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Rationale Antibiotikatherapie der Mediastinitis

Rational antibiotic treatment of mediastinitis

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Zusammenfassung

Die Mediastinitis tritt als schwere Komplikation nach operativen Eingriffen auf, ist Folge von Traumen mit Ösophagusperforation oder fortgeleiteter Infektionen oder das Ergebnis lymphogener und hämatogener Streuung spezifischer Infektionserreger. Die Behandlung muss im Regelfall antibiotisch begleitet werden, wobei hier die Kenntnis des Keimspektrums in Abhängigkeit seiner Pathogenese für eine erfolgreiche Therapie unabdingbar ist.

Bei fortgeleiteten Infektionen des Mediastinums bzw. nach Ösophagusperforation finden sich meist polymikrobielle Infektionen mit hohem Anaerobieranteil. Nach kardiochirurgischen Eingriffen dominieren Staphylokokken, wobei eine Nasenbesiedelung mit Staphylococcus aureus als Prädisposition anzusehen ist. Pilze dominieren als Infektionserreger bei Immunsupprimierten, bei Patienten mit konsumierenden Grunderkrankungen und können neben akuten auch chronische Verlaufsformen mit granulomatöser Entzündung verursachen. Zunehmend werden resistente Erreger bei Risikokollektiven gefunden, die ggf. bei einer kalkulierten Therapie berücksichtigt werden müssen.

Bei der kalkulierten Antibiotikatherapie werden beim Einsatz von Breitspektrumantibiotika – meist β‑Lactame mit oder ohne Metronidazol – sowohl grampositive als auch gramnegative Erreger einschließlich des Anaerobieranteils effektiv abgedeckt. Bei Risikopatienten können zusätzlich Antibiotikaklassen mit Wirkung gegenüber Methicillin-resistenten Staphyokokken (MRSA) oder Vancomycin-resistenten Enterokokken (VRE) eingesetzt werden. Der zunehmende Anteil an multiresistente Enterobakterien und Nonfermentern (Pseudomonaden, Acinetobacter) zwingt in Einzelfällen zum Einsatz von Polymyxinen, weiter entwickelten Tetracyclinen (Glycylglycine) und neuen β‑Lactamantibiotika/β-Lactaminhibitor-Kombinationen. Zur Therapie von Pilzinfektionen (Sprosspilze, Aspergillen, Histoplasma) scheinen ältere und neuere Azole, Amphotericin B und Echinocandine erfolgreich zu sein, wobei nicht jeder Candida-Nachweis – insbesondere bei Mischinfektionen – behandelt werden muss.

Die Mediastinitis ist immer noch eine schwere Infektionserkrankung mit hoher Mortalität, die einer frühen und breiten Antibiotikatherapie bedarf. Im Hinblick auf eine optimale Antibiotikaauswahl und Therapiedauer fehlen jedoch gute Vergleichsstudien.

Abstract

Mediastinitis occurs as a severe complication of thoracic and cardiac surgical interventions and is the result of traumatic esophageal perforation, conducted infections or as a result of lymphogenic and hematogenic spread of specific infective pathogens. Treatment must as a rule be accompanied by antibiotics, whereby knowledge of the spectrum of pathogens depending on the pathogenesis is indispensable for successful antibiotic therapy. Polymicrobial infections with a high proportion of anaerobes are found in conducted infections of the mediastinum and after esophageal perforation. After cardiac surgery Staphylococci are the dominant pathogens and a nasal colonization with Staphylococcus aureus seems to be a predisposing risk factor. Fungi are the predominant pathogens in immunocompromised patients with consumptive underlying illnesses and can cause acute or chronic forms with granulomatous inflammation. Resistant pathogens are increasingly being found in high-risk patient cohorts, which must be considered for a calculated therapy. For calculated antibiotic therapy the administration of broad spectrum antibiotics, mostly beta-lactams alone or combined with metronidazole is the therapy of choice for both Gram-positive and Gram-negative bacteria inclusive of anaerobes. For patients at risk, additional antibiotic classes with a spectrum against methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) can be administered. Increasing rates of multidrug-resistant Gram-negative bacteria (e.g. Enterobacteriaceae) and non-fermenting bacteria (e.g. Pseudomonas and Acinetobacter) in individual cases necessitates the use of polymyxins (e.g. colistin), new tetracyclines (e.g. glycylglycines) and newly developed combinations of beta-lactams and beta-lactam inhibitors. For treatment of fungal infections (e.g. Candida, Aspergillus and Histoplasma) established and novel azoles, amphotericin B and echinocandins seem to be successful; however, detection of Candida, particularly in mixed infections does not always necessitate treatment. Mediastinitis is still a severe infectious disease with a high mortality, which necessitates an early and broad spectrum antibiotic therapy; however, with respect to optimal duration of therapy and selection of antibiotics, data from good quality comparative studies are lacking.

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  1. Institut für Laboratoriumsmedizin, Mikrobiologie und Krankenhaushygiene, Krankenhaus Barmherzige Brüder, Prüfeningerstraße 86, 93049, Regensburg, Deutschland

    A. Ambrosch

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Ambrosch, A. Rationale Antibiotikatherapie der Mediastinitis. Chirurg 87, 497–503 (2016). https://doi.org/10.1007/s00104-016-0192-3

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