Pneumologie 2012; 66(12): 707-765
DOI: 10.1055/s-0032-1325924
Leitlinie
© Georg Thieme Verlag KG Stuttgart · New York

Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie[1]

S-3 Leitlinie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e.V., der Deutschen Gesellschaft für Infektiologie e.V., der Deutschen Gesellschaft für Hygiene und Mikrobiologie e.V., der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. und der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V.Epidemiology, Diagnosis and Treatment of Adult Patients with Nosocomial PneumoniaS-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy
K. Dalhoff
 1   Medizinische Klinik III, Pneumologie und Infektiologie, Universitätsklinikum Schleswig-Holstein, Lübeck
,
M. Abele-Horn
 2   Institut für Hygiene und Mikrobiologie der Universität Würzburg, Würzburg
,
S. Andreas
 3   Lungenfachklinik Immenhausen, Immenhausen
,
T. Bauer
 4   Klinik für Pneumologie, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin
,
H. von Baum
 5   Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum Ulm, Ulm
,
M. Deja
 6   Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie m. S. operative Intensivmedizin, Campus Virchow Klinikum und Campus Mitte, Berlin
,
S. Ewig
 7   Thoraxzentrum Ruhrgebiet, Klinik für Pneumologie und Infektiologie, Ev. Krankenhaus Herne, Augusta-Kranken-Anstalt Bochum, Bochum
,
P. Gastmeier
 8   Institut für Hygiene und Umweltmedizin, Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin
,
S. Gatermann
 9   Institut für Hygiene und Mikrobiologie, Abteilung für Medizinische Mikrobiologie, Ruhr-Universität Bochum, Bochum
,
H. Gerlach
10   Klinik für Anästhesie, operative Intensivmedizin und Schmerztherapie, Vivantes Klinikum Neukölln, Berlin
,
B. Grabein
11   Stabsstelle Klinische Mikrobiologie und Krankenhaushygiene am Klinikum der Universität München, München
,
G. Höffken
12   Medizinische Klinik und Poliklinik 1 m. S. Pneumologie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Dresden
,
W. V. Kern
13   Zentrum Infektiologie und Reisemedizin Freiburg, Universitätsklinikum Freiburg, Freiburg
,
E. Kramme
14   Medizinische Klinik III, Pneumologie und Infektiologie, Universitätsklinikum Schleswig-Holstein, Lübeck
,
C. Lange
15   Medizinische Klinik, Forschungszentrum Borstel, Borstel
,
J. Lorenz
16   Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Klinikum Lüdenscheid, Lüdenscheid
,
K. Mayer
17   Zentrum für Innere Medizin, Medizinische Klinik II, Pneumologie und Intensivmedizin, Universitätsklinikum Gießen und Marburg, Standort Gießen
,
I. Nachtigall
18   Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie m. S. operative Intensivmedizin, Campus Virchow Klinikum und Campus Mitte, Berlin
,
M. Pletz
19   Zentrum für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Jena
,
G. Rohde
20   Maastricht University Medical Center, Department of Respiratory Medicine, Maastricht, Niederlande
,
S. Rosseau
21   Charité, Universitätsmedizin Berlin, Medizinische Klinik m. S. Infektiologie und Pneumologie, Campus Charité Mitte, Berlin
,
B. Schaaf
22   Medizinische Klinik, Pneumologie und Infektiologie, Klinikum Dortmund gGmbH, Dortmund
,
R. Schaumann
23   Robert Koch-Institut, Berlin
,
D. Schreiter
24   Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden
,
H. Schütte
25   Charité, Universitätsmedizin Berlin, Medizinische Klinik m. S. Infektiologie und Pneumologie, Campus Virchow-Klinikum, Berlin
,
H. Seifert
26   Institut für Medizinische Mikrobiologie, Immunologie und Hygiene, Klinikum der Universität zu Köln, Köln
,
H. Sitter
27   Institut für Chirurgische Forschung, Philipps-Universität Marburg, Marburg
,
C. Spies
28   Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie m. S. operative Intensivmedizin, Campus Virchow Klinikum und Campus Mitte, Berlin
,
T. Welte
29   Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover
› Author Affiliations
Further Information

