Der Internist

, Volume 48, Issue 5, pp 507–518 | Cite as

Pneumonien bei Immunsuppression

Schwerpunkt: Lunge und Infektion

Zusammenfassung

Pneumonien bei immundefizienten Patienten sind häufige, lebensbedrohliche Komplikationen. Eine rasche, zielgerichtete Diagnostik und Therapie sind für den Krankheitsverlauf entscheidend. Das ätiologische Spektrum ist deutlich breiter als bei immunkompetenten Patienten. Wichtige Hinweise liefern Art und Intensität der Immunsuppression, Lücken im Prophylaxekonzept sowie besondere Expositionen. Zur Planung des diagnostischen Vorgehens ist häufig ein hoch auflösendes Computertomogramm des Thorax erforderlich. Standardmethode zur Erregergewinnung ist die flexible Bronchoskopie mit bronchoalveolärer Lavage. Die Indikation für invasivere bioptische Maßnahmen ist individuell zu stellen und hängt vom erwarteten Erregerspektrum sowie von Risikofaktoren und Kontraindikationen des Patienten ab. Nichtinvasive Antigen- und PCR-Tests ergänzen das diagnostische Spektrum, insbesondere für schwer anzüchtbare Erreger wie Schimmelpilze und Herpesviren. Die Wahl der initialen, kalkulierten antimikrobiellen Therapie erfolgt leitliniengestützt und sollte nach Erhalt mikrobiologischer Daten möglichst fokussiert weitergeführt werden.

Schlüsselwörter

Pneumonie Immundefizit Immunsuppression Bronchoskopie Antimikrobielle Therapie 

Pneumonias and immunosuppression

Abstract

Pneumonias are common, life threatening complications in immunodeficient patients. A rapid, targeted diagnosis and therapy are decisive for the course of the disease. The etiological spectrum is substantially broader than for immunocompetent patients. Important indications are provided by the type and intensity of the immunosuppression, gaps in the prophylactic concept and particular exposures. For diagnostic planning, high resolution computed tomogram of the thorax is necessary. The standard method for isolating the pathogen is flexible bronchoscopy with bronchoalveolar lavage. Indications for invasive bioptic measures depend on the individual situation, the expected spectrum of pathogens as well as risk factors and adverse effects. Non-invasive antigen and PCR tests complement the diagnostic spectrum, especially for difficult to cultivate pathogens such as fungi and Herpes viruses. The selection of the initial, targeted antimicrobial therapy is based on guidelines. The treatment should be followed after obtaining the relevant microbiological data.

