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Pyelonephritis und Urosepsis

Pyelonephritis and urosepsis

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Zusammenfassung

Eine größere Aufmerksamkeit für Harnwegsinfektionen (HWI) im Säuglings- und Kleinkindalter bei Kinderärzten, die Verfügbarkeit neuer Medikamente und teils überraschende Studienergebnisse haben in den letzten Jahrzehnten zur Optimierung therapeutischer und prophylaktischer Strategien geführt. Zunehmende Erregerresistenzen gegenüber einzelnen Antibiotika, u. a. auch der wachsende Anteil von multiresistenten gramnegativen (MRGN-)Erregern bzw. „Extended-spectrum-“Betalactamasen(ESBL)-bildenden Erregern bei HWI, zwingen zunehmend zur Anpassung der Therapie an neue Bedingungen. Die kalkulierte Therapie fieberhafter HWI im Säuglings- und Kindesalter orientiert sich an der Erregerwahrscheinlichkeit und an der aktuellen regionalen Resistenzsituation.

Früh- und Neugeborene sowie Kinder mit obstruktiven Uropathien sind insbesondere durch eine Urosepsis gefährdet. Nur die Anlage einer Urinkultur erlaubt nach kalkulierter antibakterieller Initialtherapie die resistenzgerechte Weiterbehandlung. In den ersten Lebensmonaten wird grundsätzlich eine parenterale Behandlung empfohlen. Jenseits des frühen Säuglingsalters gilt heute bei unkomplizierten Pyelonephritiden eine orale Medikation, bevorzugt mit einem Cephalosporin der Gruppe 3, als angemessen.

In aktuellen Leitlinien gehört die Sonographie zur Basisdiagnostik bei fieberhaften HWI im Säuglings- und Kleinkindalter. Die radiologische oder sonographische Refluxdiagnostik bleibt v. a. denjenigen Kindern vorbehalten, bei denen angesichts klinischer Kriterien oder des Vorliegens wegweisender sonographischer Auffälligkeiten ein behandlungsbedürftiger vesikoureteraler Reflux (VUR) wahrscheinlich ist.

Abstract

Over the past decades, an increased attention paid to urinary tract infections in infancy and childhood by paediatricians as well as the availability of new drugs and some surprising study results have all contributed to the improvement of therapeutic and prophylactic strategies. Increasing bacterial resistance against particular antibiotics, but also the increasing incidence of MRGN and ESBL-producing pathogens, progressively force the adaptation of therapies to new conditions. The calculated therapy of febrile urinary tract infections in infancy and childhood is oriented towards pathogen probability and the local resistance situation.

Premature and neonatal infants as well as children suffering from obstructive uropathies are especially susceptible to urosepsis. Only the creation of a urine culture allows for a resistance-adequate treatment after a calculated antibacterial initial therapy. In the first months of life, a parenteral treatment is generally recommended. Beyond early infancy, oral medication, preferably a third-generation cephalosporine, is deemed adequate for uncomplicated pyelonephritis.

In current guidelines, sonography is part of the basic diagnostics for febrile urinary tract infection in infancy and early childhood. Radiological or sonographic reflux diagnostics remain predominantly reserved for children in whom a vesicoureteral reflux requiring treatment is probable based on clinical criteria or the presence of relevant sonographic abnormalities.

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  1. Sektion Pädiatrische Nephrologie, Zentrum für Kinder- und Jugendmedizin, Johannes Gutenberg-Universität, Langenbeckstr.1, 55101, Mainz, Deutschland

    R. Beetz

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R. Beetz gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren. Alle Patienten, die über Bildmaterial oder anderweitige Angaben innerhalb des Manuskripts zu identifizieren sind, haben hierzu ihre schriftliche Einwilligung gegeben. Im Fall von nichtmündigen Patienten liegt die Einwilligung eines Erziehungsberechtigten oder des gesetzlich bestellten Betreuers vor.

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G. Hansen, Hannover

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Beetz, R. Pyelonephritis und Urosepsis. Monatsschr Kinderheilkd 166, 24–32 (2018). https://doi.org/10.1007/s00112-017-0402-1

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