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

Revision as of 12:41, 25 May 2021

Therapie

[24-26, 30]:^[1]^[2]^[3]^[4]

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 Ceftriaxon plus Metronidazol	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

↑ 24. 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
↑ 25. Mishra AK, et al., Molecular revolution in the diagnosis of microbial brain abscesses. Eur J Clin Microbiol Infect Dis, 2014; 33(12): 2083-93
↑ 26. Sonneville R, et al., An update on bacterial brain abscess in immunocompetent patients. Clin Microbiol Infect, 2017; 23(9): 614-620
↑ 30. Beer R, Lackner P, Pfausler B, Schmutzhard E: Nosocomial ventriculitis and meningitis in neurocritical care patients. J Neurol 2008; 255(11):1617-1624

[1] 24. 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

[2] 25. Mishra AK, et al., Molecular revolution in the diagnosis of microbial brain abscesses. Eur J Clin Microbiol Infect Dis, 2014; 33(12): 2083-93

[3] 26. Sonneville R, et al., An update on bacterial brain abscess in immunocompetent patients. Clin Microbiol Infect, 2017; 23(9): 614-620

[4] 30. Beer R, Lackner P, Pfausler B, Schmutzhard E: Nosocomial ventriculitis and meningitis in neurocritical care patients. J Neurol 2008; 255(11):1617-1624

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 ==Therapie==
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