Diagnostik der Sepsis – Teil 1: allgemeine Diagnostik und Fokussuche-/sanierung

Zusammenfassung

Die Sepsis ist ein medizinischer Notfall mit weiterhin hoher Sterblichkeit. Die Surviving Sepsis Campaign (SSC) gibt für die Diagnostik und die Gabe eines adäquaten Breitspektrumantibiotikums ein Zeitfenster von max. 1 h nach Stellen der Verdachtsdiagnose „Sepsis“ vor. Aktuell wird dieses sog. 1 h-Maßnahmenbündel kritisch diskutiert. Als Kernaspekt der Fokussuche orientiert sich die Art der Bildgebung am vermuteten Fokus und dem Patientenkollektiv. Bei kritisch kranken Patienten ist die kontrastmittelverstärkte Computertomografie häufig Mittel der Wahl. Die Erregerdetektion erfolgt meist kulturbasiert. Daher sind mikrobiologische Proben aus einfach zugänglichen Kompartimenten, mindestens aber die Entnahme von 2 Blutkultursets, obligat und sollten vor der Gabe eines Antibiotikums erfolgen. Von herausragender Bedeutung sind vor allem intraoperative Abstriche aus sonst sterilen Kompartimenten. Suspekte Katheter (z. B. zentralvenöse Katheter, Dialysekatheter) oder potenziell infizierte implantierte Medizinprodukte (z. B. Schrittmacher, Defibrillatoren) sollten – wenn vertretbar – zügig entfernt und einer mikrobiologischen Aufarbeitung zugeführt werden. Generell sollten alle notwendigen Maßnahmen zur Fokussanierung/-kontrolle so schnell wie medizinisch/logistisch möglich, mindestens aber innerhalb von 6(– 12)h nach Beginn der Sepsis, erfolgt sein. Es existiert bislang kein spezifischer Biomarker für das Krankheitsbild der Sepsis. Biomarker wie das Procalcitonin (PCT) und das C-reaktive Protein (CRP) spielen im Kontext der Sepsis beim infektiologischen Management und Therapiemonitoring auf der Intensivstation eine wichtige Rolle. Vielversprechende Biomarker wie das midregionale Pro-Adrenomedullin (MR-proADM) oder das Presepsin werden außerhalb von Studien noch nicht in der klinischen Routine eingesetzt. Als Marker von Mikrozirkulationsstörungen und eines gestörten Metabolismus spielt das Laktat (bzw. die Laktat-Clearance) als prognostischer Parameter der Sepsis eine große Rolle.

Die Sepsis ist ein medizinischer Notfall mit weiterhin hoher Sterblichkeit. Die besondere Herausforderung besteht darin, eine adäquate Diagnostik und entsprechende antiinfektive Therapie in möglichst kurzer Zeit nach Stellen der Verdachtsdiagnose durchzuführen. Teil 1 dieses Beitrags behandelt dabei die allgemeine Diagnostik und Fokussuche bzw. -sanierung, Teil 2 die Erregeridentifizierung.

Abstract

Sepsis and septic shock represent medical emergencies with persistently high mortality rates. According to the lately revised Surviving Sepsis Campaign (SSC) guidelines, focus identification/pathogen detection and the initial administration of broad-spectrum antibiotics are to be secluded within one hour after recognition of the symptoms of sepsis. However, there is dispute concerning the so called hour-1 bundle. Being a core aspect of focus identification, imaging modalities mainly depend on the suspected site of infection and the individual patient. Contrast agent-enhanced computed tomography (CT) is the modality usually used in critically ill patients. The microbiological pathogen detection still largely remains culture-based. This emphasizes the significance of microbiological specimen obtained from easily accessible body compartments and at least 2 blood culture sets. If possible, blood cultures should be drawn prior to antibiotic administration. Intraoperatively obtained swabs of otherwise sterile body compartments are of utmost importance with regard to microbiological pathogen detection. Catheters and implanted medical devices (i.e. cardiac pacemakers or defibrillators) suspicious of infection should be explanted and sent in for microbiological workup as soon as possible. All necessary source control measures should be realized as soon as medically possible but at least within 6 – (12) hours after the onset of symptoms. There is no specific biomarker for sepsis so far. Procalcitonin (PCT) and C-reactive protein (CRP) are crucial biomarkers in terms of infectious disease management and guidance of antimicrobial therapy in the ICU. Positive clinical trials showed that biomarkers like the midregional pro-adrenomedullin (MR-proADM) or presepsin might be promising candidates in the diagnosis of sepsis in the future. As an important marker of microcirculatory failure and disrupted cell metabolism, lactate serum concentrations (and lactate-clearance, respectively) are of prognostic value in septic patients.

