Von Bronchitis bis Influenza: Tiefe Atemwegsinfektionen – Indikation zur Antibiotikatherapie genau prüfen!

Infekte der Atemwege zählen in der täglichen Praxis zu den häufigsten Gründen für eine Arztkonsultation – insbesondere in den jetzt bevorstehenden Wintermonaten. Rund ein Drittel der Atemwegsinfekte betreffen den unteren Respirationstrakt. Hierzu zählen neben der der häufigsten Form, der akuten Bronchitis, auch die exazerbierte chronisch-obstruktive Lungenerkrankung (COPD), die ambulant erworbene Pneumonie (CAP) und die Influenza. Typische Symptome sind neben einem allgemeinen Krankheitsgefühl Fieber, Husten mit oder ohne Auswurf, Dyspnoe sowie Kopf- und Gliederschmerzen. Im Alltag werden die meisten Betroffenen antibiotisch behandelt, obwohl ein Effekt der Antibiotika nicht in allen Fällen nachgewiesen ist. Während Patienten mit einer CAP immer eine leitliniengerechte antibiotische Behandlung erhalten sollten, ist ein Nutzen bei der akuten Bronchitis und einigen Formen der exazerbierten COPD nicht belegt, da sie meist nicht bakteriell bedingt sind. Gerade in den Zeiten zunehmender Antibiotikaresistenzen ist die Vermeidung von unnötigen Verordnungen jedoch dringlicher denn je.

Infections of the respiratory tract are one of the most common reasons for GP consultations, especially in the oncoming winter season. Almost one third of these infections aff ect the lower respiratory tract, comprising acute bronchitis, the most frequent form of lower respiratory tract infections (LRTI), exacerbated chronic obstructive pulmonary disease (AE-COPD), community-acquired pneumonia (CAP), and infl uenza. Common signs and symp toms of LRTI include compromised general condition, fever, cough with or without expectoration, dyspnea, headaches, and myalgia. In every day practice, most patients receive antibiotic treatment, although an advantage of this treatment is not proven in all cases. Whereas all patients with CAP should receive antibiotics in accordance with recent guidelines, there is no indication for antibiotic treatment in acute bronchitis and some cases of exacerbated COPD, because of their mostly non bacterial origin. Especially in times of rising antibiotic resistances thoughtful prescribing of antibiotics is needed more than ever.

Key words

lower respiratory tract infection (LRTI) - acute bronchitis - acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) - communityacquired pneumonia (CAP)

