Mikrobiologisches Monitoring und kalkulierte Antibiotikatherapie beim akuten Lungenversagen

  • J.-H. Baumert
  • B. Spellerberg
Chapter

Zusammenfassung

Das ARDS kann sowohl Grundlage als auch Folge einer pulmonalen Infektion sein. Bei mehr als zwei Drittel der Patienten liegt eine systemische Infektion oder Sepsis vor, die auch einen extrapulmonalen Ausgangspunkt haben kann. Da nur in der Hälfte der Fälle ein relevanter Erreger aus dem Respirationstrakt isoliert werden kann und es sich um ein akutes, schweres Krankheitsbild handelt, muss primär meist eine kalkulierte antibiotische Therapie eingeleitet werden. Diese sollte das nach der Genese der Erkrankung wahrscheinliche Erregerspektrum vollständig erfassen. Hierbei muss nach ambulant erworbener bzw. beatmungsassoziierter Pneumonie oder primärer Sepsis und gegebenenfalls extrapulmonaler Infektion unterschieden werden. In jedem Fall sollten vor Beginn der Behandlung Material aus dem Respirationstrakt und/oder Blutkulturen zur mikrobiologischen Diagnostik gewonnen werden. Im Verlauf komplizierter Fälle bzw. bei immunsupprimierten Patienten müssen auch virale (vor allem CMV) und Pilzinfektionen berücksichtigt werden. Ob beim ARDS ohne klinische Infektionszeichen (posttraumatische oder transfusionsinduzierte Formen) eine kalkulierte antibiotische Therapie indiziert ist, ist weiterhin nicht geklärt.

Schlüsselwörter

Acute respiratory distress syndrome (ARDS) Pneumonie Infektion Antibiose 
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Literatur

