Clostridium-difficile-Infektionen (CDI) im Wandel der Zeit – ein Thema nur für den Internisten?

 

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Zusammenfassung

Hintergrund: Toxinbildende Clostridium-(C.)-difficile-Stämme sind weltweit die häufigsten Erreger von antibiotikaassoziierten Darmerkrankungen und nosokomialer Diarrhö. In den letzten 10 Jahren wurde ein kontinuierlicher Inzidenzanstieg von C.-difficile-Infektionen (CDI) beobachtet.
Material und Methoden: Mit klinischen und mikrobiologischen Originaldaten der Jahre 2002–2012 aus den Universitätskliniken Leipzig und Halle (Saale) weisen die Autoren auf die aktuelle Situation hinsichtlich CDI in den Bundesländern Sachsen und Sachsen-Anhalt hin und stellen die neuesten Entwicklungen bezüglich Inzidenz, Resistenzsituation, Diagnostik und Therapie von CDI sowie die Indikationen für eine chirurgische Intervention dar.
Ergebnisse: Dem allgemeinen Trend entsprechend, ist auch an den Universitätskliniken Leipzig und Halle (Saale) ein Inzidenzanstieg von CDI, insbesondere von schweren klinischen Verlaufsformen, zu verzeichnen. Die Vermeidung von CDI stellt in erster Linie eine Herausforderung an das Hygienemanagement dar und erfordert einen gezielten, zurückhaltenden Einsatz von Antibiotika, möglichst in Form sogenannter „Antibiotic Stewardship“-Programme. Das neue Antibiotikum Fidaxomicin hat Ende 2012 das bislang vor allem aus Metronidazol oder Vancomycin bestehende therapeutische Armamentarium bezüglich CDI bereichert und vermag die Rezidivquote zu senken. Die Wiederherstellung einer Eubiose im Kolon von rezidivierenden CDI betroffener Patienten mittels Stuhltransplantation von gesunden Spendern stellt eine hochwirksame Alternative zur antibiotischen Therapie dar. Chirurgischer Standardeingriff bei therapierefraktärer CDI ist die subtotale Kolektomie mit endständigem Ileostoma. Bei Patienten mit adäquater Lebenserwartung und ohne Organversagen kann ein kolonerhaltendes bzw. -sparendes Verfahren erwogen werden.
Schlussfolgerung: Die Einnahme von Antibiotika bleibt für die meisten Patienten der Hauptrisikofaktor für das Erleiden einer symptomatischen CDI. Mit der Einführung von Fidaxomicin deutet sich eine Verbesserung in der konservativen Therapie von CDI an. Die im Vergleich zur antibiotischen Therapie von CDI bessere Wirksamkeit der Stuhltransplantation von gesunden Spendern gilt inzwischen als ausreichend gesichert, hat bislang aber keinen Eingang in den klinischen Alltag gefunden. Bei ausbleibendem Therapieerfolg muss frühzeitig der Chirurg hinzugezogen werden. Dabei ist die Evidenz für kolonerhaltende bzw. -sparende operative Verfahren bislang leider schmal.

Abstract

Background: Toxigenic strains of Clostridium (C.) difficile are the most prevalent pathogens of antibiotic associated intestinal disease and nosocomial diarrhoea. During the last 10 years, incidences of C. difficile infection (CDI) have increased worldwide.
Materials and Methods: With clinical and microbiological original data for 2002–2012 from the University Hospitals Leipzig and Halle (Saale), Germany, the authors illustrate the current situation regarding CDI in the states of Saxony and Saxony-Anhalt and exemplify the latest developments in terms of incidence, prevalence of resistance, diagnosis and treatment strategies regarding CDI with an emphasis on surgical options.
Results: Following the general trend, at the University Hospitals of Leipzig and Halle (Saale) there was also an increase in incidence of CDI, especially of severe clinical courses. In primary and secondary care facilities, prevention of CDI is based on hygiene management and restricted usage of antibiotics, preferably as “Antibiotic Stewardship” programmes. In 2012, the new macrocyclic antibiotic Fidaxomicin was approved in the European Union for the treatment of CDI. The therapeutic armamentarium, previously based on metronidazole or vancomycin, has now been enriched by a substance that presumably will reduce the rate of recurrence of CDI. Moreover, early data from case series and controlled trials suggest that the re-establishment of eubiosis in the colon of patients with recurrent CDI by stool transplantation from healthy donors is an alternative to antibiotics. Standard surgical intervention for refractory CDI is subtotal colectomy with terminal ileostomy. In patients with adequate life expectancy and without organ dysfunction, a colon-saving surgical technique should be considered.
Conclusion: Taking antibiotics for most remains the main risk factor for suffering from symptomatic CDI. With the introduction of Fidaxomicin there is hope for an improvement in the conservative treatment of CDI. Stool transplants from healthy donors are now considered to be better than giving antibiotics for severe CDI, but this treatment has not found broad acceptance yet. In cases with a lack of early treatment success, the surgeon must be consulted. Here, the evidence for preferably colon-saving surgical procedures is so far unfortunately low.

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