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Erregerspektrum postoperativer Komplikationen in der Viszeralchirurgie

Das Problem der Multiresistenz

Spectrum of pathogens in postoperative complications of visceral surgery

The problem of multidrug resistance

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Zusammenfassung

In der Allgemeinchirurgie hat in der Ätiologie der „surgical site infections“ (SSI) in den letzten 30 Jahren keine große Veränderung stattgefunden. Nach wie vor dominieren Gram-positive Bakterien (koagulasenegative Staphylokokken, S. aureus und Enterokokken), gefolgt von Gram-negativen Bakterien (E. coli, Enterobacter spp., Klebsiella spp., P. aeruginosa). Während in der Allgemeinchirurgie 10 % der S. - aureus-bedingten SSI Methicillin-Resistenz (MRSA) zeigten, gab es keine MRGN (mehrfach resistente Gram-negative Bakterien) -bedingten SSI, die gemeldet wurden. Hefen (vor allem Candida spp.) sind nur zu einem kleinen Anteil (≤3 %) im Erregerspektrum der SSI vertreten, wobei dann mindestens ein typischer Risikofaktor (Diabetes mellitus, Chemotherapie, Immunsuppression, Mangelernährung) vorlag. Viren sind als Ursache von SSI die Ausnahme. Durch Träger von HBV, HCV oder HIV kann intraoperativ eine Übertragung stattfinden. Ebenso können Viren bei Organtransplantation übertragen bzw. persistierende Infektionen postoperativ reaktiviert werden (vor allem HBV, HCV, CMV, EBV und HIV). Als Grundlage für die Prävention von SSI wird auf die Konsequenzen einer präoperativen Kolonisation mit MRSA, MSSA (Methicillin-sensibler SA) und MRGN in Bezug auf Screening, perioperative Antibiotikaprophylaxe und Dekolonisation eingegangen. Bei nosokomialer Peritonitis ist bezüglich der kalkulierten Auswahl des Antibiotikums die antibiotische Vorbehandlung zu berücksichtigen. Der einmalige intraabdominelle Nachweis von Candida spp. bedarf beim postoperativ stabilen, immunkompetenten Patienten in der Regel keiner antimykotischen Behandlung, ist jedoch bei schwerer ambulant erworbener oder nosokomialer Peritonitis zu empfehlen. Zur Prävention von Virusinfektionen werden Organspender gescreent und Operateure serologisch überwacht.

Abstract

In general surgery the etiology of surgical site infections has not significantly changed over the last 30 years. Gram-positive bacteria, e.g. coagulase negative staphylococci (CNS), Staphylococcus aureus and Enterococcus spp. as well as Gram-negative bacteria, e.g. Escherichia coli, Enterobacter spp., Klebsiella spp. and Pseudomonas aeruginosa, are the most common findings. Although in general surgery 10% of the S. aureus causing postoperative wound infections were methicillin resistant (MRSA), no cases of multidrug-resistant Gram-negative (MRGN) bacteria were reported. Yeasts (particularly Candida spp.) are rarely the pathogen causing surgical site infections (≤3%) and concomitant risk factors are typical (e.g. diabetes, chemotherapy, immunosuppression and malnutrition). Viruses are rarely the cause of surgical site infections. Transmission can occur by HBV, HCV or HIV positive surgical staff or in organ transplantations and postoperative reactivation of persistent infections is possible (especially for HBV, HCV, CMV, EBV and HIV). The principles for prevention of surgical site infections are dealt with as consequences of preoperative colonization by MRSA, methicillin-sensitive S. aureus (MSSA) and MRGN and reviewed with respect to screening, perioperative antibiotic prophylaxis and decolonization. In nosocomial peritonitis, the selection of antibiotics should consider previous antibiotic treatment. A single intra-abdominal detection of Candida spp. usually does not require antimycotic treatment in postoperatively stable and immunocompetent patients but is recommended in severe community-acquired or nosocomial peritonitis. Viral infections can be avoided by screening of organ donors and serological surveillance of surgery personnel.

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Authors and Affiliations

  1. Institut für Hygiene und Umweltmedizin, Universitätsmedizin Greifswald, Walther-Rathenau-Str. 49a, 17495, Greifswald, Deutschland

    A. Kramer

  2. Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Stuttgart, Deutschland

    J. Pochhammer

  3. Internistische Intensivmedizin und Infektiologie, Johanniterkrankenhaus, Johanniterkliniken Bonn, Bonn, Deutschland

    P. Walger

  4. Friedrich-Loeffler-Institut für Medizinische Mikrobiologie, Universitätsmedizin Greifswald, Greifswald, Deutschland

    U. Seifert

  5. Paracelsus-Klinik Osnabrück, Osnabrück, Deutschland

    M. Ruhnke

  6. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    J. C. Harnoss

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  1. A. Kramer
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Correspondence to A. Kramer.

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Interessenkonflikt

A. Kramer, J. Pochhammer, P. Walger, U. Seifert, M. Ruhnke und J.C. Harnoss geben an, dass kein Interessenkonflikt besteht.

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Kramer, A., Pochhammer, J., Walger, P. et al. Erregerspektrum postoperativer Komplikationen in der Viszeralchirurgie. Chirurg 88, 369–376 (2017). https://doi.org/10.1007/s00104-017-0382-7

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