Skip to main content
SpringerLink
Log in

Therapie der ambulant erworbenen Pneumonie

Treatment of community acquired pneumonia

  • Schwerpunkt: Lunge und Infektion
  • Published:
Der Internist Aims and scope Submit manuscript

Zusammenfassung

Die S3-Leitlinie zur Diagnostik und Therapie hat den Standard für eine risiko- und schweregradorientierte Behandlung der ambulant erworbenen Pneumonie (CAP) auf der Basis deutscher infektionsepidemiologischer Daten gesetzt. Neue Erkenntnisse der letzten beiden Jahre zeigen eine Veränderung der Erregerepidemiologie an, die Bedeutung von Staphylokokken und Enterobacteriacae wächst. CAP wird zunehmend mehr zu einer Erkrankung des alten Menschen, für den eine breiter wirksame Initialtherapie notwendig erscheint. Resistente Erreger spielen hier eine wesentliche Rolle für den Krankheitsverlauf. Für Patienten mit niedrigem Sterblichkeitsrisiko scheint eine Verkürzung der Therapiedauer möglich. Auf der anderen Seite ist eine frühzeitige Identifizierung kritisch kranker Patienten notwendig, die frühzeitig hoch dosiert und mit breit wirksamen Antibiotika behandelt werden müssen. Die antibiotikaassoziierte Diarrhö, ausgelöst durch Clostridium difficile, ist heute eine wesentliche Komplikation einer Antibiotikatherapie. Mit Einführung der Impfung gegen S. pneumoniae bei Kindern ist eine Veränderung des Krankheitsverlaufs und eine Verbesserung der Resistenzsituation erreicht worden. Für 2008 ist ein Update der S3-Leitlinie vorgesehen, um neue Erkenntnisse in die Empfehlungen zu integrieren.

Abstract

The S3 guidelines for diagnosis and therapy use German epidemiological data to set the standards for a risk and degree of severity based treatment of community acquired pneumonia (CAP). Over the last few years, a change in pathogen epidemiology has been recognized with the significance of staphylococci and enterobacteria increasing. CAP is becoming increasingly a disease of the elderly, for whom a more broadly effective initial therapy appears to be needed. Resistant pathogens play an important role in the course of the disease. For patients with a low risk of mortality, a reduction in the length of therapy seems possible. On the other hand, the early identification of critically ill patients who require treatment with high dose, broad spectrum antibiotics is necessary. Antibiotic associated diarrhoea, caused by Clostridium difficile, is a significant complication in antibiotic therapy. With the introduction of vaccination against Streptococcus pneumoniae for children, a change in the course of the illness and an improvement in the resistance situation has been achieved. An update of the S3 guidelines is intended for 2008 in order to integrate new knowledge into the recommendations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. BQS Qualitätsreport 2005. Hrg.: Bundesgeschäftsstelle für Qualitätssicherung, Düsseldorf 2006. S. 18–27

  2. Engelhart ST, Hanses-Derendorf L, Exner M et al. (2005) Prospective surveillance for healthcare-associated infections in German nursing home residents. J Hosp Infect 60: 46–50

    Article  PubMed  Google Scholar 

  3. Kollef MH, Shorr A, Tabak YP et al. (2005) Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 128: 3854–3862

    Article  PubMed  Google Scholar 

  4. American Thoracic Society; Infectious Diseases Society of America (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171: 388–416

    Article  PubMed  Google Scholar 

  5. King MD, Humphrey BJ, Wang YF et al. (2006) Emergence of community-acquired methicillin-resistant Staphylococcus aureus USA 300 clone as the predominant cause of skin and soft-tissue infections. Ann Intern Med 144: 309–317

    PubMed  Google Scholar 

  6. Naimi TS, LeDell KH, Como-Sabetti K et al. (2003) Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA 290: 2976–2984

    Article  PubMed  Google Scholar 

  7. Metlay JP, Kapoor WN, Fine MJ (1997) Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA 278: 1440–1445

    Article  PubMed  Google Scholar 

  8. Bauer TT, Ewig S, Marre R et al.; The CAPNETZ Study Group (2006) CRB-65 predicts death from community-acquired pneumonia. J Intern Med 260: 93–101

    Article  PubMed  Google Scholar 

  9. Capelastegui A, Espana PP, Quintana JM et al. (2006) Validation of a predictive rule for the management of community-acquired pneumonia. Eur Respir J 27: 151–157

    Article  PubMed  Google Scholar 

  10. Christ-Crain M, Jaccard-Stolz D, Bingisser R et al. (2004) Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet 363: 600–607

