Diagnostik der Sepsis – Teil 2: Erregeridentifikation

Zusammenfassung

Im Rahmen der Sepsis und des septischen Schocks spielen, trotz der zunehmenden Verbreitung von neuen molekularbiologischen Verfahren, der kulturelle Erregernachweis und die Resistenztestung weiterhin die entscheidende Rolle in der antimikrobiellen Therapie auf der Intensivstation. Hierbei kann der Erregernachweis für die antimikrobielle Therapie einerseits direkt aus dem Patientenblut, andererseits aber auch aus diversen anderen Probenmaterialien (respiratorische Sekrete, Punktat, intraoperative Abstriche etc.) geführt werden. Ein Nachteil konventioneller kultureller Verfahren im Kontext kritisch kranker Patienten ist die zeitliche Latenz bis zum Erregernachweis bzw. zum Ergebnis der Resistenztestung. Molekularbiologische Verfahren wie Techniken der Erregerdiagnostik und Resistenztestung, die auf Polymerase Chain Reaction (PCR) oder vor allem Next-Generation Sequencing (NGS) basieren, versprechen hier zwar kürzere Umlaufzeiten, sind aber aktuell noch kein klinischer Standard. Trotzdem besitzen diese Verfahren das Potenzial, einen Paradigmenwechsel in der Erregerdiagnostik herbeizuführen.

Die Sepsis ist ein medizinischer Notfall mit weiterhin hoher Sterblichkeit. Die besondere Herausforderung besteht darin, eine adäquate Diagnostik und entsprechende antibiotische Therapie in möglichst kurzer Zeit nach Stellen der Verdachtsdiagnose durchzuführen. Nachdem in Teil 1 des Beitrags die allgemeine Diagnostik und Fokussuche bzw. -sanierung behandelt wurde, fokussiert Teil 2 nun auf die Erregeridentifizierung.

Abstract

Despite the dissemination of innovative, molecular biology-based and commercially available devices for pathogen detection, culture-based methods with susceptibility testing remain the key principles for guiding antimicrobial treatment of patients suffering from sepsis or septic shock on the ICU. Culture-based methods are able to facilitate pathogen detection from a diversity of specimen (respiratory secretion, intraoperatively obtained smears, aspirates, and so forth). However, the latency from obtainment of the specimen up to pathogen detection with susceptibility testing is a major disadvantage of culture-based methods in critical illness. Molecular biology-based methods like Polymerase Chain Reaction (PCR) and especially Next-Generation Sequencing (NGS) based methods promise faster pathogen and resistance detection, but are not used in clinical routine yet. With more clinical trials to come, these innovative diagnostic tools may have the potential to lead to a paradigm shift within the context of pathogen identification in sepsis.

Kernaussagen

• Grundpfeiler der mikrobiologischen Diagnostik sind weiterhin der kulturelle Erregernachweis und die Resistenztestung. Sie sollte grundsätzlich immer erfolgen – auch bei Nachweis einer invasiven Pilzinfektion. Nachteil ist die Zeitdauer bis zum Vorliegen des Befunds (> 24 h).

• Es existieren bereits erste innovative Technologien wie PCR-basierte Verfahren oder das NGS, die einen theoretischen Zeitvorteil bieten, bislang in der klinischen Routine jedoch noch nicht fest etabliert sind.

• Interdisziplinäre, interprofessionelle (klinische Pharmazeuten, Mikrobiologen, Infektiologen) Visiten, wie sie im Rahmen eines infektiologischen Konsildienstes (IDS) oder auch im Rahmen des Antibiotic Stewardships (ABS) verwirklicht werden, erhöhen die Versorgungsqualität bei komplexen Infektionen deutlich und verbessern das Behandlungsergebnis messbar.

• Die regelmäßige Reevaluation des Infektionsfokus, der antimikrobiellen Therapie auf der Basis der mikrobiologischen Befunde bildet – unabhängig vom Vorhandensein eines ABS-Teams – die Grundlage der Behandlung komplexer Infektionen und septischer Patienten.

Schlüsselwörter

Erregerdiagnostik - Blutkultur - Polymerasekettenreaktion - PCR - Next-Generation Sequencing (NGS)

Key words

pathogen detection - blood culture - polymerase chain reaction - PCR - next-generation sequencing - NGS

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