Keywords

Pneumonia Immunodeficiency Immunosuppression Bronchoscopy Antimicrobial therapy 

Literatur

  1. 1.
    Deutsche Stiftung Organtransplantation (2006) Organspende und Transplantation in Deutschland 2005. DSO, Neu-Isenburg, http://www.dso.de
  2. 2.
    Deutsches Register für Stammzelltransplantationen (2006) DRST-Jahresbericht 2005. DRST, Essen, Ulm http://www.drst.de
  3. 3.
    Robert-Koch Institut (2006) Epidemiologisches Bulletin 31.10.2006. RKI, Berlin, http://www.rki.de
  4. 4.
    Shorr AF, Susla GM, O’Grady NP( 2004) Pulmonary infiltrates in the non-HIV-infected immunocompromised patient: etiologies, diagnostic strategies, and outcomes. Chest 125: 260–271CrossRefPubMedGoogle Scholar
  5. 5.
    Martin SI, Marty FM, Fiumara K (2006) Infectious complications associated with alemtuzumab use for lymphoproliferative disorders. Clin Infect Dis 43: 16–24CrossRefPubMedGoogle Scholar
  6. 6.
    Fishman JA, Rubin RH (1998) Infection in organ-transplant recipients. N Engl J Med 338: 1741–1751CrossRefPubMedGoogle Scholar
  7. 7.
    Vernovsky I, Dellaripa PF (2000) Pneumocystis carinii pneumonia prophylaxis in patients with rheumatic diseases undergoing immunosuppressive therapy. J Clin Rheumatol 6: 94–101CrossRefGoogle Scholar
  8. 8.
    Hamilton CD (2005) Immunosuppression related to collagen vascular disease or its treatment. Proc Am Thorac Soc 2: 456–460CrossRefPubMedGoogle Scholar
  9. 9.
    Bridgen ML, Patullo AL (1999) Prevention and management of overwhelming postsplenectomy infection – an update. Crit Care Med 27: 836–842CrossRefPubMedGoogle Scholar
  10. 10.
    Christensen D, Feldman C, Rossi P et al. (2005) HIV infection does not influence clinical outcomes in bacterial community-acquired pneumonia. Clin Infect Dis 41: 554–556CrossRefPubMedGoogle Scholar
  11. 11.
    Acrasoy SM, Kotloff RM (1999) Lung transplantation. N Engl J Med 14: 1081–1091Google Scholar
  12. 12.
    Carratala J, Roson B, Fernandez-Sevilla A et al. (1998) Bacteremic pneumonia in neutropenic patients with cancer. Arch Intern Med 158: 868–872CrossRefPubMedGoogle Scholar
  13. 13.
    Knirsch CA, Jakob K, Schoonmaker D et al. (2000) An outbreak of Legionella micdadei pneumonia in transplant patients. Am J Med 108: 290–295CrossRefPubMedGoogle Scholar
  14. 14.
    Husain S, McCurry C, Dauber J et al. (2002) Nocardia infection in lung transplant recipients. J Heart Lung Transplant 21: 354–359CrossRefPubMedGoogle Scholar
  15. 15.
    Queipo JA, Broseta E, Santos M et al. (2003) Mycobacterial infection in a series of 1261 renal transplant recipients. Clin Microbiol Infect 9: 518–525CrossRefPubMedGoogle Scholar
  16. 16.
    Subira M, Martino R, Rovira M et al (2003) Clinical applicability of the new EORTC/MSG classification for invasive pulmonary aspergillosis in patients with hematological malignancies and autopsy-confirmed invasive aspergillosis. Ann Hematol 82: 80–82PubMedGoogle Scholar
  17. 17.
    Westney GE, Kesten S, DeHoyos A et al. (1996) Aspergillus infection in single and double lung transplant recipients. Transplantation 61: 915–919CrossRefPubMedGoogle Scholar
  18. 18.
    Sepkowitz KA, Brown AE, Armstrong D (1995) Pneumocystis carinii pneumonia without AIDS: more patients, same risk. Arch Intern Med 155: 1125–1128CrossRefPubMedGoogle Scholar
  19. 19.
    Thomas CF, Limper AII (1998) Pneumocystis pneumonia: clinical presentation and diagnosis in patients with and without AIDS. Semin Respir Infect 13: 289–295PubMedGoogle Scholar
  20. 20.
    Egan JJ, Lomax J, Barber L et al. (1998) Preemptive treatment for the prevention of cytomegalovirus disease in lung and heart transplant recipients. Transplantation 65: 747–752CrossRefPubMedGoogle Scholar