    PubMed  Google Scholar 

  11. Christ-Crain M, Morgenthaler NG, Stolz D et al. (2006) Pro-adrenomedullin to predict severity and outcome in community-acquired pneumonia. Crit Care 10: R96

    Article  PubMed  Google Scholar 

  12. Mandell LA, Wunderink RG, Anzueto A. et al. (2007) Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 44: S27–72

    Article  PubMed  Google Scholar 

  13. Bodi M, Rodriguez A, Sole-Violan J et al. (2005) Antibiotic prescription for community-acquired pneumonia in the intensive care unit: Impact of adherence to infectious diseases society of America guidelines on survival. Clin Infect Dis 41: 1709–1714

    Article  PubMed  Google Scholar 

  14. Kohlhammer Y, Raspe H, Marre R et al.; CAPNETZ study group (2006) Antibiotic treatment of community acquired pneumonia varies widely across Germany. J Infect [Epub ahead of print]

  15. Deshpande LM, Sader HS, Debbia E et al.; SENTRY Antimicrobial Surveillance Program (2001–2004) (2006) Emergence and epidemiology of fluoroquinolone-resistant Streptococcus pneumoniae strains from Italy: report from the SENTRY Antimicrobial Surveillance Program (2001–2004). Diagn Microbiol Infect Dis 54: 157–164

    Article  Google Scholar 

  16. Yu VL, Chiou CC, Feldman C et al.; International Pneumococcal Study Group (2003) An international prospective study of pneumococcal bacteremia: correlation with in vitro resistance, antibiotics administered, and clinical outcome. Clin Infect Dis 37: 230–237

    Article  PubMed  Google Scholar 

  17. Daneman N, McGeer A, Green K et al.; Toronto Invasive Bacterial Diseases Network (2006) Macrolide resistance in bacteremic pneumococcal disease: implications for patient management. Clin Infect Dis 43: 432–438

    Article  PubMed  Google Scholar 

  18. Malhotra-Kumar S, Lammens C, Coenen S et al. (2007) Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet 369: 482–490

    Article  PubMed  Google Scholar 

  19. Schnoor M, Klante T, Beckmann M et al.; The CAPNETZ Study Group (2007) Risk factors for community-acquired pneumonia in German adults: the impact of children in the household. Epidemiol Infect: 1–9

    Google Scholar 

  20. Low DE (2004) Quinolone resistance among pneumococci: therapeutic and diagnostic implications. Clin Infect Dis 38 (Suppl 4): S357–S362

    Article  PubMed  Google Scholar 

  21. Meyer E, Schwab F, Jonas D et al. (2005) Temporal changes in bacterial resistance in German intensive care units, 2001–2003: data from the SARI (surveillance of antimicrobial use and antimicrobial resistance in intensive care units) project. J Hosp Infect 60: 348–352

    Article  PubMed  Google Scholar 

  22. Höffken G, Lorenz J, Kern W et al. (2005) S3-Leitlinie zu ambulant erworbener Pneumonie und tiefen Atemwegsinfektionen. Pneumologie 59: 612–664

    PubMed  Google Scholar 

  23. Vanderkooi OG, Low DE, Green K et al. (2005) Predicting antimicrobial resistance in invasive pneumococcal infections. Clin Infect Dis 40: 1288–1297

    Article  PubMed  Google Scholar 

  24. Oosterheert JJ, Bonten MJ, Schneider MM et al. (2006) Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial. BMJ 333: 1193

    Article  PubMed  Google Scholar 

  25. Baddour LM, Yu VL, Klugman KP et al. (2004) Combination antibiotic therapy lowers mortality among severly ill patients with pneumococcal bacteremia pneumococcal bacteremia. Am J Respir Crit Care Med 170: 440–444

    Article  PubMed  Google Scholar 

  26. Aspa J, Rajas O, Rodriguez de Castro F et al.; The Pneumococcal Pneumonia in Spain Study Group (2006) Impact of initial antibiotic choice on mortality from pneumococcal pneumonia. Eur Respir J 27: 1010–1019

    PubMed  Google Scholar 

  27. Paul M, Benuri-Silbiger I, Soares-Weiser K et al. (2004) Beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and meta-analysis of randomised trials. BMJ 328: 668

    Article  PubMed  Google Scholar 

  28. Safdar N, Handelsman J, Maki DG (2004) Does combination antimicrobial therapy reduce mortality in gram-negative bacteraemia? A meta-analysis. Lancet Infect Dis 4: 519--527

