id000058
10.3205/id000058
urn:nbn:de:0183-id0000589
Leitlinie
Guideline
Kalkulierte parenterale Initialtherapie bakterieller Infektionen: Infektionen im Hals-, Nasen-, Ohren- und Mund-Kiefer-Gesichtsbereich
Calculated parenteral initial treatment of bacterial infections: Infections in the ear, nose, throat and mouth and jaw area
Olzowy
Olzowy
Bernhard
B
Prof. Dr.
HNO-Zentrum Landsberg am Lech, Ahornallee 2a, 86899 Landsberg am Lech, DeutschlandHNO-Zentrum Landsberg am Lech, Deutschland
HNO-Zentrum Landsberg am Lech, Ahornallee 2a, 86899 Landsberg am Lech, GermanyHNO-Zentrum Landsberg am Lech, Germany
olzowy@hno-landsberg.de
author
Al-Nawas
Al-Nawas
Bilal
B
Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätsmedizin Mainz, Deutschland
Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätsmedizin Mainz, Germany
author
Havel
Havel
Miriam
M
Klinik und Poliklinik für HNO-Heilkunde, Klinikum der Universität München, Deutschland
Klinik und Poliklinik für HNO-Heilkunde, Klinikum der Universität München, Munich, Germany
author
Karbach
Karbach
Julia
J
Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätsmedizin Mainz, Deutschland
Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätsmedizin Mainz, Germany
author
Müller
Müller
Rainer
R
Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Carl Gustav Carus Dresden, Deutschland
Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Carl Gustav Carus Dresden, Germany
author
German Medical Science GMS Publishing House
Düsseldorf
610
Calculated parenteral initial therapy
Kalkulierte parenterale Initialtherapie
20200326
germ
engl
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License.
Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung).
2195-8831
8
GMS Infectious Diseases
GMS Infect Dis
14
Dies ist das sechste Kapitel der von der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) herausgegebenen S2k Leitlinie „Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen – Update 2018“ in der 2. aktualisierten Fassung.Es befasst sich mit der antibakteriellen Behandlung schwererer Infektionen im Hals-, Nasen-, Ohren- und Mund-Kiefer-Gesichtsbereich einschließlich odontogener und Speicheldrüseninfektionen.
This is the sixth chapter of the guideline “Calculated initial parenteral treatment of bacterial infections in adults – update 2018” in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience.The chapter deals with the antibacterial treatment of more severe infections of the ear, the nose, the throat and the maxillofacial region, including odontogenic and salivary gland infections.
EinleitungBakterielle Infektionen der Kopf-Hals-Region erfordern häufig den Einsatz von Antibiotika. Die Entscheidung für eine parenterale Therapie hängt vom Schweregrad der Infektion, von möglichen Risiken einer Ausbreitung (z.B. Atemwegsverlegung), den Begleiterkrankungen und von den individuellen Applikationsvoraussetzungen ab. Die gute Bioverfügbarkeit von Fluorchinolonen und Clindamycin nach oraler Gabe ermöglicht in manchen Fällen auch bei schweren Infektionen eine orale Therapie. Dieser sollte wegen der einfacheren Anwendung, soweit sinnvoll, der Vorzug gegeben werden. Demgegenüber sollte die Behandlung der Mastoiditis, der Otitis externa maligna, der Sinusitis mit orbitalen oder intrakraniellen Kompli<![CDATA[ka</PlainText></TextGroup>tionen, der Epiglottitis, des schweren odontogenen Abszesses und der Halsphlegmone in der Regel immer mit einem parenteralen Antibiotikum eingeleitet werden. In der Regel muss die Therapie kalkuliert begonnen werden; jedoch ist eine mikrobiologische Erregerdiagnostik bei diesen schweren Erkrankungen anzustreben. Meist ist eine Sequenztherapie, d.h. eine orale Therapie nach klinischer Besserung, möglich.</Pgraph><Pgraph>Die Datenlage zur oralen Antibiotika-Therapie von leichteren Infektionen der Kopf-Hals-Region hat sich in den letzten Jahren verbessert. Für entsprechende Empfehlungen kann auf Metaanalysen zahlreicher randomisierter Vergleichsstudien mit größeren Patientenkollektiven zurückgegriffen werden. Solche Studien sind für schwere Infektionen kaum vorhanden. Da schwere Infektionen relativ selten sind und ethische Bedenken gegenüber einer Randomisierung auf Therapiearme bestehen, bei denen ein statistisch signifikanter Unterschied zu erwarten wäre, ist eine Verbesserung der Datenlage auch mittelfristig kaum zu erwarten. Dementsprechend beruhen die aktuellen Empfehlungen im Wesentlichen auf dem wahrscheinlichen Erregerspektrum, der lokalen Resistenzlage der Erreger und dem Wirkspektrum der verfügbaren Antibiotika. Bezüglich des zu erwartenden Erregerspek<TextGroup><PlainText>t</PlainText></TextGroup>rums ist – abhängig von Variablen wie Antibiotikage<TextGroup><PlainText>b</PlainText></TextGroup>rauch und Impfsituation – mit erheblichen regionalen Unterschieden zu rechnen. Aktuelle Untersuchungen zum Erregerspektrum schwerer bakterieller Infektionen der Kopf-Hals-Region für den deutschsprachigen Raum sind rar. Die derzeitigen Empfehlungen der relevanten Fachgesellschaften wurden bei den nachfolgenden Empfehlungen berücksichtigt <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>, <TextLink reference="3"></TextLink>, <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Introduction">
<MainHeadline>Introduction</MainHeadline><Pgraph>Bacterial infections of the head and neck region often require the use of antibiotics. The decision for parenteral treatment depends on the severity of the infection, possible risk of spread (for example obstruction of the airways), comorbidities and individual application requirements. In some cases, even in severe infections, the good bioavailability of orally administered fluoroquinolones and clindamycin allows oral administration. This should be given preference as much as possible due to the greater ease of administering it. In contrast, initial treatment of mastoiditis, external otitis maligna, sinusitis with orbital or intracranial complications, epiglottitis, severe odontogenic abscess and cervical phlegmon should generally be with a parenteral antibiotic. As a rule, initial treatment must be calculated; however, in these serious diseases a diagnosis of the microbiological pathogen should be the aim. Sequential therapy is usually possible, i.e. oral treatment after clinical improvement.</Pgraph><Pgraph>The data on oral antibiotic treatment for minor infections of the head and neck region has improved in recent years. For appropriate recommendations, meta-analyzes of numerous randomized comparative studies with large patient populations are to hand. Such studies are rare for severe infections. Since severe infections are relatively uncommon and since there are ethical concerns regarding randomization of forms of treatment in which a statistically significant difference would be expected, an improvement of the data situation cannot to be expected in the medium term. Accordingly, current recommendations are essentially based on the likely pathogen spectrum, the local pathogen resistance situation and the action spectrum of the available antibiotics. Significant regional differences are to be expected with regard to the expected pathogen spectrum – depending on variables such as antibiotic use and vaccination situation. Current studies are scarce on the pathogen spectrum of severe bacterial infections of the head and neck region for the German-speaking countries. The current recommendations of the relevant specialist associations have been taken into account in the following recommendations <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>, <TextLink reference="3"></TextLink>, <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Otitis externa maligna und Osteomyelitis der Schädelbasis">
