" data-ve-attributes="{"style":"width:63.8pt;"}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{"style":"box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;"}">Therapie der Wahl</span> | ||
| style="width:77.95pt;" width="104" valign="top" data-ve-attributes="{"style":"width:77.95pt;"}" |Vancomycin | | style="width:77.95pt;" width="104" valign="top" data-ve-attributes="{"style":"width:77.95pt;"}" |Vancomycin | ||
plus | |||
Ceftriaxon | Ceftriaxon | ||
plus | |||
Metronidazol | Metronidazol | ||
Revision as of 19:18, 22 December 2020
Therapie
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 Patienten 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
| Klinische Situation | Präferenz | Substanz | Dosierung | Dauer | Anpas-sungen | Kommentar |
|---|---|---|---|---|---|---|
| Ohne Operation/ Trauma | Therapie der Wahl | Ceftriaxon
plus |
2 x 2 g i.v. | 30 d | - | |
| Metronidazol | 3 x 500 mg i.v. | 30 d | eGFR > 10ml/min | |||
| Nach Trauma/ Operation | Therapie der Wahl | Vancomycin
plus
plus
|
2 x 1 g i.v.
2 x 2 g i.v. 3 x 500 mg i.v. |
eGFR > 50ml/min,
eGFR > 10ml/min |
Spiegel-
Kontrollen |
Tabelle 5: Kalkulierte antibiotische Therapie
Abszessaspiration
· Relativ kurzer Eingriff mit entsprechend niedriger Operationsletalität und –morbidität
· GeringeTraumatisierung 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
- ↑ Xu XX, et al., Can diffusion-weighted imaging be used to differentiate brain abscess from other ring-enhancing brain lesions? A meta-analysis. Clin Radiol, 2014; 69(9): 909-15
- ↑ Mishra AK, et al., Molecular revolution in the diagnosis of microbial brain abscesses. Eur J Clin Microbiol Infect Dis, 2014; 33(12): 2083-93
- ↑ Beer R, Lackner P, Pfausler B, Schmutzhard E: Nosocomial ventriculitis and meningitis in neurocritical care patients. J Neurol 2008; 255(11):1617-1624