    Article  PubMed  Google Scholar 

  29. Kumar A, Roberts D, Wood KE (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 34: 1589–1596

    Article  PubMed  Google Scholar 

  30. Dunbar LM, Wunderink RG, Habib MP et al. (2003) High-dose, short-course levofloxacin for community-acquired pneumonia: a new treatment paradigm. Clin Infect Dis 37: 752--760

    Article  PubMed  Google Scholar 

  31. el Moussaoui R, de Borgie CA, van den Broek P et al. (2006) Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. BMJ 332: 1355

    Article  PubMed  Google Scholar 

  32. Welte T, Petermann W, Schurmann D et al.; MOXIRAPID Study Group (2005) Treatment with sequential intravenous or oral moxifloxacin was associated with faster clinical improvement than was standard therapy for hospitalized patients with community-acquired pneumonia who received initial parenteral therapy. Clin Infect Dis 41: 1697–1705

    Article  PubMed  Google Scholar 

  33. Christ-Crain M, Stolz D, Bingisser R et al. (2006) Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med 174: 84–93

    Article  PubMed  Google Scholar 

  34. Confalonieri M, Urbino R, Potena A et al. (2005) Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med 171: 242–248

    Article  PubMed  Google Scholar 

  35. Colice GL, Curtis A, Deslauriers J et al. (2000) Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest 118: 1158–1171

    Article  PubMed  Google Scholar 

  36. Maskell NA, Davies CWH, Nunn AJ et al. (2005) U.K. controlled trial of intrapleural streptokinase for pleural infection. N Eng J Med 352: 865–874

    Article  Google Scholar 

  37. Maskell NA, Batt S, Hedley EL et al. (2006) The bacteriology of pleural infection by genetic and standard methods and its mortality significance. AJRCCM 174: 817–823

    Google Scholar 

  38. Hammond JM, Potgieter PD, Hanslo D et al. (1995) The etiology and antimicrobial susceptibility patterns of microorganisms in acute community-acquired lung abscess. Chest 108: 937–941

    PubMed  Google Scholar 

  39. Herth F, Ernst A, Becker HD (2005) Endoscopic drainage of lung abscesses: technique and outcome. Chest 127: 1378–1381

    Article  PubMed  Google Scholar 

  40. Allewelt M, Schuler P, Bolcskei PL et al. (2004) Ampicillin + sulbactam vs clindamycin +/- cephalosporin for the treatment of aspiration pneumonia and primary lung abscess. Clin Microbiol Infect 10: 163–170

    Article  PubMed  Google Scholar 

  41. Loo VG, Poirier L, Miller MA et al. (2005) A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 353: 2442–2449

    Article  PubMed  Google Scholar 

  42. Bartlett JG (2002) Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 346: 334–339

    Article  PubMed  Google Scholar 

  43. Whitney CG, Farley MM, Hadler J et al. (2003) Active bacterial core surveillance of the emerging infections program network. Invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med 348: 1737–1746

    Article  PubMed  Google Scholar 

  44. Stephens DS, Zughaier SM, Whitney CG et al. (2005) Georgia Emerging Infections Program. Incidence of macrolideresistance in Streptococcus pneumoniae after introduction of the pneumococcal conjugate vaccine: population-based assessment. Lancet 365: 855–863

    Article  PubMed  Google Scholar 

  45. Watson L, Wilson BJ, Waugh N (2002) Pneumococcal polysaccharide vaccine: a systematic review of clinical effectiveness in adults. Vaccine 20: 2166–2173

    Article  PubMed  Google Scholar 

  46. Vila-Corcoles A, Ochoa-Gondar O, Hospital I et al. (2006) Protective effects of the 23-valent pneumococcal polysaccharide vaccine in the elderly population: the EVAN-65 study. Clinical Infectious Diseases 43: 860–868

    Article  PubMed  Google Scholar 

Download references

Interessenkonflikt

Es besteht kein Interessenkonflikt. Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt ist, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral.

Author information

Authors and Affiliations

  1. Abteilung Pneumologie, Medizinische Hochschule Hannover, Carl-Neubert-Straße 1, 30625, Hannover, Deutschland

    T. Welte

Authors
  1. T. Welte
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T. Welte.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Welte, T. Therapie der ambulant erworbenen Pneumonie. Internist 48, 476–488 (2007). https://doi.org/10.1007/s00108-007-1852-7

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00108-007-1852-7

Schlüsselwörter

Keywords

Search

Navigation