<MainHeadline>Otitis externa maligna und Osteomyelitis der Schädelbasis</MainHeadline><Pgraph>Die Otitis externa maligna ist eine seltene Form der Osteomyelitis, die typischerweise ältere Diabetiker, seltener anderweitig immunsupprimierte Patienten, betrifft. Sie imponiert klinisch wie eine Otitis externa mit ungewöhnlich starker Otalgie, Otorrhoe und Granulationen im äußeren Gehörgang, kann jedoch mit der üblichen lokalen Therapie aus Gehörgangsreinigung und antibakteriellen Ohrentropfen nicht zur Ausheilung gebracht werden. Im Verlauf können Hirnnervenausfälle, v.a. Paresen des N. facialis, auftreten. Tödliche Verläufe kommen vor <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>. Der klinische Verdacht sollte mittels CT, Knochenszi<TextGroup><PlainText>n</PlainText></TextGroup>tigraphie oder MRT abgeklärt werden und in unkomplizierten Fällen sollte nach einer 48-stündigen Pause jeglicher antimikrobieller Therapie eine mikrobiologische Diagnostik erfolgen <TextLink reference="9"></TextLink>. Die Erkrankung wird in der Regel durch <Mark2>Pseudomonas aeruginosa</Mark2> und nur selten durch andere Erreger verursacht <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>. </Pgraph><Pgraph>Im Hospitalbereich kommen <Mark2>Pseudomonas</Mark2>-Isolate mit einer Resistenz gegen drei bzw. vier der gängigen <Mark2>Pseudomonas</Mark2>-wirksamen Antibiotika-Klassen (3MRGN bzw. 4MRGN) in relevantem Umfang vor. Colistin ist jedoch nach wie vor fast immer in vitro wirksam. Dagegen stellt sich die Resistenzlage bei <Mark2>Pseudomonas</Mark2>-Isolaten aus Ohrabstrichen im ambulanten Versorgungsbereich in Deutschland relativ günstig dar. Die im Rahmen der PEG-Resistenzstudie 2013 für den ambulanten (hier spezifisch von Ohrabstrichen gewonnene Isolate) bzw. stationären Versorgungsbereich gefundenen Empfindlichkeitswahrscheinlichkeiten waren wie folgt: Levofloxacin 88% bzw. 70%, Ciprofloxacin 88% bzw. 77%, Meropenem 100% bzw. 82%, Piperacillin 98% bzw. 84%, Cefepim 98% bzw. 90%, Ceftazidim 98% bzw. 87%, und Colistin 100% bzw. 100% <TextLink reference="12"></TextLink>, <TextLink reference="13"></TextLink>. </Pgraph><Pgraph>Eine kürzlich publizierte Metaanalyse von 30 Fallserien kommt zu dem Ergebnis, dass eine initiale Kombinationstherapie einer Monotherapie überlegen ist. Die Autoren empfehlen – sofern keine entsprechenden Resistenzen vorliegen – Ceftazidim + Ciprofloxacin für 3 Wochen, gefolgt von 3 Wochen Ciprofloxacin p.o. als Therapie der ersten Wahl <TextLink reference="11"></TextLink>. In Deutschland sollte diese Kombination daher zumindest bei komplizierten Fällen (Hirnnervenpa<TextGroup><PlainText>r</PlainText></TextGroup>esen) als Therapie der ersten Wahl eingesetzt werden (Empfehlungsgrad B). Alternativ können bei unkomplizierten Fällen Ceftazidim oder Piperacillin in Monotherapie eingesetzt werden (Empfehlungsgrad C). Die initiale parenterale Monotherapie mit einem Fluorchinolon kommt wegen der vergleichsweise ungünstigen Resistenzlage nur für Patienten mit einer Allergie gegen Beta-Lactame in Betracht. Meropenem bietet hinsichtlich der <Mark2>Pseudomonas</Mark2>-Aktivität keinen Vorteil gegenüber Ceftazidim oder Piperacillin. Vielmehr ist das Wirkspektrum unnötig breit. Aminoglykoside sind wegen eingeschränkter Penetration in den Knochen ungeeignet. Colistin wurde im Jahr 2012 – trotz ausgeprägter nephrotoxischer Reaktionen – zur Behandlung multiresistenter gramnegativer Erreger wieder für die parenterale Therapie in Deutschland zugelassen. Der Einsatz im Rahmen der kalkulierten Initialtherapie sollte nur in komplizierten Fällen für Patienten mit einer Allergie gegen Beta-Lactame erwogen werden, wobei die Dosierung an die Nierenfunktion angepasst werden muss (Empfehlungsgrad C). Die Therapiedauer sollte etwa 6 Wochen betragen. Ausgedehntere Knochennekrosen erfordern gegebenenfalls ein chirurgisches Débridement betroffener Areale <TextLink reference="14"></TextLink>.</Pgraph><Pgraph>Zwei aktuelle Arbeiten aus China und den USA berichten über eine zunehmende Inzidenz von Osteomyelitiden der lateralen und zentralen Schädelbasis mit nur geringer Schmerzsymptomatik und therapieresistenter Otorrhoe, v.a. bei Patienten nach Ohroperationen, aber auch solchen ganz ohne Ohrsymptome, bei denen als Erreger neben <Mark2>Pseudomonas aeruginosa</Mark2> in gleicher Häufigkeit <Mark2>Staphylococcus aureus</Mark2>, insbesondere auch MRSA, gefunden wurde <TextLink reference="10"></TextLink>, <TextLink reference="15"></TextLink>. In diesen seltenen Situationen sollten die <Mark2>Pseudomonas</Mark2>-wirksamen Standardantibiotika mit einem knochengängigen MRSA-wirksamen Antibiotikum, z.B. Linezolid oder Daptomycin (siehe Kapitel 10 <TextLink reference="16"></TextLink>) kombiniert werden (Empfehlungsgrad B).</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Otitis externa maligna and osteomyelitis of the base of the skull">
<MainHeadline>Otitis externa maligna and osteomyelitis of the base of the skull</MainHeadline><Pgraph>Otitis externa maligna is a rare form of osteomyelitis that typically affects older diabetics and, more rarely, other immunosuppressed patients. It presents clinically as an otitis externa with unusually strong otalgia, otorrhea and granulation in the external auditory canal but cannot be cured with the usual local treatment of ear canal cleaning and antibacterial ear drops. In the process, cranial nerve failure can occur, especially pareses of the facial nerve. Fatal outcomes are recorded <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>. The suspected clinical condition should be clarified by means of CT, bone scintigraphy or MRI and in uncomplicated cases a microbiological diagnosis should be carried out after a 48-hour break of any antimicrobial treatment <TextLink reference="9"></TextLink>. The disease is usually caused by <Mark2>Pseudomonas aeruginosa</Mark2> and only rarely by other pathogens <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>. </Pgraph><Pgraph>In hospitals, <Mark2>Pseudomonas</Mark2> isolates with a resistance to three or four of the common <Mark2>Pseudomonas</Mark2>-effective classes of antibiotics (3MRGN or 4MRGN) have a significant presence. However, colistin is almost always effective in vitro. In contrast, the resistance situation in <Mark2>Pseudomonas</Mark2> isolates from ear-smears in the outpatient care sector in Germany is relatively favorable. Sensitivity probabilities found during the 2013 PEG resistance study (specifically isolates from ear-smears) for outpatient or inpatient care were as follows: Levofloxacin 88% and 70%, ciprofloxacin 88% and 77%, meropenem 100% and 82%, piperacillin 98% and 84%, cefepime 98% and 90%, ceftazidime 98% and 87%, and colistin 100% and 100% respectively <TextLink reference="12"></TextLink>, <TextLink reference="13"></TextLink>. </Pgraph><Pgraph>A recently published meta-analysis of 30 case series concludes that initial combination treatment is superior to monotherapy. The authors recommend – if no relevant resistance is present - ceftazidime and ciprofloxacin for 3 weeks, followed by 3 weeks of ciprofloxacin p.o. as a treatment of choice <TextLink reference="11"></TextLink>. In Germany, this combination should therefore be used at least in complicated cases (cranial nerve pareses) as the treatment of choice (recommendation grade B). Alternatively in uncomplicated cases, ceftazidime or piperacillin can be used in monotherapy (recommendation grade C). Initial parenteral monotherapy with a fluoroquinolone should only be considered due to the relatively unfavorable resistance situation for patients with an allergy to beta-lactams. Meropenem has no advantage over ceftazidime or piperacillin regarding <Mark2>Pseudomonas</Mark2> activity. Rather, the spectrum of action is unnecessarily broad. Aminoglycosides are unsuitable because of their limited bone penetration. Despite severe nephrotoxic reactions, colistin was re-approved in Germany in 2012 for parenteral treatment of multidrug-resistant Gram-negative pathogens The use in the context of calculated initial treatment should only be considered in complicated cases for patients with an allergy to beta-lactams, with the dosage adapted to the kidney function (recommendation grade C). Treatment duration should be about 6 weeks. More extensive bone necrosis may require surgical debridement of affected areas <TextLink reference="14"></TextLink>.