CAP, HAP, VAP O. Janata Krankenhaushygiene DSP, Wien Ätiologie (%) der CAP bei Erwachsenen in England Pathogen S. pneumoniae H. influenzae S. aureus Legionella spp. M. pneumoniae C. pneumoniae C. psittaci C. burnetii Viral gemischt andere unbekannt Tx ambulant (n=236) 36.0 10.2 0.8 0.4 1.3 — 1.3 0.0 13.1 11.0 2.0 45.3 Tx stationär (n=870) 36.1 4.5 2.1 3.7 13.1 — 2.6 1.4 9.1 10.3 3.2 32.4 Tx an ICU (n=185) 21.6 3.8 8.7 17.8 2.7 — 2.2 0.0 9.7 6.0 6.5 32.4 Substanzen für die Initialtherapie Dosierung der Initialtherapie (pro Tag) Gesamttherapiedauer Ampicillin/Sulbactam 3 x 3 g i. v. 8–10 Tage Ceftriaxon 1 x 2,0 g i. v. 8–10 Tage Cefotaxim 3 x 2,0 g i. v. 8–10 Tage 1 x 1,0 g i. v. 8–10 Tage Ertapenem plus Makrolid oder Doxycyclin (?) Erythromycin, Clarithromycin, Azithromycin (?) 8–10 Tage 200 – 400 mg mg i.v. 8–10 Tage Levofloxacin 2 x 500 mg i. v. 8–10 Tage Moxifloxacin 1 x 400 mg i. v. 8–10 Tage Alternative Erregerspektrum „near – drowning“ • Pneumokokken • Mykoplasmen • Anaerobier Tazonam Zienam, Optinem & Zithromax • Aeromonas • Pseudomonas • Legionellen & Vfend • Aspergillus • Pseudoalleschia causes of ... The HCAP Gap: Differences between Self-Reported Practice Patterns and Published Guidelines for Health Care–Associated Pneumonia Gregory B. Seymann Percent of respondents selecting guideline-concordant antibiotics, by health care–associated pneumonia (HCAP) risk factors - IV, intravenous therapy; MDRO, multidrug-resistant organism; SNF, skilled nursing facil Rethinking the concepts of community-acquired and health-care-associated pneumonia Santiago Ewig, Tobias Welte, Jean Chastre, Antoni Torres Empiric antibiotic therapy for suspected ventilator-associated pneumonia: A systematic review and meta-analysis of randomized trials Mary-Anne W. Aarts Crit Care Med 2008 Was bedeutet Penem – Resistenz ? Decontamination of the Digestive Tract and Oropharynx in ICU Patients A.M.G.A. de Smet, M.D., J.A.J.W. Kluytmans N Engl J Med 2009 Decontamination of the Digestive Tract and Oropharynx in ICU Patients A.M.G.A. de Smet, M.D., J.A.J.W. Kluytmans N Engl J Med 2009 Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units Anne Marie G A de Smet, Jan A J W Kluytmans Lancet Infect Dis 2011 In conclusion, scientific evidence is still limited to suggest the clinical use of systemic corticosteroids in patients with severe CAP despite their antiinflammatory properties Causes of treatment failure in CAP Infectious Resistant microorganisms: • Pseudomonas aeruginosa • MRSA • MRGN Unusual microorganisms • Mycobacterium tuberculosis • Nocardia spp • Fungi (Aspergillus spp) • Pneumocystis jirovecii • Hantavirus • • • • • • • • Noninfectious Neoplasms Pulmonary edema Pulmonary embolism Pulmonary hemorrhage Cryptogenic organizing pneumonia Eosinophilic pneumonia Acute respiratory distress syndrome Sarcoidosis Vasculitis Nosocomial pneumonia Complications of pneumonia • Empyema • Abscess or necrotizing pneumonia • Metastatic infection: endocarditis, • meningitis, arthritis Management bei Nichtansprechen der Therapie bei CAP • Diagnostik • Therapeutik • • CT der Lunge Pleurapunktion • • Rocephin 1 x 2 g & Zithromax 1 x 0,5 g • • • Invanz 1 x 1 g & Zithromax 1 x 0,5 g • wen fragen … • Sputum ZN Legionellen Zytologie ! Legionellen – AG • Tuberkulin – Test Legionellosen • Makrolide – Zithromax 1 x 500 mg – Erythromycin 2–3x1g • Tetracycline • Quinolone – • Vibravenös 2 x 200 mg – Tavanic 2 x 500 mg – Avelox 1 x 400 mg Rifoldin 2 x 600 mg Andere – Klinik Lungenabszeß Husten Fieber Putrides Sputum Pleuraschmerz Gewichtsverlust Nachtschweiß Hämoptysen Dauer der Symptome Anämie Leukozytose 90 % 83 % 59 % 54 % 54 % 45 % 31 % 21 Tage 63 % 76 % Differentialdiagnose Lungenabszeß – nekrotisierende Pneumonie Lungenabszeß Nekrot. Pneumonie Radiologie Kaverne Multipler Zerfall Wo erworben ... Ambulant Nosokomial Diagnose < 7 Tage nach Beginn 20 % 31 % < 38,8° C > 38,8° C Gewichtverlust 62 % 43 % Anämie 82 % 64 % Leukozytose 14 G/l 24 G/l Sterblichkeit 7% 29 % Temperatur Guidelines of the Surgical Infection Society of North America (SISNO) for antimicrobial therapy of aerobic / anaerobic infections • Amoxicillin + Clavulansäure / Ampicillin + Sulbactam • Piperacillin/Tazobactam • Ertapenem / Imipenem/Cilastatin / Meropenem • Cefuroxim + Metronidazol • Ceftriaxon / Cefotaxim + Metronidazol • Cefepime / Cefpirom + Metronidazol • Ciprofloxacin + Metronidazol / Clindamycin • Tigecyclin Modifiziert nach Mazuski JE. Surgical Infections 2002;3:161-173 Erregerspektrum Pleuraempyem Keimbefund Anteil steril 0 – 43 % Pneumokokken 2 – 15 % S. aureus 2 – 25 % B – Streptokokken 2 – 25 % Anaerobier 11 – 76 % Chirurgie bei anaeroben Lungeninfekten Aspirationspneumonie Konservativ Lungenabszeß Bei Nichtansprechen Blutungen, Malignome Lungengangrän Nekrosektomie ! Pleuraempyem Adäquate Drainage Therapiedauer Aspirationspneumonie 2 Wochen Lungenabszeß 4 – 6 Wochen
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