  1. 1.
    1. Antonelli M, Moro ML, Capelli O, De Blasi RA, D’Errico RR, Conti G, Bufi M, Gasparetto A (1994) Risk factors for early onset pneumonia in trauma patients. Chest 105(l):224–228PubMedCrossRefGoogle Scholar
  2. 2.
    2. Bartlett JG, Dowell SF, Mandell LA, File TM Jr, Musher DM, Fine MJ (2000) Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis 31(2):347–382PubMedCrossRefGoogle Scholar
  3. 3.
    3. Bauer TT, Monton C, Torres A, Cabello H, Fillela X, Maldonado A, Nicolas JM, Zavala E (2000) Comparison of systemic cytokine levels in patients with acute respiratory distress syndrome, severe pneumonia, and controls. Thorax 55(1):46–52PubMedCrossRefGoogle Scholar
  4. 4.
    4. Baughman RP (2000) Protected-specimen brush technique in the diagnosis of ventilator-associated pneumonia. Chest 117(4 Suppl 2):203–206CrossRefGoogle Scholar
  5. 5.
    5. Bergogne-Berezin E (1995) Treatment and prevention of nosocomial pneumonia. Chest 108(2 Suppl):26–34CrossRefGoogle Scholar
  6. 6.
    6. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R (1994) The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Re-spir Crit Care Med 149(3 Pt 1):818–824Google Scholar
  7. 7.
    7. Blanquer J, Blanquer R, Borras R, Nauffal D, Morales P, Menendez R, Subias I, Herrero L, Redon J, Pascual J (1991) Aetiology of community acquired pneumonia in Valencia, Spain: a multicentre prospective study. Thorax 46(7):508–511PubMedCrossRefGoogle Scholar
  8. 8.
    8. Bodman K, Vogel F (2001) Anti-mikrobielle Therapie der Sepsis. Chemotherapie-Journal 10:43–54Google Scholar
  9. 9.
    9. Bonten MJ, Kullberg BJ, van Dalen R, Girbes AR, Hoepelman IM, Hustinx W, van der Meer JW, Speelman P, Stobberingh EE, Verbrugh HA, Ver-hoef J, Zwaveling JH (2000) Selective digestive decontamination in patients in intensive care. The Dutch Working Group on Antibiotic Policy. J Antimicrob Chemother 46(3):351–362PubMedCrossRefGoogle Scholar
  10. 10.
    10. Brunkhorst FM, Eberhard OK, Brunkhorst R (1999) Discrimination of infectious and noninfectious causes of early acute respiratory distress syndrome by procalcitonin. Crit Care Med 27(10):2172–2176PubMedCrossRefGoogle Scholar
  11. 11.
    11. Charash WE, Fabian TC, Croce MA (1994) Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma. J Trauma 37(4):667–672PubMedCrossRefGoogle Scholar
  12. 12.
    12. Chastre J, Trouillet JL, Vuagnat A, Joly-Guillou ML, Clavier H, Dombret MC, Gibert C (1998) Nosocomial pneumonia in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 157(4 Pt 1): 1165–1172PubMedGoogle Scholar
  13. 13.
    13. Confalonieri M, Potena A, Carbone G, Porta R, Tolley E, Umberto Meduri G (1999) Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 160:1585–1591PubMedGoogle Scholar
  14. 14.
    14. Craven DE, Steger KA (1995) Epidemiology of nosocomial pneumonia. New perspectives on an old disease. Chest 108(2 Suppl):1–16CrossRefGoogle Scholar
  15. 15.
    15. Croce MA (2000) Diagnosis of acute respiratory distress syndrome and differentiation from ventilator-associated pneumonia. Am J Surg 179(2 Suppl 1):26–29PubMedCrossRefGoogle Scholar
  16. 16.
    16. Darby JM, Linden P, Pasculle W, Saul M (1997) Utilization and diagnostic yield of blood cultures in a surgical intensive care unit. Crit Care Med 25(6):989–994PubMedCrossRefGoogle Scholar
  17. 17.
    17. Davidson TA, Rubenfeld GD, Caldwell ES, Hudson LD, Steinberg KP (1999) The effect of acute respiratory distress syndrome on long-term survival. Am J Respir Crit Care Med 160(6):1838–1842PubMedGoogle Scholar
  18. 18.
    18. Delclaux C, Roupie E, Blot F, Brochard L, Lemaire F, Brun-Buisson C (1997) Lower respiratory tract colonization and infection during severe acute respiratory distress syndrome: incidence and diagnosis. Am J Respir Crit Care Med 156(4 Pt l):1092–1098PubMedGoogle Scholar
  19. 19.
    19. Dellinger RP (1999) Current therapy for sepsis. Infect Dis Clin North Am 13(2):495–509PubMedCrossRefGoogle Scholar
  20. 20.
    20. Dudas V, Hopefl A, Jacobs R, Gugliel-mo BJ (2000) Antimicrobial selection for hospitalized patients with presumed community-acquired pneumonia: a survey of nonteaching US community hospitals. Ann Pharmacother 34(4):446–452PubMedCrossRefGoogle Scholar