</Pgraph><Pgraph>Two recent studies from China and the US report an increasing incidence of osteomyelitis of the lateral and central skull base with only minor pain symptoms and therapy-resistant otorrhea, especially in patients after ear operations but also those without any ear symptoms, in which, in addition to <Mark2>Pseudomonas aeruginosa</Mark2>, <Mark2>Staphylococcus aureus</Mark2>, also in particular MRSA was found as the causative agent <TextLink reference="10"></TextLink>, <TextLink reference="15"></TextLink>. In these rare situations, the standard <Mark2>Pseudomonas</Mark2> antibiotics should be combined with a bone-active MRSA-effective antibiotic, for example linezolid or daptomycin (see chapter 10 <TextLink reference="16"></TextLink>) (recommendation grade B).</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Mastoiditis">
<MainHeadline>Mastoiditis</MainHeadline><Pgraph>Die akute Mastoiditis ist eine relativ häufige Komplikation der akuten oder chronischen Otitis media, bei der es zur eitrigen Einschmelzung der Knochenbälkchen im Mastoid kommt. Sie tritt überwiegend bei Kindern auf, zuletzt wieder mit steigender Inzidenz <TextLink reference="17"></TextLink>. Es konnte nur eine Studie zur Mastoiditis an Erwachsenen identifiziert werden. Das Erregerspektrum entspricht im Wesentlichen dem der akuten oder chronischen Otitis media. Im Folgenden wird die Datenlage bezüglich des zu erwartenden Erregerspektrums bei Kindern dargestellt und für die Therapieempfehlungen auf Erwachsene extrapoliert.</Pgraph><Pgraph>Das schwere Krankheitsbild der akuten Mastoiditis ist von anderen Flüssigkeitsansammlungen im Mastoid abzugrenzen, die radiologisch häufig ebenfalls als Mastoiditis beschrieben werden. Die Diagnose akute Mastoiditis wird klinisch anhand von Rötung, Schwellung und Druckschmerz über dem Mastoid sowie einem dadurch bedingten Abstehen der Ohrmuschel gestellt <TextLink reference="18"></TextLink>. Meist wird sie durch Pneumokokken verursacht <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>, <TextLink reference="20"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>, <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>. Die Einführung der Pneumokokken-Impfung hat laut Studien in Finnland und den USA nur kurzfristig zu einer niedrigeren Inzidenz mit anschließend deutlichem Anstieg an Pneumokokken mit verminderter Antibiotika-Empfindlichkeit geführt <TextLink reference="20"></TextLink>, <TextLink reference="23"></TextLink>. Weitere häufig isolierte Erreger sind <Mark2>Streptococcus pyogenes</Mark2>, <Mark2>Pseudomonas aeruginosa</Mark2>, <Mark2>Staphylococcus aureus</Mark2> und <Mark2>Haemophilus influenzae </Mark2><TextLink reference="17"></TextLink>, <TextLink reference="19"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>, <TextLink reference="24"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink> und neuerdings auch <Mark2>Fusobacterium necrophorum</Mark2> <TextLink reference="21"></TextLink>, <TextLink reference="28"></TextLink>. Bei Kindern unter 2 Jahren dominiert <Mark2>Streptococcus pneumoniae</Mark2> deutlich. <Mark2>Pseudomonas aeruginosa</Mark2> und <Mark2>Fusobacterium necrophorum</Mark2> werden fast ausschließlich bei Kindern über 2 Jahren isoliert <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. Mit <Mark2>Pseudomonas aeruginosa</Mark2> muss insbesondere bei einer Vorgeschichte von rezidivierenden Otitiden, liegenden Paukenröhrchen und Otorrhoe gerechnet werden. Der klinische Verlauf scheint zudem blande zu sein <TextLink reference="26"></TextLink>, <TextLink reference="29"></TextLink>, sodass es bei Fehlen der genannten Kriterien vertretbar scheint, im Rahmen der initialen kalkulierten Antibiotika-Therapie auf <Mark2>Pseudomonas</Mark2>-wirksame Antibiotika zu Gunsten von Antibiotika ohne <Mark2>Pseudomonas</Mark2>-Aktivität zu verzichten. Die Antibiotika-Therapie sollte in diesem Fall mit Amoxicillin/Clavulansäure, Ampicillin/Sulbactam, Cefotaxim bzw. Ceftriaxon + Clindamycin oder Levoflo<TextGroup><PlainText>xa</PlainText></TextGroup>cin erfolgen. Soll auch <Mark2>Pseudomonas aeruginosa</Mark2> mit erfasst werden, sollte eine Therapie mit Ceftazidim + Clindamycin, Piperacillin/Tazobactam oder Meropenem erwogen werden. Bei Vorliegen einer echten Allergie <TextGroup><PlainText>gegen</PlainText></TextGroup> Beta-Lactame stellt die Kombination Ciprofloxacin + Clindamycin eine Option dar. Begleitend sollte eine Parazentese mit mikrobiologischer Erregerdiagnostik, ggf. mit Paukenröhrchen-Einlage, durchgeführt werden. Bei Komplikationen, subperiostalem Abszess oder ausbleibender Besserung sollte eine Antrotomie bzw. Mastoidektomie durchgeführt werden <TextLink reference="30"></TextLink>, <TextLink reference="31"></TextLink>. Die Therapiedauer beträgt 7–10 Tage.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Mastoiditis">
<MainHeadline>Mastoiditis</MainHeadline><Pgraph>Acute mastoiditis is a relatively common complication of acute or chronic otitis media, in which there is a suppurative liquefaction of the trabeculae in the mastoid. It predominantly occurs in children, recently with an increasing incidence <TextLink reference="17"></TextLink>. Only one study on mastoiditis in adults could be identified. The pathogen spectrum corresponds essentially to that of acute or chronic otitis media. In the following, the data on the expected pathogen spectrum in children is presented and extrapolated for the treatment recommendations for adults.</Pgraph><Pgraph>The serious clinical picture of acute mastoiditis should be differentiated from other fluid accumulations in the mastoid, which are also frequently described radiologically as mastoiditis. The diagnosis of acute mastoiditis is clinically based on redness, swelling and pressure pain over the mastoid and the resulting protrusion of the auricle <TextLink reference="18"></TextLink>. It is mostly caused by pneumococci <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>, <TextLink reference="20"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>, <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>. According to studies in Finland and the USA, the introduction of vaccinatio<TextGroup><PlainText>n a</PlainText></TextGroup>gainst pneumococci has only resulted in a short-term lower incidence, followed by a marked increase in pneumococci with reduced susceptibility to antibiotics <TextLink reference="20"></TextLink>, <TextLink reference="23"></TextLink>. Other frequently isolated pathogens are <Mark2>Streptococcus pyogenes</Mark2>, <Mark2>Pseudomonas aeruginosa</Mark2>, <Mark2>Staphylococcus aureus</Mark2> and <Mark2>Haemophilus influenzae</Mark2> <TextLink reference="17"></TextLink>, <TextLink reference="19"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>, <TextLink reference="24"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink> and more recently also <Mark2>Fusobacterium