Rezidivprophylaxe bei Harnwegsinfektionen – noch zeitgemäß?

Einleitung

Bei einer Pyelonephritis im Säuglings- und Kindesalter stellt die rasche Diagnose und Therapie eine wirksame Vorbeugung gegenüber Nierenparenchymdefekten dar. Mit einem Rezidiv muss bei mindestens einem Drittel der Kinder gerechnet werden [1]. Die Empfänglichkeit für ein Rezidiv ist in den ersten 2 – 3 Monaten nach einer Harnwegsinfektion (HWI) am größten und korreliert direkt mit der Zahl vorangegangener Infektionen [2]. Je länger das infektionsfreie Intervall ist, desto geringer wird die Wahrscheinlichkeit für ein weiteres Rezidiv [2] [3].

Bei hohem Rezidiv- und Schädigungsrisiko kann nach sorgfältiger Abwägung eine antibakterielle Langzeitinfektionsprophylaxe sinnvoll sein. Zu den Risikokindern gehören u. a. Säuglinge und Kleinkinder mit höhergradigem vesikoureteralem Reflux (VUR) (Abb. [1]), mit rezidivierenden Pyelonephritiden oder mit hochgradigen Harntransportstörungen. Die Hauptziele prophylaktischer Maßnahmen in dieser Alterstufe sind die Verhinderung von rezidivierenden Pyelonephritiden und von Nierenparenchymschäden.

Abb. 1 Ein dilatierender vesikorenaler Reflux (hier im Röntgen-MCU während der Blasenentleerung bei einem männlichen Säugling) ist eine der möglichen Indikationen für eine antibakterielle Infektionsprophylaxe.

Helmholtz empfahl erstmals 1941 die Langzeitgabe kleiner Dosen Sulfathiazol zur Behandlung „chronischer” HWI [4]. Einige Jahre später demonstrierten Marshall und Stansfield den Nutzen einer antibakteriellen Infektionsprophylaxe bei Säuglingen und jungen Kindern durch Nitrofurantoin [5] [6]. Basierend auf der Beobachtung, dass 27 % aller Kinder mit rezidivierenden HWI bereits pyelonephritische Parenchymdefekte aufwiesen [7], empfahlen Smellie et al. den Einsatz einer Langzeitinfektionsprophylaxe für Kinder mit rezidivierenden HWI [8] und zeigten eine signifikante Reduktion der Rezidivhäufigkeit unter antibakterieller Prophylaxe [9]. Eine Doppelblindstudie bei 18 Mädchen im Alter von 3 – 13 Jahren kam zu einem ähnlichen Ergebnis [10].

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