  21. 21.
    21. Ferring M, Vincent JL (1997) Is outcome from ARDS related to the severity of respiratory failure? Eur Respir J 10(6):1297–1300PubMedCrossRefGoogle Scholar
  22. 22.
    22. Geerdes HF, Ziegler D, Lode H, Hund M, Loehr A, Fangmann W, Wagner J (1992) Septicemia in 980 patients at a university hospital in Berlin: prospective studies during 4 selected years between 1979 and 1989. Clin Infect Dis 15(6):991–1002PubMedCrossRefGoogle Scholar
  23. 23.
    23. Gleason PP, Meehan TP, Fine JM, Galusha DH, Fine MJ (1999) Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia. Arch Intern Med 159(21):2562–2572PubMedCrossRefGoogle Scholar
  24. 24.
    24. Headley AS, Tolley E, Meduri GU (1997) Infections and the inflammatory response in acute respiratory distress syndrome. Chest 111(5):1306–1321PubMedCrossRefGoogle Scholar
  25. 25.
    25. Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi-Benissan G, Dupon M, Reiffers J, Cardinaud J (2001) Noninvasive ventilation in immunosup-pressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344:481–487PubMedCrossRefGoogle Scholar
  26. 26.
    26. Hoffken G, Steinhoff D, Lode H (1995) Ätiologie von ambulant erworbenen Pneumonien bei älteren Menschen. Chemotherapie J 4 (Suppl 7):13–19Google Scholar
  27. 27.
    27. Holtermann W, Kramer M, Geppert P, van Wickern M, Lukasewitz P (1998) Epidemiology, clinical aspects and prognosis of severe progressive community-acquired pneumonia. Pneumologie 52(5):263–270PubMedGoogle Scholar
  28. 28.
    28. Hughes WT, Armstrong D, Bodey GP, Brown AE, Edwards JE, Feld R, Pizzo P, Rolston KV, Shenep JL, Young LS (1997) 1997 guidelines for the use of antimicrobial agents in neutropenic patients with unexplained fever. Infectious Diseases Society of America. Clin Infect Dis 25(3):551–573PubMedCrossRefGoogle Scholar
  29. 29.
    29. Kaufhold A, Behrendt W, Krauss T, van Saene H (1992) Selective decontamination of the digestive tract and methicillin-resistant Staphylococcus aureus. Lancet 339(8806):1411–1412PubMedCrossRefGoogle Scholar
  30. 30.
    30. Kollef MH, Sherman G, Ward S, Fraser VJ (1999) Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 115(2): 462–474PubMedCrossRefGoogle Scholar
  31. 31.
    31. Levin PD, Hersch M, Rudensky B, Yinnon AM (1997) Routine surveillance blood cultures: their place in the management of critically ill patients. J Infect 35(2):125–128PubMedCrossRefGoogle Scholar
  32. 32.
    32. Liberati A, D’Amico R, Pifferi S, Leonetti C, Torri V, Brazzi L, Tinazzi A (2000) Antibiotics for preventing respiratory tract infections in adults receiving intensive care. Cochrane Database Syst Rev 2Google Scholar
  33. 33.
    33. Lingnau W, Berger J, Javorsky F, Fille M, Allerberger F, Benzer H (1998) Changing bacterial ecology during a five-year period of selective intestinal decontamination. J Hosp Infect 39(3): 195–206PubMedCrossRefGoogle Scholar
  34. 34.
    34. Lynch JP (2001) 3rd. Hospital-acquired pneumonia: risk factors, microbiology, and treatment. Chest 119(2 Suppl):373–384CrossRefGoogle Scholar
  35. 35.
    35. Marquette CH (2001) Diagnosis and treatment of nosocomial pneumonia: bronchial fibroscopy, protected brushing and/or bronchial lavage is not indispensable. Rev Pneumol Clin 57(2):124–131PubMedGoogle Scholar
  36. 36.
    36. Mauch H, Wagner J, Marklein G (1999) MiQ-Richtlinie 7 Infektionen der tiefen Atemwege Teil I. Urban & FischerGoogle Scholar
  37. 37.
    37. Meduri GU, Reddy RC, Stanley T, El-Zeky F (1998) Pneumonia in acute respiratory distress syndrome. A prospective evaluation of bilateral bronchoscopic sampling. Am J Respir Crit Care Med 158(3):870–875PubMedGoogle Scholar
  38. 38.
    38. Messent M, Sullivan K, Keogh BF, Morgan CJ, Evans TW (1992) Adult respiratory distress syndrome following cardiopulmonary bypass: incidence and prediction. Anaesthesia 47(3):267–268PubMedCrossRefGoogle Scholar
  39. 39.
    39. Namias N, Harvill S, Ball S, McKenney MG, Sleeman D, Ladha A, Civetta J (1998) A reappraisal of the role of Gram’s stains of tracheal aspirates in guiding antibiotic selection in the surgical intensive care unit. J Trauma 44(l):102–106PubMedCrossRefGoogle Scholar
  40. 40.