necrophorum</Mark2> <TextLink reference="21"></TextLink>, <TextLink reference="28"></TextLink>. In children under two, <Mark2>Streptococcus pneumoniae</Mark2> dominates significantly. <Mark2>Pseudomonas aeruginosa</Mark2> and <Mark2>Fusobacterium necrophorum</Mark2> are almost exclusively isolated in children over the age of two <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. <Mark2>Pseudomonas aeruginosa</Mark2>, in particular, has to be expected in cases of recurrent otitis, tympanostomy tubes and otorrhea. The clinical progression also seems to be normal <TextLink reference="26"></TextLink>, <TextLink reference="29"></TextLink>, so that it seems justifiable in the absence of the mentioned criteria, in the context of an initial calculated antibiotic treatment to drop <Mark2>Pseudomonas</Mark2>-effective antibiotics in favor of antibi<TextGroup><PlainText>o</PlainText></TextGroup>tics without <Mark2>Pseudomonas</Mark2> activity. Antibiotic treatmen<TextGroup><PlainText>t in</PlainText></TextGroup> this case should rely on amoxicillin/clavulanic acid, ampicillin/sulbactam, cefotaxime or ceftriaxone + clindamycin or levofloxacin. If <Mark2>Pseudomonas aeruginosa</Mark2> has also been detected, treatment with ceftazidime + clindamycin, piperacillin/tazobactam or meropenem should be considered. In the presence of a genuine allergy to beta-lactams, the combination ciprofloxacin + clindamycin is an option. A paracentesis accompanied by a microbiological pathogen diagnose, possibly with tympanostomy insert, should be performed. In case of complications, subperiosteal abscess or lack of improvement, an antrotomy or mastoidectomy should be performed <TextLink reference="30"></TextLink>, <TextLink reference="31"></TextLink>. The duration of treatment is 7–10 days.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Epiglottitis">
<MainHeadline>Epiglottitis</MainHeadline><Pgraph>Während die akute Epiglottitis in der Zeit vor Einführung der Impfung gegen <Mark2>Haemophilus influenzae</Mark2> Typ B vornehmlich eine durch diesen Erreger hervorgerufene Erkrankung des Kindesalters war, werden heute häufiger auch andere Erreger isoliert und Erwachsene sind häufiger betroffen als Kinder <TextLink reference="32"></TextLink>, <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>, <TextLink reference="36"></TextLink>. Meist handelt es sich um ein akutes, schweres Krankheitsbild mit rascher Progredienz, das wegen der Gefahr einer Atemwegsverlegung in der Regel einer sofortigen stationären, eventuell sogar intensivmedizinischen Überwachung mit der Möglichkeit einer Intubation oder Tracheotomie bedarf. Bei Erwachsenen kann die Erkrankung von vorbestehenden Zysten ausgehen, was mit schwereren Verläufen und einer erhöhten Wahrscheinlichkeit für die Notwendigkeit einer chirurgischen Maßnahme verbunden ist <TextLink reference="37"></TextLink>, <TextLink reference="38"></TextLink>. Da in der Akutsituation sonst jede Manipulation vermieden werden sollte, erfolgt eine Erregerdiagnostik nur selten. Daher sind Aussagen zur Häufigkeit des Vorkommens bestimmter Erreger nur mit Einschränkungen möglich. Bei Erwachsenen dominieren verschiedene Streptokokken-Arten, während Anaerobier und <Mark2>Haemophilus influenzae</Mark2> Typ B seltener, aber in relevanter Häufigkeit isoliert werden, nicht seltenen als Teil einer Mischinfektion <TextLink reference="32"></TextLink>, <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>. Einzelfallberichte existieren über eine akute Epiglottitis durch <Mark2>Staphylococcus aureus</Mark2> <TextLink reference="39"></TextLink>, <Mark2>Haemophilus parainfluenzae</Mark2> <TextLink reference="40"></TextLink>, <Mark2>Corynebacterium diphtheriae</Mark2> <TextLink reference="41"></TextLink>, <Mark2>Mycobacterium tuberculosis</Mark2> <TextLink reference="42"></TextLink> und Meningokokken <TextLink reference="43"></TextLink>. Daneben kann die akute Epiglottitis auch durch Viren verursacht werden oder eine nicht-infektiöse Ursachen haben. Da es sich um ein lebensbedrohliches Krankheitsbild handelt, sollte die häufigsten Erreger mit der kalkulierten Antibiotika-Therapie sicher erfasst werden. Primär kommen Amoxicillin/Clavulansäure oder Ampicillin/Sulbactam in Betracht <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>. Alternative Behandlungsoptionen sind Ceftriaxon bzw. Cefotaxim + Clindamycin oder Metronidazol <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink> sowie Moxifloxacin. Zeitgleich sollten initial hochdosiert Kortikosteroide verabreicht werden <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Epiglottitis">
<MainHeadline>Epiglottitis</MainHeadline><Pgraph>While acute epiglottitis in the period prior to the introduction of the <Mark2>Haemophilus influenzae</Mark2> type B vaccine was primarily a pediatric disease caused by this pathogen, other pathogens are more commonly isolated today and adults are more frequently affected than children <TextLink reference="32"></TextLink>, <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>, <TextLink reference="36"></TextLink>. It is usually an acute, severe disease with rapid progression, which usually requires immediate inpatient admission, maybe even intensive care monitoring with the possibility of intubation or tracheostomy due to the risk of airway obstruction. In adults, the disease may be caused by pre-existing cysts, which is associated with more severe outcomes and an increased likelihood of requiring surgical intervention <TextLink reference="37"></TextLink>, <TextLink reference="38"></TextLink>. Since any form of manipulation should be avoided in an emergency situation, pathogen diagnostics are rarely performed. Therefore, statements on the frequency of occurrence of certain pathogens are possible only with reservations. In adults, various types of streptococci dominate, while anaerobes and <Mark2>Haemophilus influenzae</Mark2> type B are isolated less frequently but in relevant frequency, quite often as part of a mixed infection <TextLink reference="32"></TextLink>, <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>. Individual case reports exist of acute epiglottitis caused by <Mark2>Staphylococcus aureus</Mark2> <TextLink reference="39"></TextLink>, <Mark2>Haemophilus parainfluenzae</Mark2> <TextLink reference="40"></TextLink>, <Mark2>Corynebacterium diphtheriae</Mark2> <TextLink reference="41"></TextLink>, <Mark2>Mycobacterium tuberculosis</Mark2> <TextLink reference="42"></TextLink> and meningococci <TextLink reference="43"></TextLink>. In addition, acute epiglottitis can also be caused by viruses or have a non-infectious cause. Since this is a life-threatening clinical scenario, the most frequent pathogens should be reliably covered by the calculated antibiotic treatment. Amoxicillin/clavulanic acid or ampicillin/sulbactam should be considered in the main <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>. Alternative treatment options are ceftriaxone or cefotaxime + clindamycin or metronidazole <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink> and moxifloxacin. At the same time, high-dose corticosteroids should be administered initially <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Ohrmuschelperichondritis">
