DGI:ZNS-Infektionen/Nosokomiale Ventrikulitis und Meningitis/Therapie: Difference between revisions
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DE" data-ve-attributes="{"style":"mso-ansi-language:\nDE"}">intrathekale Applikation </span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{"style":"mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":0" /><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{"style":"mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"> | DE" data-ve-attributes="{"style":"mso-ansi-language:\nDE"}">intrathekale Applikation </span><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{"style":"mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":0" /><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{"style":"mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref><span style="color: #333333">32. <span class="ve-pasteprotect"><span data-ve-attributes="{"style":"mso-tab-count:1"}" 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><span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{"style":"mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span> | ||
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===<span class="ve-pasteProtect" style="font-size:13.5pt; mso-fareast-font-family:"Times New Roman";mso-bidi-font-family:Calibri; mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;\nmso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:Calibri;\nmso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}">Kalkulierte Therapie</span>=== | ===<span class="ve-pasteProtect" style="font-size:13.5pt; mso-fareast-font-family:"Times New Roman";mso-bidi-font-family:Calibri; mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;\nmso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:Calibri;\nmso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}">Kalkulierte Therapie</span>=== | ||
<span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":0" /><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":1" /><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"> | <span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":0" /><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":1" /><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span> | ||
<span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{"style":"mso-ansi-language:DE"}">Vancomycin PLUS Meropenem</span> | <span class="ve-pasteProtect" style="mso-ansi-language:DE" data-ve-attributes="{"style":"mso-ansi-language:DE"}">Vancomycin PLUS Meropenem</span> | ||
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===<span class="ve-pasteProtect" style="font-size:13.5pt; mso-fareast-font-family:"Times New Roman";mso-bidi-font-family:Calibri; mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;\nmso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:Calibri;\nmso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}">Erregerspezifische Therapie</span>=== | ===<span class="ve-pasteProtect" style="font-size:13.5pt; mso-fareast-font-family:"Times New Roman";mso-bidi-font-family:Calibri; mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;\nmso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:Calibri;\nmso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}">Erregerspezifische Therapie</span>=== | ||
<span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":0" /><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":1" /><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"> | <span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":0" /><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span><ref name=":1" /><span class="ve-pasteProtect" style="font-size:13.5pt;mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: Calibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:13.5pt;mso-fareast-font-family:\"Times New Roman\";mso-bidi-font-family:\nCalibri;mso-bidi-theme-font:minor-latin;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span></span> | ||
{| 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="{"style":"border-collapse:collapse;mso-yfti-tbllook:1184;mso-padding-alt:5.65pt 5.4pt 5.65pt 5.4pt"}" | {| 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="{"style":"border-collapse:collapse;mso-yfti-tbllook:1184;mso-padding-alt:5.65pt 5.4pt 5.65pt 5.4pt"}" | ||
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line-height:107%;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:12.0pt;\nline-height:107%;mso-ansi-language:DE"}">Bei carbapenemresistenten gram-negativen Erregern sollte eine ergänzende intrathekale Therapie erfolgen. Für dieses Therapieregime konnte eine signifikante Reduktion der Sterblichkeit gezeigt werden <span class="ve-pasteProtect" style="mso-spacerun:yes" data-ve-attributes="{"style":"mso-spacerun:yes"}"> </span></span><span class="ve-pasteProtect" style="font-size:12.0pt;line-height:107%;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:12.0pt;line-height:107%;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}">[</span></span><span class="ve-pasteProtect" style="font-size:12.0pt; | line-height:107%;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:12.0pt;\nline-height:107%;mso-ansi-language:DE"}">Bei carbapenemresistenten gram-negativen Erregern sollte eine ergänzende intrathekale Therapie erfolgen. Für dieses Therapieregime konnte eine signifikante Reduktion der Sterblichkeit gezeigt werden <span class="ve-pasteProtect" style="mso-spacerun:yes" data-ve-attributes="{"style":"mso-spacerun:yes"}"> </span></span><span class="ve-pasteProtect" style="font-size:12.0pt;line-height:107%;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:12.0pt;line-height:107%;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}">[</span></span><span class="ve-pasteProtect" style="font-size:12.0pt; | ||
line-height:107%;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:12.0pt;\nline-height:107%;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-spacerun:yes" data-ve-attributes="{"style":"mso-spacerun:yes"}">33</span></span><ref><span style="color: #333333">33. <span class="ve-pasteprotect"><span data-ve-attributes="{"style":"mso-tab-count:1"}" 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><span class="ve-pasteProtect" style="font-size:12.0pt;line-height:107%;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:12.0pt;line-height:107%;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"> | line-height:107%;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:12.0pt;\nline-height:107%;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-spacerun:yes" data-ve-attributes="{"style":"mso-spacerun:yes"}">33</span></span><ref><span style="color: #333333">33. <span class="ve-pasteprotect"><span data-ve-attributes="{"style":"mso-tab-count:1"}" 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><span class="ve-pasteProtect" style="font-size:12.0pt;line-height:107%;mso-ansi-language:DE" data-ve-attributes="{"style":"font-size:12.0pt;line-height:107%;mso-ansi-language:DE"}"><span class="ve-pasteProtect" style="mso-no-proof:yes" data-ve-attributes="{"style":"mso-no-proof:yes"}"></span>. Diese Erkenntnisse konnten noch nicht in die aktuellen Leitlinien aufgenommen werden.</span> | ||
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Revision as of 11:49, 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 | 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 |
Legende:
- CI: kontinuierliche Infusion (engl. continuous infusion)
- PI: prolongierte Infusion (engl. prolonged infusion)
- TDM: Therapeutisches Drug Monitoring (engl. therapeutic drug monitoring)
intrathekale Applikation [1][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
Vancomycin PLUS Meropenem
Alternative Meropenem: Ceftazidim oder Cefepim (im Falle eines operativen Zugangs durch Schleimhäute PLUS Metronidazol)
Alternative Vancomycin: Linezolid (cave: bakteriostatisch)
Erregerspezifische Therapie
| 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