  21. 21.
    Singh N (2005) Late-onset cytomegalovirus disease as a significant complication in solid organ transplant recipients receiving antiviral prophylaxis: a call to heed the mounting evidence. Clin Infect Dis 40: 704–708CrossRefPubMedGoogle Scholar
  22. 22.
    Afessa B, Green W, Chiao J et al. (1998) Pulmonary complications of HIV-infection. Chest 113: 1225–1229PubMedGoogle Scholar
  23. 23.
    Ison MG (2006) Adenovirus infections in transplant recipients. Clin Infect Dis 43: 331–339CrossRefPubMedGoogle Scholar
  24. 24.
    Kaiser L, Aubert JD, Pache JC et al. (2006) Chronic rhinoviral infection in lung transplant recipients. Am J Respir Crit Care Med 174: 1392–1399CrossRefPubMedGoogle Scholar
  25. 25.
    Koch A., Kothe H, Braun J et al. (1998) Inzidenz bakterieller Pneumonien bei HIV-positiven Patienten unter Co-trimoxazol oder Pentamidin. Pneumologie 52: 614–621PubMedGoogle Scholar
  26. 26.
    Mayaud C, Cadranel J (2001) AIDS and the lung in a changing world. Thorax 56: 423–426CrossRefPubMedGoogle Scholar
  27. 27.
    Logan PM, Primack SL, Staples C (1995) Acute lung disease in the immunocompromised host. Diagnostic accuracy of the chest radiograph. Chest 108: 1283–1287PubMedGoogle Scholar
  28. 28.
    Maschmeyer G, Beinert T, Buchheidt D et al. (2003) Diagnosis and antimicrobial therapy of pulmonary infiltrates in febrile neutropenic patients - Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol (Suppl 2) 82: S118–S126Google Scholar
  29. 29.
    Heussel CP, Kauczor HU, Heussel GE et al. (1999) Pneumonia in febrile neutropenic patients and in bone marrow and blood stem-cell transplant recipients: use of high-resolution computed tomography. J Clin Oncol 17: 796–805PubMedGoogle Scholar
  30. 30.
    Rano A, Agusti C, Jimenez P et al. (2001) Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures. Thorax 56: 379–387CrossRefPubMedGoogle Scholar
  31. 31.
    Horvath J, Dummer S (1996) The use of respiratory tract cultures in the diagnosis of invasive aspergillosis. Am J Med 100: 171–178CrossRefPubMedGoogle Scholar
  32. 32.
    Ewig S, Tuschy P, Fätkenheuer G (2002) Diagnostik und Therapie der Legionellenpneumonie. Pneumologie 56: 695–703CrossRefPubMedGoogle Scholar
  33. 33.
    Bohme A, Ruhnke M, Buchheidt D (2003) Treatment of fungal infections in hematology and oncology – guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol (Suppl 2) 82: S133–140Google Scholar
  34. 34.
    Maertens J, Theunissen K, Verhoef G et al. (2005) Galactomanna and CT-based preemptive antifungal therapy in neutropenic patients at high risk for invasive fungal infection. Clin Infect Dis 41: 1242–1250CrossRefPubMedGoogle Scholar
  35. 35.
    Pfeiffer CD, Fine JP, Safdar N (2006). Diagnosis of invasive aspergillosis using a galactomannan assay: a metaanalysis. Clin Infect Dis 42: 1417–1427CrossRefPubMedGoogle Scholar
  36. 36.
    Humar A, Gregson D, Caliendo AM et al. (1999) Clinical utility of quantitative cytomegalovirus viral load determination for pedicting cytomegalovirus disease in liver transplant recipients. Transplantation 68: 1305–1311CrossRefPubMedGoogle Scholar
  37. 37.
    Honda J, Yonemitsu J, Kitajiama H et al. (2001) Clinical utility of capillary polymerase chain reaction for diagnosis of cytomegalovirus pneumonia. Scand J Infect.Dis 33: 702–705Google Scholar
  38. 38.
    Jain P, Sandur S, Meli Y et al. (2004) Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Chest 125: 712–722CrossRefPubMedGoogle Scholar
  39. 39.
