Diagnostik und Therapie der Legionellen-Pneumonie

Zusammenfassung

Die Herausforderung in der Diagnostik der Legionellen-Pneumonie besteht darin, dass die Legionellen-Pneumonie relativ selten ist, andererseits jedoch häufiger als viele andere Erreger einen schweren Verlauf nimmt. Den wichtigsten Fortschritt in der Diagnostik der Legionellen-Pneumonie stellt der Antigennachweis im Urin durch einen immunchromatografischen Schnelltest (ICT) dar. Dieser kann bettseitig durchgeführt werden, ist einfach in der Handhabung und kann binnen 15 Minuten abgelesen werden. Die Sensitivität beträgt ca. 80 %, die Spezifität 100 %. Der Stellenwert dieses Tests innerhalb der Entscheidungsalgorithmen in der Versorgung von Patienten mit ambulant erworbener Pneumonie ist jedoch noch nicht geklärt. Mit Makroliden, Doxycyclin, Fluorchinolonen und Ketoliden, mit Einschränkung auch mit Streptograminen, stehen Substanzen mit sicher oder sehr wahrscheinlich ausreichender Wirksamkeit gegenüber Legionella spp. zur Verfügung, die somit für eine kalkulierte initiale antimikrobielle Therapie der ambulant erworbenen Pneumonie infrage kommen. In der gezielten antimikrobiellen Therapie sollten Makrolide und Fluorchinolone den Vorzug erhalten. Bei leichten bis mittelschweren Pneumonien sollten vorzugsweise neue Makrolide oral zur Anwendung kommen, innerhalb der Makrolide ergeben sich für das Azithromycin Vorteile. Alternativen sind Ciprofloxacin, Levofloxacin und Moxifloxacin. Bei schweren Legionellen-Pneumonien sowie unabhängig vom Schweregrad bei nosokomialen Legionellen-Pneumonien und solchen unter Immunsuppression stellen die genannten Flurochinolone intravenös die Therapie erster Wahl dar. Alternativ kann intravenös Azithromycin zur Anwendung kommen. Ob eine Kombinationstherapie aus Azithromycin oder Fluorchinolon und Rifampicin oder Azithromycin und Fluorchinolon einer Monotherapie überlegen ist, muss zum jetzigen Zeitpunkt offen bleiben.

Abstract

Legionellosis is a relatively rare condition but nevertheless is associated more frequently than many other pathogens with a severe course. Therefore, establishing a diagnosis of Legionellosis remains a challenge. The most significant progress in the diagnosis of Legionellosis is antigen-testing in urine by a rapid immunochromatographic test (ICT). This is an easy to handle bedside test which provides a result within 15 minutes. Sensitivity and specificity reach 80 % and 100 %, respectively. However, the exact place of this test within algorithms of clinical decision making still remains unsettled. Macrolides, doxycycline, fluoroquinolones and ketolides, and possibly also streptogramins are drugs with definitely or most probably sufficient activity against Legionella spp. and, therefore, are appropriate candidates within empirical initial antimicrobial treatment regimen of community-acquired pneumonia. Macrolides and fluoroquinolones should be the drugs of choice for the treatment of established Legionellosis. Oral macrolides should be prefered in patients with mild to moderate pneumonia; within the macrolides, azithromycin has the most favourable profile of activity. Alternatively, ciprofloxacin, levofloxacin and moxifloxacin may be selected. In severe Legionellosis as well as independently of severity in nosocomial legionellosis and immunosuppressed patients, intravenous fluoroquinolones are first choice drugs. Alternatively, azithromycin may be used. Whether a combination treatment including azithromycin or fluoroquinolones with rifampin or azithromycin with fluoroquinolone exert superior activity remains currently unknown.

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