    40. Ortqvist A, Hedlund J, Grillner L, Jalonen E, Kallings I, Leinonen M, Kalin M (1990) Aetiology, outcome and prognostic factors in community-acquired pneumonia requiring hospitalization. Eur Respir J 3(10): 1105–1113PubMedGoogle Scholar
  41. 41.
    41. Papazian L, Autillo-Touati A, Thomas P, Bregeon F, Garbe L, Saux P, Seite R, Gouin F (1997) Diagnosis of ventilator-associated pneumonia: an evaluation of direct examination and presence of intracellular organisms. Anesthesiology 87(2):268–276PubMedCrossRefGoogle Scholar
  42. 42.
    42. Papazian L, Thomas P, Bregeon F, Garbe L, Zandotti C, Saux P, Gaillat F, Drancourt M, Auffray JP, Gouin F (1998) Open-lung biopsy in patients with acute respiratory distress syndrome. Anesthesiology 88(4):935–944PubMedCrossRefGoogle Scholar
  43. 43.
    43. Rosenthal E (1993) Epidemiologie von Septikämie-Erregern. Deutsch Med Wochenschr 118:1269–1275CrossRefGoogle Scholar
  44. 44.
    44. Simhon A, Rahav G, Shapiro M, Block C (2001) Skin disease presenting as an outbreak of pseudobacteremia in a laboratory worker. J Clin Microbiol 39(l):392–393PubMedCrossRefGoogle Scholar
  45. 45.
    45. Singh N, Falestiny MN, Rogers P, Reed MJ, Pularski J, Norris R, Yu VL (1998) Pulmonary infiltrates in the surgical ICU: prospective assessment of predictors of etiology and mortality. Chest 114(4):1129–1136PubMedCrossRefGoogle Scholar
  46. 46.
    46. Stahl JE, Barza M, DesJardin J, Martin R, Eckman MH (1999) Effect of macrolides as part of initial empiric therapy on length of stay in patients hospitalized with community-acquired pneumonia. Arch Intern Med 159(21):2576–2580PubMedCrossRefGoogle Scholar
  47. 47.
    47. Steinhoff D, Lode H, Ruckdeschel G, Heidrich B, Rolfs A, Fehrenbach FJ, Mauch H, Hoffken G, Wagner J (1996) Chlamydia pneumoniae as a cause of community-acquired pneumonia in hospitalized patients in Berlin. Clin Infect Dis 22(6):958–964PubMedCrossRefGoogle Scholar
  48. 48.
    48. Stoutenbeek CP, van Saene HK, Miranda DR, Zandstra DF (1984) The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Care Med 10(4): 185–192PubMedCrossRefGoogle Scholar
  49. 49.
    49. Sutherland KR, Steinberg KP, Maunder RJ, Milberg JA, Allen DL, Hudson LD (1995) Pulmonary infection during the acute respiratory distress syndrome. Am J Respir Crit Care Med 152(2):550–556PubMedGoogle Scholar
  50. 50.
    50. Trautmann (1997) Computergestützte prospektive Erfassung nosokomialer Septikämien in einem Universitätsklinikum. Hyg Med 22:467–473Google Scholar
  51. 51.
    51. van Saene HK, Damjanovic V, Murray AE, de la Cal MA (1996) How to classify infections in intensive care units — the carrier state, a criterion whose time has come? J Hosp Infect 33(1):1–12PubMedCrossRefGoogle Scholar
  52. 52.
    52. Vollaard EJ, Clasener HA (1994) Colonization resistance. Antimicrob Agents Chemother 38(3):409–414PubMedCrossRefGoogle Scholar
  53. 53.
    53. Weinstein MP, Mirrett S, Reimer LG, Wilson ML, Smith-Elekes S, Chuard CR, Joho KL, Reller LB (1995) Controlled evaluation of BacT/Alert standard aerobic and FAN aerobic blood culture bottles for detection of bacteremia and fungemia. J Clin Microbiol 33(4):978–981PubMedGoogle Scholar
  54. 54.
    54. Weinstein MP, Reller LB, Murphy JR, Lichtenstein KA (1983) The clinical significance of positive blood cultures: a comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Rev Infect Dis 5(1):35–53PubMedCrossRefGoogle Scholar
  55. 55.
    55. Wilson ML, Weinstein MP, Mirrett S, Reimer LG, Feldman RJ, Chuard CR, Reller LB (1995) Controlled evaluation of BacT/alert standard anaerobic and FAN anaerobic blood culture bottles for the detection of bacteremia and fungemia. J Clin Microbiol 33(9): 2265–2270PubMedGoogle Scholar
  56. 56.
    56. Zilberberg MD, Epstein SK (1998) Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome. Am J Respir Crit Care Med 157(4 Pt 1):1159–1164PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2003

Authors and Affiliations

  • J.-H. Baumert
    • 1
  • B. Spellerberg
    • 2
  1. 1.Klinik für AnästhesiologieUniversitätsklinikum AachenAachenGermany
  2. 2.Institut für Medizinische MikrobiologieUniversitätsklinikum AachenGermany

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