Publication History

Publication Date:
06 December 2012 (online)

Zusammenfassung

Die nosokomiale Pneumonie ist eine häufige Komplikation von Krankenhausaufenthalten. Die meisten Daten liegen zur beatmungsassoziierten Pneumonie vor, aber auch auf Normalstationen ist vermehrt mit dieser Erkrankung zu rechnen. Problematisch ist die Zunahme von Infektionen mit multiresistenten Erregern (MRE). Diese erschwert die adäquate Initialtherapie und kann zu unkritischem Einsatz von Breitspektrumantibiotika führen.

Die vorliegende S3-Leitlinie wurde von einer interdisziplinären Arbeitsgruppe auf der Basis einer systematischen Literaturrecherche erarbeitet. Die Empfehlungen zu Diagnostik und Therapie der nosokomialen Pneumonie wurden nach dem GRADE-System abgefasst. Sie berücksichtigen neben der Evidenzqualität auch Nutzen und Risiko bzw. Aufwand der empfohlenen Maßnahmen. Graduierung und Empfehlungsstärke entsprechen der Methodik der Nationalen Versorgungsleitlinien.

Die Leitlinie besteht aus zwei Teilen. Der allgemeine Teil vermittelt einen Überblick zu Epidemiologie, Erregerspektrum und Therapieoptionen der nosokomialen Pneumonie. Handlungsorientierte Empfehlungen werden im zweiten Teil zu zentralen Fragen der Diagnostik und Therapie abgegeben, die Hintergründe hierfür im Fließtext erklärt. Im Diagnostikteil wird besonderer Wert auf eine gezielte mikrobiologische Diagnostik gelegt, da diese die Voraussetzung für die Kenntnis des lokalen Erregerspektrums und der Resistenzraten bildet. Darüber hinaus stellt sie beim individuellen Patienten die beste Grundlage für die Deeskalation dar. Die Intensität der antiinfektiven Therapie ist vorwiegend davon abhängig, ob ein erhöhtes Risiko für Infektionen mit MRE besteht. Strukturierte Deeskalationskonzepte und konsequente Begrenzung der Therapiedauer dienen der Verminderung des Selektionsdrucks.

Abstract

Nosocomial pneumonia (HAP) is a frequent complication of hospital care. Most data are available on ventilator-associated pneumonia. However infections on general wards are also increasing. A central issue are infections with multi drug resistant (MDR) pathogens which are difficult to treat particularly in the empirical setting potentially leading to inappropriate use of antimicrobial therapy.

This guideline was compiled by an interdisciplinary group on the basis of a systematic literature review. Recommendations are made according to GRADE giving guidance for the diagnosis and therapy of HAP on the basis of quality of evidence and benefit/risk ratio.

The guideline has two parts. First an update on epidemiology, spectrum of pathogens and antiinfectives is provided. In the second part recommendations for the management of diagnosis and treatment are given. Proper microbiologic work up is emphasized for knowledge of the local patterns of microbiology and drug susceptibility. Moreover this is the optimal basis for deescalation in the individual patient. The intensity of antimicrobial therapy is guided by the risk of infections with MDR. Structured deescalation concepts and strict limitation of treatment duration should lead to reduced selection pressure.

1 Unter Mitwirkung der folgenden wissenschaftlichen Fachgesellschaften und Institutionen:
Deutsche Gesellschaft für Chirurgie (D. S.)
Deutsche Gesellschaft für Innere Medizin e. V. (S. A.)
Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (T. W.)
Deutsche Sepsis-Gesellschaft e. V. (K. M.) und
Robert Koch-Institut
Verabschiedet von den Vorständen der beteiligten Fachgesellschaften am 1.10. 2012.


 
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