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21.11.2017 | Diagnostik und Monitoring | Leitthema

Bakterielle Sepsis

Diagnostik und kalkulierte Antibiotikatherapie

verfasst von: Dr. D. C. Richter, A. Heininger, T. Brenner, M. Hochreiter, M. Bernhard, J. Briegel, S. Dubler, B. Grabein, A. Hecker, W. A. Krüger, K. Mayer, M. W. Pletz, D. Störzinger, N. Pinder, T. Hoppe-Tichy, S. Weiterer, S. Zimmermann, A. Brinkmann, M. A. Weigand, Christoph Lichtenstern

Erschienen in: Die Anaesthesiologie | Ausgabe 10/2017

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Zusammenfassung

Die Sterblichkeit von Patienten mit Sepsis und septischem Schock ist weiterhin inakzeptabel hoch. Eine effektive, kalkulierte Antibiotikatherapie binnen der ersten Stunde nach Erkennen der Sepsis ist ein wichtiges Ziel der effektiven Sepsistherapie. Verzögerungen führen zum deutlichen Anstieg der Sterblichkeit. Daher bilden strukturierte Behandlungskonzepte eine rationale Grundlage unter Beachtung relevanter Diagnose- und Behandlungsschritte. Neben dem vermuteten Focus und individuellen Risiken einzelner Patienten müssen lokale Resistenzmuster und spezifische Problemerreger bei der Wahl der antiinfektiven Therapie berücksichtigt werden. Vielfältige pathophysiologische Veränderungen beeinflussen im Rahmen der Sepsis die substanzspezifische Pharmakokinetik (PK) vieler Antibiotika. Daher sollte das Prinzip der „Standarddosierung“ verlassen und durch einen individuelleren Therapieansatz mit stärkerer Gewichtung der Pharmakokinetik(PK)‑/Pharmakodynamik(PD)-Indizes der Substanzgruppen ersetzt werden. Wenngleich dies noch nicht der klinische Standard ist, können Applikationsformen wie die prolongierte (oder kontinuierliche) Infusion von β‑Lactamen und ein therapeutisches Drugmonitoring (TDM) helfen, definierte PK-Ziele zu erreichen. Während die prolongierte Infusion auch ohne TDM auskommt, ist TDM bei kontinuierlicher Infusion grundsätzlich notwendig. Ein weiteres Argument für den individuellen, PK/PD-orientierten Antibiotikaeinsatz ist die Zunahme komplizierter Infektionen durch multiresistente Erreger (MRE) auf Intensivstationen. Zur effektiveren Behandlung etablieren sich dort zunehmend „antibiotic stewardship teams“ (ABS-Team). Die interprofessionelle Zusammenarbeit des Behandlungsteams mit Infektiologen/Mikrobiologen und klinischen Pharmazeuten führt nicht nur zum rationaleren Antibiotikaeinsatz, sondern beeinflusst das Behandlungsergebnis positiv. Den Goldstandard der Erregerdiagnostik stellen weiterhin der kulturbasierte Nachweis aus Probenmaterial und die mikrobiologische Resistenztestung auf die verschiedenen Antibiotikagruppen dar. Neue Polymerase-Kettenreaktion(PCR)-basierte Verfahren der Erregeridentifikation und Resistenzbestimmung ergänzen trotz hoher Untersuchungsgeschwindigkeit aufgrund der limitierten aktuellen Studienlage, der hohen Kosten und der eingeschränkten Verfügbarkeit derzeit die Sepsisroutinediagnostik lediglich. Bei komplizierten, septischen Krankheitsverläufen mit mehrfacher, antiinfektiver Vorbehandlung oder rekurrenter Sepsis können PCR-basierte Verfahren ergänzend zu Therapie-Monitoring und Diagnostik eingesetzt werden. Neue Antibiotika stellen potente Alternativen in der Behandlung von MRE-Infektionen dar. Aufgrund des oftmals definierten Erregerspektrums und der praktisch (noch) nicht vorhandenen Resistenzen sind diese zur gezielten Behandlung schwerer MRE-Infektionen geeignet (Therapieeskalation).

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http://www.awmf.org/uploads/tx_szleitlinien/013-038l_S2k_Staphyococcus_aureus_2011-abgelaufen.pdf

Titel: Bakterielle Sepsis
Diagnostik und kalkulierte Antibiotikatherapie
verfasst von: Dr. D. C. Richter
A. Heininger
T. Brenner
M. Hochreiter
M. Bernhard
J. Briegel
S. Dubler
B. Grabein
A. Hecker
W. A. Krüger
K. Mayer
M. W. Pletz
D. Störzinger
N. Pinder
T. Hoppe-Tichy
S. Weiterer
S. Zimmermann
A. Brinkmann
M. A. Weigand
Christoph Lichtenstern
Publikationsdatum: 21.11.2017
Verlag: Springer Medizin
Schlagwörter: Diagnostik und Monitoring
Multiresistente Erreger
Pflege
Sepsis
Sepsis
Multiresistente Erreger
Antibiotika
Pharmakokinetik
Septischer Schock
Erschienen in: Die Anaesthesiologie / Ausgabe 10/2017
Print ISSN: 2731-6858
Elektronische ISSN: 2731-6866
DOI: https://doi.org/10.1007/s00101-017-0363-8

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