Literatur

• 1 Ruiz M, Ewig S, Marcos MA. et al. . Etiology of community-acquired pneumonia: impact of age, comorbidity, and severity.  Am J Respir Crit Care Med. 1999;  160 397-405
• 2 Lim WS, Macfarlane JT, Boswell TC. et al. . Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines.  Thorax. 2001;  56 296-301
• 3 Höffken G, Lorenz J, Kern W. et al. . S3-Leitlinie zu ambulant erworbener Pneumonie und tiefen Atemwegsinfektionen.  Pneumologie. 2005;  59
• 4 Macfarlane J, Holmes W, Gard P. et al. . Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community.  Thorax. 2001;  56 109-114
• 5 Creer DD, Dilworth JP, Gillespie SH. et al. . Aetiological role of viral and bacterial infections in acute adult lower respiratory tract infection (LRTI) in primary care.  Thorax. 2006;  61 75-79
• 6 de Roux A, Marcos MA, Garcia E. et al. . Viral community-acquired pneumonia in nonimmunocompromised adults.  Chest. 2004;  125 1343-1351
• 7 Rohde G, Wiethege A, Borg I. et al. . Respiratory viruses in exacerbations of chronic obstructive pulmonary disease requiring hospitalisation: a case-control study.  Thorax. 2003;  58 37-42
• 8 Huchon G, Woodhead M, Gialdroni-Grassi G. et al. . Management of adult community-acquired lower respiratory tract infections.  Eur Respir Rev. 1998;  8 389-426
• 9 Fahey T, Stocks N, Thomas T.. Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults.  BMJ. 1998;  316 906-910
• 10 Anthonisen NR, Manfreda J, Warren CP. et al. . Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease.  Ann Intern Med. 1987;  106 196-204
• 11 Chung A, Perera R, Brueggemann AB. et al. . Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study.  BMJ. 2007;  335 429
• 12 Malhotra-Kumar S, Lammens C, Coenen S. et al. . Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study.  Lancet. 2007;  369 482-490
• 13 Altiner A, Wilm S, Däubener W. et al. . Sputum colour for diagnosis of a bacterial infection in patients with acute cough.  Scand J Prim Health Care. 2009;  27 70-73
• 14 Holmes WF, Macfarlane JT, Macfarlane RM, Hubbard R.. Symptoms, signs, and prescribing for acute lower respiratory tract illness.  Br J Gen Pract. 2001;  51 177-181
• 15 Knutson D, Braun C.. Diagnosis and management of acute bronchitis.  Am Fam Physician. 2002;  65 2039-2044
• 16 Birkebaek NH, Kristiansen M, Seefeldt T. et al. . Bordetella pertussis and chronic cough in adults.  Clin Infect Dis. 1999;  29 1239-1242
• 17 Boldy DA, Skidmore SJ, Ayres JG.. Acute bronchitis in the community: clinical features, infective factors, changes in pulmonary function and bronchial reactivity to histamine.  Respir Med. 1990;  84 377-385
• 18 Freymuth F, Vabret A, Gounarin S. et al. . [Epidemiology and diagnosis of respiratory syncitial virus in adults].  Rev Mal Respir. 2004;  21 35-42
• 19 van den Hoogen BG, Osterhaus DM, Fouchier RA.. Clinical impact and diagnosis of human metapneumovirus infection.  Pediatr Infect. 2004;  23
• 20 Smucny J, Fahey T, Becker L, Glazier R.. Antibiotics for acute bronchitis. Cochrane Database Syst Rev 2004
• 21 Macfarlane J, Holmes W, Gard P. et al. . Reducing antibiotic use for acute bronchitis in primary care: blinded, randomised controlled trial of patient information leaflet.  BMJ. 2002;  324 91-94
• 22 Rabe KF, Hurd S, Anzueto A. et al. . Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.  Am J Respir Crit Care Med. 2007;  176 532-555
• 23 Kanner RE, Anthonisen NR, Connett JE. Lung Health Study Research Group. . Lower respiratory illnesses promote FEV(1) decline in current smokers but not ex-smokers with mild chronic obstructive pulmonary disease: results from the lung health study.  Am J Respir Crit Care Med. 2001;  164 358-364
• 24 Donaldson GC, Seemungal RA, Bhowmik A, Wedzicha JA.. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease.  Thorax. 2002;  57 847-852
• 25 Burge S, Wedzicha JA.. COPD exacerbations: definitions and classifications.  Eur Respir J Suppl. 2003;  41
• 26 Connors Jr AF, Dawson NV, Thomas C. et al. . The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments).  Am J Respir Crit Care Med. 1996;  154 959-967
• 27 Groenewegen KH, Schols AM, Wouters EF.. Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD.  Chest. 2003;  124 459-467
• 28 WHO. World Health Report. 2008
• 29 Rodriguez-Roisin R.. Toward a consensus definition for COPD exacerbations.  Chest. 2000;  117
• 30 Murphy TF, Sethi S, Niederman MS.. The role of bacteria in exacerbations of COPD. A constructive view.  Chest. 2000;  118 204-209
• 31 Greenberg SB, Allen M, Wilson J, Atmar RL.. Respiratory viral infections in adults with and without chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2000;  162 167-173
• 32 Bandi V, Apicella MA, Mason E. et al. . Nontypeable Haemophilus influenzae in the lower respiratory tract of patients with chronic bronchitis.  Am J Respir Crit Care Med. 2001;  164 2114-2119
• 33 Patel IS, Seemungal TA, Wilks M. et al. . Relationship between bacterial colonisation and the frequency, character, and severity of COPD exacerbations.  Thorax. 2002;  57 759-764
