Diagnostik und Therapie Katheter-assoziierter Infektionen in der pädiatrischen Onkologie

Zusammenfassung

Bei jedem Patienten mit zentralvenösem Verweilkatheter (central venous access device, CVAD) muss bei klinischen Zeichen einer Infektion ohne weiteren Fokus immer von einer CVAD-assoziierten Infektion ausgegangen werden. Die Sicherung der Diagnose gelingt mit Abstrichen, Blutkulturen und ggf. Kultur der Katheterspitze oder des Portreservoirs. Häufigste Erreger sind grampositive Keime, insbesondere Koagulase-negative Staphylokokken (CoNS). Bei Verdacht auf Infektion bei pädiatrisch onkologischen Patienten ist vor der Explantation des Systems meistens der Versuch einer in-situ-Therapie über den CVAD gerechtfertigt (IB). Ein intraluminal infizierter CVAD sollte explantiert werden, wenn unter einer in vitro effektiven antibakteriellen Chemotherapie nach mehr als 72 Stunden weiterhin Erreger in der Blutkultur nachweisbar sind (IB) oder früher, falls sich Vitalzeichen und Allgemeinzustand des Patienten unter der in-situ-Behandlung deutlich verschlechtern (IB). Die gesicherte Infektion des CVAD durch bestimmte Erregerspezies, wie z. B. S. aureus, Pseudomonas aeruginosa oder multiresistente Acinetobacter baumannii und Candida spp. erfordern die umgehende Entfernung des Systems, da die Heilungsraten niedrig und septische Komplikationen häufig sind (IB). Bei positiver Blutkultur sollte die antibakterielle Chemotherapie nach klinischer Genesung frühestens nach 7 Tagen, möglichst nach Rekonvaleszenz der neutrophilen Granulozyten und nach mindestens zwei sterilen Kontrollen der aus dem CVAD entnommenen Blutkultur beendet werden (IIC). Antibiotika-Heparin-Blocklösungen haben sich bei grampositiven Infektionen bewährt (IB). Über den adjuvanten Einsatz von Urokinase oder Taurolidin in der Therapie kann zur Zeit nur individuell entschieden werden (IIB).

Abstract

Otherwise unexplained clinical signs of infection in patients with tunneled or totally implanted central venous access devices (CVAD) are highly suspicious of an underlying CVAD-associated infection. Diagnostic methods include catheter swabs, blood cultures and cultures of the catheter tipp or port reservoir. In case of a suspected CVAD-related blood stream infection in pediatric cancer patients in situ treatment without prompt removal of the device can be tried. The removal of the CVAD should be considered, if bacteremia persists or relapses 72 hours or longer after the initiation of an (in vitro effective) antibacterial therapy administered through the line. The CVAD should be removed even earlier, if the patient suffers from hypotension or other signs of severe organ dysfunction related to the infection. If S. aureus, Pseudomonas aeruginosa, multiresistant Acinetobacter baumannii or Candida spp.are isolated from blood cultures taken through a CVAD, patients are at a high risk for severe complications and immediate device removal is also recommended. Duration of therapy depends on the immunological recovery of the patient (neutrophils counts), the pathogen isolated and on the presence of related complications like thrombosis, pneumonia, endocarditis, osteomyelitis. Antibiotic-lock techniques in addition to systemic treatment are beneficial in Gram-positve infections. Although prospectively controlled studies are missing, the concomitant use of urokinase- or taurolidine seems to favour catheter salvage.

Stichwörter

Diagnose und Therapie - zentralvenöse Katheter - Kinder mit Krebserkrankung

Key words

diagnosis and therapy - intravascular catheter - child - cancer

Literatur

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1 Die spezielle antibakterielle Therapie bakterieller Infektionen bei pädiatrisch onkologischen Patienten wird im Beitrag von A. Simon in diesem Band diskutiert, während die Beiträge von H. J. Laws und von A. Groll die empirische Therapie bei Granulozytopenie-Fieber bzw. die gezielte Therapie bei Pilzinfektionen besprechen.

2 Siehe Beitrag von A. Groll in diesem Band.

3 Das antimikrobiell wirksame EDTA wird von der Arbeitsgruppe von Isaam Raad (MD Anderson Cancer Center, Houston, Texas) zum Blocken des Katheters verwendet.

4 Siehe Übersicht von A. Groll in diesem Band

5 Nicht übereinstimmend mit den Empfehlungen zu Infektionen durch S. aureus oder P. aeruginosa in diesem Artikel, siehe Text.

6 TauroLock™, 5-ml-Ampullen, 1,35 % Taurolidin, 4 % Citrat, TauroPharm GmbH, Waldbüttelbrunn