    Reichenberger F, Dickenmann M, Binet I et al. (2001) Diagnostic yield of bronchoalveolar lavage following renal transplantation. Transplant Infect Dis 3: 2–7CrossRefGoogle Scholar
  40. 40.
    Stover DE, Zaman MB, Hajdu SI et al. (1984) Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host. Ann Intern Med 101: 1–7PubMedGoogle Scholar
  41. 41.
    Klont RR, Mennink-Kersten MA, Verweij PE (2004) Utility of Aspergillus antigen detection in specimens other than serum specimens. Clin Infect Dis 39: 1467–1474CrossRefPubMedGoogle Scholar
  42. 42.
    Cazzadori A, Di Perri G, Todeschini G (1995) Transbronchial biopsy in the diagnosis of pulmonary infiltrates in immunocompromised patients. Chest 107: 101–106PubMedGoogle Scholar
  43. 43.
    Cadranel J, Gillet-Juvin K, Antoine M et al. (1995) Site-directed bronchoalveolar lavage and transbronchial biopsy in HIV-infected patients with pneumonia. Am J Respir Crit Care Med 152: 1103–1106PubMedGoogle Scholar
  44. 44.
    Wong WP, Stefanec T, Brown K et al. (2002) Role of fine-needle aspirates of focal lung lesions in patients with hematologic malignancies. Chest 121: 527–532CrossRefPubMedGoogle Scholar
  45. 45.
    White DA, Wong PW, Downey R (2000) The utility of open lung biopsy in patients with hematologic malignancies. Am J Respir Crit Care Med 161: 723–729PubMedGoogle Scholar
  46. 46.
    Dalhoff K, Ewig S, Höffken G et al. (2002) Empfehlungen zur Diagnostik, Therapie und Prävention von Pneumonien bei erworbenem Immundefizit. Deutsche Gesellschaft für Pneumologie. Pneumologie 56: 807–831CrossRefPubMedGoogle Scholar
  47. 47.
    Rosenthal EJ et al. (2003) Antibiotika-Empfindlichkeit von Sepsiserregern 2000–2001. Chemother J 12: 71–78CrossRefGoogle Scholar
  48. 48.
    Sattler FR, Cowan R, Nielsen DM et al. (1988) Trimethoprim-sulfamethoxazole compared with pentamidine for treatment of Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. Ann Intern Med 109: 280–287PubMedGoogle Scholar
  49. 49.
    Bozzette SA, Sattler FR, Chiu J et al. (1990) A controlled trial of early adjunctive treatment with corticosteroids für Pneumocyctis carinii pneumonia in the acquired immunodeficiency syndrome. N Engl J Med 323: 1451–1457PubMedGoogle Scholar
  50. 50.
    Pareja JG, Garland R, Koziel H (1998) Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia. Chest 113: 1215–1224PubMedGoogle Scholar
  51. 51.
    Munoz P, Rodriguez C, Bouza E (2005) Mycobacterium tuberculosis infection in recipients of solid organ transplants. Clin Infect Dis 40: 581–587CrossRefPubMedGoogle Scholar
  52. 52.
    Winston A, Boffito M (2005) The management of HIV-1 protease inhibitor pharmacokinetic interactions. J Antimicrob Chemother 7: 1–5CrossRefGoogle Scholar
  53. 53.
    Blanshard C, Benhamou Y, Dohin E et al. (1995) Treatment of AIDS-associated gastrointestinal cytomegalovirus infection with foscarnet and ganciclovir: A randomized comparison. J Infect Dis 172: 622–628PubMedGoogle Scholar
  54. 54.
    Martin DF, Sierra-Madero J, Walmsley S et al.; Valganciclovir Study Group (2002) A controlled trial of valganciclovir as induction therapy for cytomegalovirus retinitis. N Engl J Med 346: 1119–1126CrossRefPubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag 2007

Authors and Affiliations

  1. 1.Medizinische Klinik III, PulmologieUniversitätsklinikum Schleswig-Holstein, Campus LübeckLübeckDeutschland
  2. 2.Medizinische Klinik I, Hämatologie/OnkologieUniversitätsklinikum Schleswig-Holstein, Campus LübeckLübeckDeutschland
  3. 3.Medizinische Klinik I, NephrologieUniversitätsklinikum Schleswig-Holstein, Campus LübeckLübeckDeutschland

Personalised recommendations