<MainHeadline>Ohrmuschelperichondritis</MainHeadline><Pgraph>Die Ohrmuschelperichondritis ist durch das Übergreifen einer akuten Entzündung des äußeren Ohres auf das Perichondrium gekennzeichnet. Mögliche Ursachen sind Kratzdefekte, mechanische Traumata (Othämatom, Otserom), operative Eingriffe mit Freilegen des Ohrknorpels, Erfrierung, Verbrennung, Insektenstiche und Piercing, jedoch ist in mehr als der Hälfte der Fälle keine Ursache zu erkennen <TextLink reference="44"></TextLink>. Der mit Abstand häufigste Erreger ist <Mark2>Pseudomonas aeruginosa</Mark2>. Nach Angaben einer Übersichtsarbeit beträgt sein Anteil bei Infektionen nach Piercing 87% <TextLink reference="45"></TextLink>. Zweithäufigster Erreger ist <Mark2>Staphylococcus aureus</Mark2>, gefolgt von <Mark2>Streptococcus pyogenes</Mark2> und anderen Streptokokken-Arten. In Einzelfällen wurden auch Enterobacteriaceae und Enterokokken isoliert <TextLink reference="44"></TextLink>, <TextLink reference="45"></TextLink>, <TextLink reference="46"></TextLink>, <TextLink reference="47"></TextLink>. </Pgraph><Pgraph>Vor Therapiebeginn sollte Material zur mikrobiologischen Diagnostik gewonnen werden. Die Anfertigung eines Grampräparats, dessen Ergebnis oft innerhalb weniger Stunden verfügbar ist, kann helfen, den Einsatz unnötig breit wirksamer Antibiotika zu vermeiden. Bei Vorliegen leichterer Formen der Infektion mit grampositiven Kokken (<Mark2>Staphylococcus aureus</Mark2>, Streptokokken) kann Clindamycin, bei solchen mit gramnegativen Stäbchen (zumeist <Mark2>Pseudomonas aeruginosa</Mark2>) Ciprofloxacin p.o. gegeben werden. Schwerere Formen sollten wegen des Risikos der Abszessbildung mit der Folge bleibender Ohrmuscheldeformitäten primär parenteral therapiert werden. Mittel der 1. Wahl für die Antibiotika-Therapie sind Piperacillin/Tazobactam, Cefepim und Ceftazidim + Clindamycin (Empfehlungsgrad B). Zudem erfolgt eine antiseptische Behandlung. Ciprofloxacin und Levofloxacin sollten wegen der deutlich höheren Anteils Fluorchinolon-resistenter Stämme nur bei Penicillin-Allergie eingesetzt werden (Empfehlungsgrad B). Bei fehlendem Ansprechen der Therapie können entweder eine Relapsing Polychondritis vorliegen, Knorpelnekrosen ein chirurgisches Debridement erfordern oder ein resistenter <Mark2>Pseudomonas</Mark2>-Stamm die Ursache der Infektion sein. Die im Rahmen der PEG-Resistenzstudie 2013 gefundenen Antibiotika-Empfindlichkeitswahrscheinlichkeiten von <Mark2>Pseudomonas aeruginosa</Mark2> für den ambulanten (hier spezifisch aus den Ohren gewonnene Isolate) bzw. stationären Versorgungsbereich waren wie folgt: Levofloxacin 88% bzw. 70%, Ciprofloxacin 88% bzw. 77%, Meropenem 100% bzw. 82%, Piperacillin 98% bzw. 84%, Cefepim 98% bzw. 90%, Ceftazidim 98% bzw. 87%, und Colistin 100% bzw. 100% <TextLink reference="12"></TextLink>, <TextLink reference="13"></TextLink>. Nach Vorliegen des Antibiogramms kann die Therapie ggf. oral fortgeführt werden. Bei Eiteransammlung ist eine Inzision, bei Nekrosen eine schonende Knorpelabtragung mit bestmöglichem Erhalt der Ohrmuschel und ggf. eine plastische Rekonstruktion der Ohrmuschel nach Abheilung erforderlich.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Auricular perichondritis">
<MainHeadline>Auricular perichondritis</MainHeadline><Pgraph>Auricular perichondritis is characterized by the spread of acute inflammation of the outer ear to the perichondrium. Possible causes include scratch damage, mechanical trauma (othematoma, otostomy), surgical procedures with exposure of the ear cartilage, frostbite, burns, insect bites and piercing but in more than half of cases no cause can be identified <TextLink reference="44"></TextLink>. By far the most common pathogen is <Mark2>Pseudomonas aeruginosa</Mark2>. According to one review, it occurs in 87% of infections following piercing <TextLink reference="45"></TextLink>. The second most common pathogen is <Mark2>Staphylococcus aureus</Mark2>, followed by <Mark2>Streptococcus pyogenes</Mark2> and other streptococcal species. In individual cases, Enterobacteriaceae and enterococci have also been isolated <TextLink reference="44"></TextLink>, <TextLink reference="45"></TextLink>, <TextLink reference="46"></TextLink>, <TextLink reference="47"></TextLink>. </Pgraph><Pgraph>Material should be obtained for microbiological diagnostics before the start of treatment. Carrying out a Gram preparation, the result of which is often available within a few hours, can help prevent the use of antibiotics with an unnecessarily broad spectrum. In case of mild forms of Gram-positive cocci (<Mark2>Staphylococcus aureus</Mark2>, streptococci), ciprofloxacin p.o. should be given; clindamycin may be useful in cases of Gram-negative rods (usually <Mark2>Pseudomonas aeruginosa</Mark2>). More severe forms should be treated primarily parenterally because of the risk of abscess formation resulting in permanent deformation of the pinna. Piperacillin/tazobactam, cefepime + clindamycin and ceftazidime and ceftazidime (recommendation grade B) are the antibiotics of choice for treatment. Antiseptic treatment is also applicable. Ciprofloxacin and levofloxacin should only be used in cases of penicillin allergy due to the significantly higher proportion of fluoroquinolone-resistant strains (recommendation grade B). If there is no response to treatment, this may point to relapsing polychondritis or a resistant strain of <Mark2>Pseudomonas</Mark2> as the cause of the infection or cartilage necrosis requiring surgical debridement. The antibiotic susceptibility rates of <Mark2>Pseudomonas aeruginosa</Mark2> found in the 2013 PEG resistance study for outpatient (specifically ear-de<TextGroup><PlainText>r</PlainText></TextGroup>ived isolates) or inpatient care were as follows: Levofloxacin 88% and 70%, ciprofloxacin 88% and 77%, meropenem 100% and 82%, piperacillin 98% and 84%, cefepime 98% and 90%, ceftazidime 98% and 87%, and colistin 100% and 100% respectively <TextLink reference="12"></TextLink>, <TextLink reference="13"></TextLink>. Once the antibiogram is available, treatment may possibly be continued orally. An incision is necessary if there is pus accumulation, in case of necroses gentle cartilage removal with best possible preservation of the auricle and possibly plastic reconstruction of the auricle after healing.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Nasenfurunkel">
<MainHeadline>Nasenfurunkel</MainHeadline><Pgraph>Nasenfurunkel sind schmerzhafte Infektionen der Haarfollikel im Vestibulum nasi mit phlegmonöser Ausbreitung zur Nasenspitze, zum Nasensteg, zur Oberlippe und entlang des Nasenrückens, die durch <Mark2>Staphylococcus aureus</Mark2> im Sinne einer endogenen Infektion, ausgehend von einer Besiedlung des Nasenvorhofs, verursacht werden <TextLink reference="48"></TextLink>, <TextLink reference="49"></TextLink>. Eine Studie zur Resistenzlage von den Nasenvorhof besiedelnden <Mark2>Staphylococcus aureus</Mark2> aus neun europäischen Ländern weist für Erwachsene eine MRSA-Häufigkeit von 0–2,4% auf. Gegen Clindamycin waren 5–15% der Isolate resistent <TextLink reference="50"></TextLink>. In der PEG Resistenzstudie 2013 fand sich ein Anteil von 8% MRSA an allen <Mark2>Staphylococcus aureus</Mark2>-Isolaten von Patienten aus dem ambulanten Versorgungsbereich <TextLink reference="51"></TextLink>.</Pgraph><Pgraph>Bei den sehr häufig vorkommenden leichten Verlaufsformen (Follicullitis ohne Einschmelzung und ohne wesentliche phlegmentöse Umgebungsreaktion) ist eine ambulante Therapie mit topischen Antiseptika oder Antibiotika meist ausreichend, bei beginnender Ausbreitungstendenz kann zusätzlich eine orale Antibiotika-Therapie erfolgen. Wenn möglich ist das Furunkel zu inzidieren. Bei kompliziertem Krankheitsverlauf erfolgt die Behandlung wegen der Gefahr der Thrombose der V. angularis mit fortgeleiteter Sepsis zum Sinus cavernosus intravenös und stationär <TextLink reference="52"></TextLink>. Die Antibiotika-Therapie erfolgt nach Möglichkeit mit einem Penicillinase-festen Penicillin oder einem Staphylokokken-wirksamen Schmalspektrum-Cephalosporin. Antibiotikum der ersten Wahl ist Cefazolin. Flucloxacillin weist aufgrund der hepatotoxischen Nebenwirkungen <TextLink reference="53"></TextLink> ein ungünstigeres Nebenwirkungsprofil als Cefazolin auf. Alternativ können auch Cefuroxim, Amoxicillin/Clavulansäure oder Ampicillin/Sulbactam eigesetzt werden, die jedoch ein unnötig breites Wirkspektrum besitzen. Clindamycin wird bei Patienten mit Penicillin-Allergie eingesetzt. Bei ausbleibender Besserung ist das Vorliegen von MRSA zu evaluieren. Eine Therapiedauer von einer Woche ist in der Regel ausreichend. Eine rasche Umsetzung auf eine orale Sequenztherapie ist anzustreben. Geeignete Antibiotika sind Cefalexin, Doxycyclin und Clindamycin.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Nasal boil">
