Nosokomiale Pneumonie: Empfehlungen zur Therapie und Prophylaxe
Deutsche Gesellschaft für PneumologieS. Ewig (Bonn), federführend, K. Dalhoff (Lübeck), J. Lorenz (Lüdenscheid), T. Schaberg (Rotenburg), T. Welte (Magdeburg), H. Wilkens (Homburg)
Die initiale antimikrobielle Therapie der nosokomialen Pneumonie erfolgt kalkuliert anhand einer Zuordnung des Patienten zu einer definierten Risikogruppe mit charakteristischem Erregerspektrum. Grundkriterien der Risikoeinschätzung umfassen: 1) Spontanatmung versus Beatmung; 2) Zeitpunkt des Auftretens (früh versus spät erworbene Pneumonie); 3) zusätzliche Risikofaktoren (Dauer der vorbestehenden antimikrobiellen Therapie; ZNS-Trauma oder Koma, strukturelle pulmonale Komorbidität, iatrogene Immunsuppression, gesicherte Aspiration). Während früh einsetzende Pneumonien mit Aminopenicillin/β-Laktamase-Hemmer oder Cephalosporinen der 2. Generation ausreichend behandelt sind, ergibt sich für spät einsetzende Pneumonien die Notwendigkeit einer breiteren Kombinationstherapie aus Antipseudomonas-Penicillin oder -Cephalosporin oder Carbapenem plus Ciprofloxacin oder Aminoglykosid. Bei spontan atmenden Patienten mit spät einsetzender und leichter bis mittelschwerer Pneumonie ist eine Monotherapie mit einem Chinolon oder einem Cephalosporin der 3. Generation ausreichend. Im Falle des Vorliegens einer der definierten Risikofaktoren wird die antimikrobielle Therapie entsprechend des zu erwartenden Erregerspektrums modifiziert. Eine adäquate Dosierung entsprechend Körpergewicht und Nierenfunktion (sowie bei isoliertem mutmaßlichen Erreger entsprechend MHC) ist für den Therapieerfolg essenziell. Strategien zur Limitierung der Selektion von multiresistenten Keimen umfassen den zurückhaltenden und gezielten Einsatz antimikrobieller Substanzen auf der Intensivstation sowie Konzepte eines zyklischen Einsatzes verschiedener Regime mit differenten Wirkspektren.
In der Prävention der nosokomialen Pneumonie sind folgende Maßnahmen wissenschaftlich gesichert und werden generell empfohlen: 1) Händedesinfektion und besondere Hygiene einschließlich Strategien zur Isolation von Patienten; 2) Oberkörperhochlagerung; 3) Beatmungssystemwechsel einmal pro Woche; 4) Vermeidung von Relaxantien. Für die orotracheale anstelle der nasotrachealen Intubation sprechen empirische Daten und theoretische Überlegungen.
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