• 34 Wedzicha JA.. Role of viruses in exacerbations of chronic obstructive pulmonary disease.  Proc Am Thorac Soc. 2004;  1 115-120
• 35 Seemungal T, Harper-Owen R, Bhowmik A. et al. . Respiratory viruses, symptoms, and inflammatory markers in acute exacerbations and stable chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2001;  164 1618-1623
• 36 Papi A, Bellettato CM, Braccioni F. et al. . Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations.  Am J Respir Crit Care Med. 2006;  173 1114-1121
• 37 Tan WC, Xiang X, Oju D. et al. . Epidemiology of respiratory viruses in patients hospitalized with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease.  Am J Med. 2003;  115 272-277
• 38 Wilkinson TM, Hurst JR, Perara WR. et al. . Effect of interactions between lower airway bacterial and rhinoviral infection in exacerbations of COPD.  Chest. 2006;  129 317-324
• 39 Vogelmeier C, Buhl R, Criée CP. et al. . Leitlinie der Deutschen Atemwegsliga und der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin zur Diagnostik und Therapie von Patienten mit chronisch obstruktiver Bronchitits und Lungenemphysem (COPD).  Pneumologie. 2007;  61
• 40 Saint S, Bent S, Vittinghoff E, Grady D.. Antibiotics in chronic obstructive pulmonary disease exacerbations.  A meta-analysis. JAMA. 1995;  273 957-960
• 41 Puhan MA, Vollenweider D, Steurer J. et al. . Where is the supporting evidence for treating mild to moderate chronic obstructive pulmonary disease exacerbations with antibiotics? A systematic review.  BMC Med. 2008;  6 28
• 42 Eller J, Ede A, Schaberg T. et al. . Infective exacerbations of chronic bronchitis: relation between bacteriologic etiology and lung function.  Chest. 1998;  113 1542-1548
• 43 Statistisches Bundesamt. Todesursachen in Deutschland 2006
• 44 Loddenkemper R, Sibille . Y. Major respiratory diseases: pneumonia, in European lung white book: the first comprehensive survey on respiratory health in Europe. European Respiratory Society and European Lung Foundation: Sheffield, UK 2003: 55-64
• 45 Qualitätssicherung B.. Ambulant erworbene Pneumonie. In: Qualitätsbericht 2007: 2007
• 46 Blasi F, Iori I, Bulfoni A. et al. . Can CAP guideline adherence improve patient outcome in internal medicine departments?.  Eur Respir J. 2008;  32 902-910
• 47 Gennis P, Gallagher J, Falvo C. et al. . Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department.  J Emerg Med. 1989;  7 263-268
• 48 Heckerling PS.. The need for chest roentgenograms in adults with acute respiratory illness. Clinical predictors.  Arch Intern Med. 1986;  146 1321-1324
• 49 Melbye H, Straume B, Aasebø U, Dale K.. Diagnosis of pneumonia in adults in general practice. Relative importance of typical symptoms and abnormal chest signs evaluated against a radiographic reference standard.  Scand J Prim Health Care. 1992;  10 226-233
• 50 Bauer TT, Ewig S, Marre R. et al. . CRB-65 predicts death from community-acquired pneumonia.  J Intern Med. 2006;  260 93-101
• 51 Ewig S, de Roux A, Bauer T. et al. . Validation of predictive rules and indices of severity for community acquired pneumonia.  Thorax. 2004;  59 421-427
• 52 Woodhead M.. Community-acquired pneumonia guidelines – an international comparison: a view from Europe.  Chest. 1998;  113
• 53 von Baum H, Ewig S, Marre R. et al. . Community-acquired Legionella pneumonia: new insights from the German competence network for community acquired pneumonia.  Clin Infect Dis. 2008;  46 1356-1364
• 54 Meehan TP, Chua-Reyes JM, Tate J. et al. . Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community-acquired or nursing home-acquired pneumonia.  Chest. 2000;  117 1378-1385
• 55 Houck PM, MacLehose RF, Niederman MS, Lowery JK.. Empiric antibiotic therapy and mortality among medicare pneumonia inpatients in 10 western states: 1993, 1995, and 1997.  Chest. 2001;  119 1420-1426
• 56 Appelbaum PC.. Microbiological and pharmacodynamic considerations in the treatment of infection due to antimicrobial-resistant Streptococcus pneumoniae.  Clin Infect Dis. 2000;  31
• 57 Reinert RR, Reinert S, van der Linden M. et al. . Antimicrobial susceptibility of Streptococcus pneumoniae in eight European countries from 2001 to 2003.  Antimicrob Agents Chemother. 2005;  49 2903-2913
• 58 Dunbar LM, Wunderink RG, Habib MP. et al. . High-dose, short-course levofloxacin for community-acquired pneumonia: a new treatment paradigm.  Clin Infect Dis. 2003;  37 752-760
• 59 Genne D, Kaiser L, Kinge TN, Lew D.. Community-acquired pneumonia: causes of treatment failure in patients enrolled in clinical trials.  Clin Microbiol Infect. 2003;  9 949-954
• 60 Menendez R, Torris A, Zalacain R. et al. . Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome.  Thorax. 2004;  59 960-965
• 61 Morens DM, Taubenberger JK, Fauci AS.. The persistent legacy of the 1918 influenza virus.  N Engl J Med. 2009;  361 225-229

1 Global initiative for chronic Obstructive Lung Disease

2 Confusion, Urea, Respiratory rate, Blood pressure

3 Kompetenznetz Ambulant Erworbene Pneumonie

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