<MainHeadline>Nasal boil</MainHeadline><Pgraph>Nasal boil is a painful infection of the hair follicles in the nasal vestibule with phlegmonous spread to the tip of the nose, to the bridge of the nose, to the upper lip and along the bridge of the nose caused by <Mark2>Staphylococcus aureus</Mark2> in the sense of an endogenous infection from colonization of the nasal atrium <TextLink reference="48"></TextLink>, <TextLink reference="49"></TextLink>. A study of the resistance status of the nasopharyngeal <Mark2>Staphylococcus aureus</Mark2> from nine European countries shows an MRSA frequency of 0–2.4% for adults. 5–15% of isolates were resistant to clindamycin <TextLink reference="50"></TextLink>. In the 2013 PEG Resistance Study, all <Mark2>Staphylococcus aureus</Mark2> isolates from outpatient care contained 8% MRSA <TextLink reference="51"></TextLink>.</Pgraph><Pgraph>Outpatient treatment with topical antiseptics or antibiotics is usually sufficient in the case of the frequently occurring mild forms (folliculitis without liquefaction and without significant phlegmonous reaction in the surrounding tissue); if a tendency to spread develops, oral antibiotic treatment can be carried out in addition. If possible, the boil should be lanced. In cases of complicated progression, treatment is carried out intravenously and under inpatient care due to the risk of thrombosis of the angular vein with transmitted sepsis to the cavernous sinus <TextLink reference="52"></TextLink>. If possible, antibiotic treatment is carried out with a penicillinase-resistant penicillin or a staphylococcal-effective narrow-spectrum cephalosporin. The antibiotic of choice is cefazolin. Flucloxacillin has a less favorable side-effect profile than cefazolin due to its hepatotoxic side effects <TextLink reference="53"></TextLink>. Alternatively, cefuroxime, amoxicillin/clavulanic acid or ampicillin/sulbactam can be used but have an unnecessarily broad action spectrum. Clindamycin is used in patients with a penicillin allergy. If there is no improvement, the presence of MRSA should be investigated. A treatment duration of one week is usually sufficient. Moving to oral sequential therapy quickly is desirable. Suitable antibiotics are cefalexin, doxycycline and clindamycin.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Peritonsillitis und Peritonsillarabszess">
<MainHeadline>Peritonsillitis und Peritonsillarabszess</MainHeadline><Pgraph>Bei der Peritonsillitis hat sich eine Entzündung im Bindegewebe zwischen Tonsille und Musculus constrictor pharyngis ausgebreitet. Als Peritonsillarabszess wird die in der Regel einseitige Einschmelzung des phlegmonös entzündeten peritonsillären Gewebes mit Eiteransammlung verstanden. Der Peritonsillarabszess kommt überwiegend bei jungen Erwachsenen und eher selten bei Kindern vor. Klinisch imponiert er mit einer Vorwölbung der Tonsille begleitet von einer Rötung und Schwellung der Gaumenbögen. Zusätzlich können ein Uvulaödem und eine Kieferklemme vorliegen. </Pgraph><Pgraph>Eine 2013 publizierte Übersichtsarbeit mit gepoolten Daten von 15 zwischen 1980 und 2012 veröffentlichten Studien lässt einen differenzierten Blick auf das wahrscheinliche Spektrum ursächlicher Erreger zu <TextLink reference="54"></TextLink>. In der Mehrzahl der Fälle handelt es sich um Mischinfektionen Die häufigsten isolierten Erreger bei Monoinfektionen waren Gruppe-A-Streptokokken (20–45%, diese Werte unterschätzen auf Grund oft bereits erfolgter Antibiotika-Therapie möglicherweise jedoch die tatsächliche Häufigkeit) und Fusobakterien (4–55%; in drei dänischen Studi<TextGroup><PlainText>e</PlainText></TextGroup>n der dominierende Erreger, insbesondere bei Kindern häufig). Bei Mischinfektionen spielen vermutlich v.a. Streptokokken der <Mark2>Streptococcus-anginosus</Mark2>-Gruppe (<Mark2>Streptococcus intermedius</Mark2>, <Mark2>Streptococcus anginosus</Mark2> und <Mark2>Streptococcus constellatus</Mark2>), die in bis zu 51% der Fälle isoliert wurden, eine wichtige Rolle. Bei Monoinfektionen wurden gelegentlich oder in Einzelfällen auch <Mark2>Staphylococcus aureus</Mark2>, <Mark2>Nocardia asteroides</Mark2>, <Mark2>Haemophilus influenzae</Mark2>, <Mark2>Arcanobacterium haemolyticum</Mark2> und <Mark2>Streptococcus pneumoniae</Mark2> isoliert. Im Gegensatz dazu wird bestimmten, im Rahmen von Mischinfektionen häufig isolierten Spezies, v.a. Streptokokken der serologischen Gruppe C, <Mark2>Peptostreptococcus</Mark2> und <Mark2>Prevotella</Mark2> spp, nur eine untergeordnete Bedeutung für den Krankheitsprozess eingeräumt <TextLink reference="54"></TextLink>. Spätere Veröffentlichungen, die das Erregerspektrum thematisieren, ergaben keine wesentlich neuen Aspekte <TextLink reference="55"></TextLink>, <TextLink reference="56"></TextLink>, <TextLink reference="57"></TextLink>.</Pgraph><Pgraph>Im Hinblick auf die Wahl einer adäquaten antibiotischen Therapie liegen zwei randomisierte Vergleichsstudien vor, die beide keinen Unterschied im klinischen Krankheitsverlauf zwischen den Therapiearmen ausweisen. In der einen Studie wurde die Wirksamkeit von Penicillin im Vergleich zu Penicillin + Metronidazol <TextLink reference="58"></TextLink> und in der anderen die Wirksamkeit von Penicillin im Vergleich zu Ampicillin + Sulbactam geprüft <TextLink reference="59"></TextLink>. Die Aussagekraft beider Studien ist wegen der geringen Fallzahl (n=40 bzw. 42) und der simultan erfolgten Abszessdrainage jedoch eingeschränkt. Im Rahmen einer nicht randomisierten, prospektiven Beobachtungsstudie an 117 Patienten nach einmaliger Nadelaspiration war ein erneuter chirurgischer Eingriff nach Monotherapie mit Penicillin signifikant häufiger erforderlich als nach Monotherapie mit Amoxicillin/Clavulansäure oder Cefuroxim + Metronidazol (14,7% vs. 4,7%) <TextLink reference="60"></TextLink>.</Pgraph><Pgraph>Die Behandlung der Peritonsillitis erfolgt durch eine orale oder parenterale Antibiotika-Therapie. Der Peritonsillarabszess wird chirurgisch therapiert und mit einer peri- sowie postoperativen Antibiotika-Therapie kombiniert. Abszesspunktion, Abszessinzision und Spülung oder Abszesstonsillektomie sind, wann immer sinnvoll möglich, anzustreben. Der gewonnene Eiter sollte mikrobiologisch untersucht werden <TextLink reference="4"></TextLink>.