Kernaussagen

• Die Sepsis wird als eine lebensbedrohliche Organdysfunktion auf dem Boden einer dysregulierten Wirtsantwort durch eine (wahrscheinliche) Infektion verstanden.

• Die Diagnose der Sepsis erfolgt nach Leitlinie der SSC unabhängig von Biomarkern unter Verwendung klinischer Parameter und des SOFA-Scores.

• Fokussuche (hier vor allem Anamnese, klinische Untersuchung, Blutkulturen, Bildgebung), hämodynamische Stabilisierung und die empirische Gabe eines Breitspektrumantibiotikums sind Kernelemente des „hour-1 bundles“ und sollten höchste Priorität genießen.

• Das kontrastmittelunterstützte CT ist ein zeitsparendes Verfahren, das gleichzeitig viele potenzielle Infektionsfoci darstellen kann. Vorteil ist, dass auch kritisch kranke, beatmete Patienten fast problemlos dieser Untersuchung zugeführt werden können.

• Sonografische Verfahren können im Einzelfall zur Fokussuche angewendet werden (Endokarditis, Empyeme), kommen aber eher auf der Intensivstation im Rahmen der differenzierten Herz-Kreislauf-Therapie zum Einsatz (Lungensonografie, HZV-Messung und Katecholaminsteuerung).

• Die Entnahme weiterer mikrobiologischer Proben (respiratorische Sekrete, Urin, Abstriche usw.) sollte in der Initialphase kritisch gegenüber dem möglichen Zeitverlust evaluiert werden.

• Die Sanierung des Infektionsfokus sollte so schnell wie medizinisch vertretbar/logistisch möglich erfolgen, längstens jedoch innerhalb von 6(– 12)h realisiert sein.

• Grundsätzlich sollte die initiale Versorgung des septischen Patienten überlappend und parallel – analog der Schwerstverletztenversorgung – erfolgen. Dazu zählt auch, dass wichtige Schritte wie die hämodynamische Stabilisierung und die erweiterte mikrobiologische Diagnostik u. U. während der Fokussanierung im OP als parallele Arbeitsschritte erfolgen müssen.

• Eine Diagnosestellung der Sepsis aufgrund von Biomarkern ist nicht möglich. Weder existieren spezifische Sepsis-Biomarker, noch sind die in der Routine verwendeten Infektions-Biomarker (CRP, PCT) hinreichend sensitiv und spezifisch, um eine Sepsis sicher anzuzeigen bzw. auszuschließen. Ihr Stellenwert liegt vielmehr im Therapiemonitoring und im Nachweis der Effektivität der antimikrobiellen Therapie.

• Grundpfeiler der mikrobiologischen Diagnostik sind weiterhin der kulturelle Erregernachweis und die Resistenztestung.

Schlüsselwörter

Sepsis - 1-h-Maßnahmenbündel - Fokussuche - Computertomografie (CT) - Fokussanierung - Biomarker - Laktat - C-reaktives Protein (CRP) - Procalcitonin (PCT) - midregionales Pro-Adrenomedullin (MR-proADM)

Key words

sepsis - hour-1 bundle - focus identification - computed tomography (CT) - source control measures - biomarker - lactate - C-reactive protein (CRP) - procalcitonin (PCT) - midregional pro-adrenomedullin (MR-proADM)

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