Respiratory infections

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chronic bronchiectasis
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Nosocomial pneumonia

Case report:

A 56-year-old patient with severe obstructive Chronic Bronchitis was ventilated in intensive care because of respiratory failure three weeks. A first nosocomial pneumonia, six days after the start of ventilation, was successfully treated for ten days. Now the patient develops an increasing turn mucopurulent secretion, fever up to 39 C, a deterioration of the respiratory as well as the circulatory parameters of necessity of a catecholamine. Auscultation bronchial sounds are increasingly determined and the inspiratory oxygen concentration must be increased to 60%.

Diagnosis:

The findings illustrated that prolonged ventilation, and greatly increased inflammation parameters (leukocytosis: 18,000 / ul; stab polynuclear granulocytes: 12%; CRP: 55 mg / l) indicate a so-called ventilator-associated "late" pneumonia. This diagnosis is confirmed by radiological examination of the chest, it can be found in a bronchopneumonia Lingulabereich. The bronchoscopy with bronchoalveolar lavage in the infiltration area leads to the detection of Pseudomonas aeruginosa in a germ count of 109 / ml BAL.

Pathogenesis:

In patients with severe underlying diseases, prolonged ventilatory support and antibiotic therapy, the risk for the manifestation of a so-called "late" pneumonia is extremely high. Pathogenetically responsible for this are in particular the highly disturbed bronchoalveolar clearance on the basis of advanced chronic bronchitis, reducing the physical defenses of the respiratory tract as a result of prolonged ventilation, and the selection of frequently resistant Gram-negative bacteria by the preceding antibiotic therapy. Mostly is Hospital germs that have colonized the oropharynx and reach over Miniaspiration in the lower respiratory tract. Common pathogens are therefore Pseudomonas aeruginosa, Enterobacter species, Stenotrophomonas maltophilia, and also increasingly staphylococci as multiresistant strains of Staphylococcus aureus (MRSA).

Therapy:

The empirical initial therapy so-called "later" nosocomial ventilation pneumonia in intensive care begins immediately after the bronchoscopy and should be done with antibiotics, which detect the said Hospital germs. These are likely to mainly cephalosporins Pseudomonas activity [ceftazidime (FORTUM), cefepime (Maxipime)] act, but also to penicillins such as piperacillin tazobactam plus (TAZOBAC); furthermore come as carbapenems meropenem (MERONEM) or imipenem / cilastatin (ZIENAM) and fluoroquinolones such as ciprofloxacin (Cipro) into consideration. When selecting the substances typical for the clinic resistance patterns should be considered first, and later can be optimized based on the results of resistance selection. The majority of these patients is a combination therapy with aminoglycosides such as Gentamicin (Refobacin et al), Tobramycin (GERNEBCIN) and amikacin (BIKLIN) be necessary. This combination therapy with aminoglycosides is performed under close monitoring of renal function and the aminoglycoside trough levels about seven to ten days, thereafter based on clinical judgment monotherapy should be continued with the -Laktamantibiotikum even for a limited time. The prognosis of such a heavy late ventilator-associated pneumonia caused by Pseudomonas aeruginosa is quite unfavorable, the lethality is expected to be in a range between 30-60%.

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