</Pgraph><Pgraph>Als Antibiotika der ersten Wahl sollen Amoxicillin/Clavulansäure, Ampicillin/Sulbactam oder Cefuroxim + Metronidazol eingesetzt werden (Empfehlungsrad A). Alle wesentlichen in der Literatur als Erkrankungsursache diskutierten Erreger werden hiermit erfasst. Als Alternativen bei Penicillin-Allergie kommen Clindamycin oder Moxifloxacin in Betracht (Empfehlungsrad B), wobei hier in 16–25% bzw. 7–53% der Fälle mit Resistenzen bei Fusobakterien zu rechnen ist <TextLink reference="61"></TextLink>. Eine kanadische Arbeit berichtet über einen Anteil von 32% Clindamycin-resistenten Stämmen an den Streptokokken-Isolaten aus Peritonsillarabszessen <TextLink reference="57"></TextLink>, während in Deutschland im Jahr 2013 nach den Angaben der PEG-Resistenzstudie nur 3% der Isolate von <Mark2>Streptococcus pyogenes</Mark2> Clindamycin-resistent waren und keine Resistenz gegen Moxifloxacin gefunden wurde <TextLink reference="12"></TextLink>. Die Monotherapie mit einem Cephalosporin ist nicht ratsam, da Fusobakterien in der Regel eine Cephalosporinase produzieren <TextLink reference="61"></TextLink>. Eine rasche Oralisierung der Medikation sollte angestrebt werden. Die Therapiedauer beträgt in der Regel 5–7 Tage. Im Rahmen einer prospektiven, randomisierten Studie an 105 Patienten, bei denen nach Abszesstonsillektomie entweder mit Benzylpenicillin nachbehandelt oder jegliche Antibiotika-Therapie abgesetzt wurde, fand sich kein Unterschied, was subjektive Schluck- und Schmerz-Score-Werte sowie den Verlauf von Leukozytenzahl und C-reaktivem Protein betrifft <TextLink reference="62"></TextLink>, sodass nach erfolgter Abszesstonsillektomie in unkomplizierten Fällen auch ein unmittelbares Absetzen der Antibiotika-Therapie vertretbar scheint.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Peritonsillitis and peritonsillar abscess">
<MainHeadline>Peritonsillitis and peritonsillar abscess</MainHeadline><Pgraph>In peritonitis, inflammation has spread in the connective tissue between a tonsil and the constrictor pharyngeal muscle. Peritonsillar abscess is understood to mean the generally one-sided liquefaction of phlegmonously inflamed peritonsillar tissue with accumulation of pus. Peritonsillar abscesses occur predominantly in young adults and more rarely in children. Clinically, it presents as protrusion of the tonsils accompanied by redness and swelling of the palatal arches. In addition, a uvula edema and jaw clamp may be present. </Pgraph><Pgraph>A review published in 2013 with pooled data from 1<TextGroup><PlainText>5 s</PlainText></TextGroup>tudies published between 1980 and 2012 provides a differentiated view of the probable spectrum of causative pathogen <TextLink reference="54"></TextLink>. In the majority of cases, these are mixed infections. The most commonly isolated pathogens in monoinfections were group A streptococci (20–45%, but this may be a low frequency estimate due to prior antibiotic treatment) and fusobacteria (4–55%; the dominant pathogen in three Danish studies, especially among children). In mixed infections presumably especially Streptococci of the <Mark2>Streptococcus anginosus</Mark2> group (<Mark2>Streptococcus intermedius</Mark2>, <Mark2>Streptococcus anginosus</Mark2> and <Mark2>Streptococcus constellatus</Mark2>), which were isolated in up to 51% of cases, play an important role. In monoinfections <Mark2>Staphylococcus aureus</Mark2>, <Mark2>Nocardia asteroids</Mark2>, <Mark2>Haemophilus influenzae</Mark2>, <Mark2>Arcanobacterium haemolyticum</Mark2> and <Mark2>Streptococcus pneumoniae</Mark2> have been isolated occasionally or in isolated cases. In contrast, certain species often isolated in the context of mixed infections, especially Streptococci of the serological group C, <Mark2>Peptostreptococcus</Mark2> and <Mark2>Prevotella</Mark2> spp, are only of secondary importance for the disease process <TextLink reference="54"></TextLink>. Subsequent publications, which address the pathogen spectrum, did not reveal many new aspects <TextLink reference="55"></TextLink>, <TextLink reference="56"></TextLink>, <TextLink reference="57"></TextLink>.</Pgraph><Pgraph>With regard to the selection of an adequate antibiotic treatment, two randomized comparative studies are available, both of which show no difference in the clinical course of the disease between the treatment arms. In one study, the efficacy of penicillin compared to penicillin + metronidazole <TextLink reference="58"></TextLink> and in the other the efficacy of penicillin compared to ampicillin + sulbactam was tested <TextLink reference="59"></TextLink>. However, the significance of both studies is limited because of the small number of cases (n=40 and 42 respectively) and simultaneous abscess drainage. In a non-randomized, prospective observational study with <TextGroup><PlainText>117 p</PlainText></TextGroup>atients after single needle aspiration, following monotherapy with penicillin new surgical intervention was required significantly more often than after monotherapy with amoxicillin/clavulanic acid or cefuroxime + metronidazole (14.7% vs. 4.7%) <TextLink reference="60"></TextLink>.</Pgraph><Pgraph>Treatment of peritonsillitis is by oral or parenteral antibiotic therapy. Peritonsillar abscesses are treated surgically and combined with peri- and postoperative antibiotic therapy. Whenever possible abscess aspiration, abscess incision and irrigation or abscess tonsillectomy are desirable. The recovered pus should be examined microbiologically <TextLink reference="4"></TextLink>.</Pgraph><Pgraph>Amoxicillin/clavulanic acid, ampicillin/sulbactam or cefuroxime + metronidazole should be used as first line antibiotics (recommendation grade A). All essential pathogens discussed in the literature as the cause of the disease are hereby covered. As alternatives in case of penicillin allergy, clindamycin or moxifloxacin may be considered (recommendation grade B), with the expectation of likely fusobacteria resistance in 16–25% and 7–53% of cases respectively <TextLink reference="61"></TextLink>. A Canadian study reports that 32% of clindamycin-resistant strains were isolated from the streptococcal isolates from peritonsillar abscesses <TextLink reference="57"></TextLink>, whereas in Germany in 2013 only 3% of the isolates of <Mark2>Streptococcus pyogenes</Mark2> were clindamycin-resistant, according to the PEG resistance study and no resistance to moxifloxacin was found <TextLink reference="12"></TextLink>. Cephalosporin monotherapy is not recommended as fusobacteria usually produce cephalosporinase <TextLink reference="61"></TextLink>. A rapid change to oral administration of medication should be the target. The duration of treatment is around 5–7 days. In a prospective randomized study with 105 patients who were either treated with benzylpenicillin after abscess tonsillectomy or who discontinued any antibiotic treatment, no difference was found between subjective swallowing and pain scores and the progression of leukocyte count and C-score reactive protein <TextLink reference="62"></TextLink> so that in uncomplicated cases after abscess tonsillectomy, immediate discontinuation of antibiotic treatment seems justifiable.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Bakterielle Sinusitiden und deren Komplikationen">
<MainHeadline>Bakterielle Sinusitiden und deren Komplikationen</MainHeadline><Pgraph>Die akute Rhinosinusitis soll nur bei schweren Verläufen oder ausbleibender Spontanheilung mit Antibiotika behandelt werden, die dann primär oral verabreicht werden (Empfehlungsgrad A) <TextLink reference="63"></TextLink>, <TextLink reference="64"></TextLink>. In Einzelfällen kann bei Patienten mit schweren Begleiterkrankungen, ungewöhnlich schweren Verläufen oder bei ausbleibender Besserung nach oraler Antibiotika-Therapie die Indikation für eine parenterale Therapie bestehen. In diesen Fällen sollte differentialdiagnostisch auch eine invasive Mykose oder eine nicht-infektiöse Erkrankung (z.B. granulomatöse Polyangiitis, früher Wegener-Granulomatose) in Erwägung gezogen sowie die Indikation für eine chirurgische Maßnahme geprüft werden. Mit der kalkulierten parenteralen Antibiotika-Therapie sollten die wichtigsten Erreger der akuten Rhinosinusitis – <Mark2>Streptococcus pneumoniae</Mark2>, <Mark2>Haemophilus influenzae</Mark2>, <Mark2>Moraxella catarrhalis</Mark2>, <Mark2>Streptococcus pyogenes</Mark2>, <Mark2>Staphylococcus aureus</Mark2> und bei dentogener Ursache auch diverse andere Streptokokken-Spe<TextGroup><PlainText>z</PlainText></TextGroup>ies und Anaerobier <TextLink reference="64"></TextLink> erfasst werden. Hierzulande empfiehlt sich eine Therapie mit Amoxicillin/Clavulansäu<TextGroup><PlainText>r</PlainText></TextGroup>e, Ampicillin/Sulbactam, Cefotaxim oder Ceftriaxon + Clindamycin, oder Moxifloxacin bzw. – bei schlechterer Anaerobier-Wirksamkeit – Levofloxacin. Bei Patienten mit Mukoviszidose <TextLink reference="65"></TextLink> und Patienten nach Knochenmarkstransplantation <TextLink reference="66"></TextLink> muss an <Mark2>Pseudomonas aeruginosa</Mark2> als Erreger gedacht werden. In diesen Fällen ist der Einsatz von Piperacillin/Tazobactam, Ceftazidim + Clindamycin oder Meropenem sinnvoll.</Pgraph><Pgraph>Die verschiedenen Formen der chronischen Sinusitis werden grundsätzlich primär nicht antibiotisch, sondern mit topischen Steroiden (Empfehlungsgrad A) und Nasenspülungen therapiert. Bei primär sehr ausgeprägten oder konservativ nicht ausreichend therapierbaren Fällen ist ein chirurgisches Vorgehen zu erwägen. Im Falle einer odontogenen Ursache steht die Sanierung des dentogenen Fokus im Vordergrund. Eine begleitende orale Antibiotika-Therapie kann bei akuten Exazerbationen (Empfehlungsgrad B) oder ausgeprägt eitrigen Formen sinnvoll sein. Eine parenterale Therapie sollte demgegenüber Patienten mit schweren Begleiterkrankungen oder ungewöhnlich schweren Verläufen vorbehalten bleiben. Da bei der chronischen Sinusitis zahlreiche Bakterienspezies als Erreger infrage kommen, sollte die Therapie möglichst gezielt erfolgen. Zu den häufig isolierten Erregern gehören <Mark2>Staphylococcus aureus</Mark2>, Streptokokken, <Mark2>Haemophilus influenzae</Mark2>, verschiedene Enterobacteriaceae-Spezies (<Mark2>Escherichia coli</Mark2>, <Mark2>Klebsiella pneumoniae</Mark2>, <Mark2>Klebsiella </Mark2><TextGroup><Mark2>oxytoca</Mark2></TextGroup>, <Mark2>Serratia marcescens</Mark2>, <Mark2>Proteus mirabilis</Mark2>), <Mark2>Pseudomonas aeruginosa</Mark2> und Anaerobier <TextLink reference="67"></TextLink>, <TextLink reference="68"></TextLink>, <TextLink reference="69"></TextLink>, <TextLink reference="70"></TextLink>. Kalkuliert können Piperacillin/Tazobactam, Ceftazidim + Clindamycin oder Levofloxacin bzw. Moxifloxacin eingesetzt werden. </Pgraph><Pgraph>Das Erregerspektrum der odontogenen Sinusitis maxillaris ist besser kalkulierbar. Meist handelt es sich um Mischinfektionen durch Streptokokken und Anaerobier. Mit <Mark2>Moraxella</Mark2> spp. und <Mark2>Haemophilus</Mark2> spp. muss im Gegensatz zur rhinogenen Sinusitis nicht gerechnet werden. Die kalkulierte Therapie, begleitend zur Fokussanierung, erfolgt entweder mit Amoxicillin/Clavulansäure, Ampicillin/Sulbactam oder Clindamycin <TextLink reference="70"></TextLink>. Neben der Antibiotikatherapie sind – spätestens nach dem Abklingen der akuten Syptomatik – die chirurgische Sanierung der odontogenen Ursache und ggf. der Verschluss einer eventuell vorliegenden Mund-Antrum-Verbindung notwendig.</Pgraph><Pgraph>Bei entsprechender Risikoanamnese muss sowohl bei der akuten als auch bei der chronischen Sinusitis mit multiresistenten Erregern gerechnet werden. In einer <TextGroup><PlainText>retrospektiven</PlainText></TextGroup> Studie der Stanford University wurden die Nasennebenhöhlenabstriche aus einem Zeitraum von etwas mehr als 20 Jahren analysiert. Der Anteil von <TextGroup><Mark2>Staphylococcus</Mark2></TextGroup><Mark2> aureus</Mark2>, der aus den Abstrichen angezüch<TextGroup><PlainText>t</PlainText></TextGroup>et wurde, betrug 7,7%. Dabei stieg der Anteil von MRSA an den <Mark2>Staphylococcus-aureus</Mark2>-Isolaten von 1,7% (1990–1999) auf 26,8% (2006–2010) <TextLink reference="71"></TextLink>, wobei diese Situation spezifisch für die USA ist und nicht auf Deutschland übertragen werden kann. Dennoch sollte bei entsprechendem Risiko und schwerem Krankheitsbild der Einsatz von Vancomycin oder Linezolid in Kombination mit Meropenem, Ceftazidim oder Ciprofloxacin in Erwägung gezogen werden. </Pgraph><Pgraph>Orbitale (60–75%), intrakranielle (15–20%) und ossäre Komplikationen (5–10%), die sehr viel häufiger in Folge akuter als chronischer Rhinosinusitiden auftreten, müssen zwingend mit parenteralen Antibiotika behandelt werden <TextLink reference="64"></TextLink>.</Pgraph><SubHeadline>Orbitale Komplikationen von Sinusitiden</SubHeadline><Pgraph>Orbitale Komplikationen entstehen entweder über eine direkte Entzündungsausbreitung durch die Lamina papyracea oder durch Fortleitung über Venen. Abweichend von der lange gebräuchlichen Unterteilung nach Chandler, bei der präseptale Lidphlegmone, Orbitaphlegmone, subperiostaler Abszess, intraorbitaler Abszess und die septische Thrombose des Sinus cavernosus als stadienhafter Ablauf verstanden wurden <TextLink reference="72"></TextLink>, versteht man die präseptale Lidphlegmone und die septische Thrombose des Sinus cavernosus heute eher als eigenständige Entitäten <TextLink reference="64"></TextLink>.</Pgraph><Pgraph>Reine Lidphlegmonen entstehen meist nicht in Folge von Sinusitiden, sondern sehr viel häufiger im Rahmen von Infekten der oberen Atemwege, bei Dakryoadenitis oder Hautinfektionen. Eine umgehende Mitbeurteilung durch einen Augenarzt ist zu empfehlen. Wurden eine Proptosis, Einschränkungen der Bulbusmotilität und Sehstörungen (Beginn mit Verlust der Rot-Grün-Diskrimination) ausgeschlossen, kann bei geringer Krankheitsausprägung ohne Bildgebung eine ambulante Behandlung mit oralen Antibiotika erfolgen. Die schweren postseptalen Infektionen sind mit einem Anteil von ca. 20% sehr viel seltener als präseptale Lidphlegmonen (ca. 80%) <TextLink reference="73"></TextLink>, <TextLink reference="74"></TextLink>. Im Zweifel oder bei den genannten Zeichen für das Vorliegen einer Entzündung des Orbitainhalts ist umgehend eine stationäre Aufnahme und parentale Antibiotika-Therapie einzuleiten und eine kontrastmittelverstärkte CT oder MRT anzufertigen <TextLink reference="64"></TextLink>. </Pgraph><Pgraph>Die häufigsten Erreger sind <Mark2>Staphylococcus aureus</Mark2>, Streptokokken der <Mark2>Streptococcus-anginosus</Mark2>-Gruppe und Anaerobier. Seltener, aber regelmäßig isoliert werden auch <Mark2>Streptococcus pyogenes</Mark2>, <Mark2>Streptococcus pneumoniae</Mark2>, <Mark2>Haemophilus influenzae</Mark2> und <Mark2>Eikenella corrodens</Mark2>. Vereinzelt werden auch <Mark2>Pseudomonas aeruginosa</Mark2>, <Mark2>Escherichia coli</Mark2>, <Mark2>Klebsiella pneumoniae</Mark2>, <Mark2>Clostridium perfringens</Mark2> und <Mark2>Arcanobacterium haemolyticum</Mark2> angezüchtet <TextLink reference="73"></TextLink>, <TextLink reference="74"></TextLink>, <TextLink reference="75"></TextLink>, <TextLink reference="76"></TextLink>, <TextLink reference="77"></TextLink>, <TextLink reference="78"></TextLink>, <TextLink reference="79"></TextLink>, <TextLink reference="80"></TextLink>, <TextLink reference="81"></TextLink>, <TextLink reference="82"></TextLink>.</Pgraph><Pgraph>Die antimikrobielle Behandlung soll initial hochdosiert mit Amoxicillin/Clavulansäure, Ampicillin/Sulbactam (Empfehlungsgrad A) oder Cefotaxim bzw. Ceftriaxon + Clindamycin (Empfehlungsgrad B) erfolgen. Bei Penicillin-Allergie bietet sich z.B. die Kombination von Ciprofloxacin + Clindamycin an (Empfehlungsgrad B). Je nach Ansprechen der Therapie kann eine rasche Oralisierung der Medikation erfolgen <TextLink reference="83"></TextLink>. Ciprofloxacin und Clindamycin können in ausgewählten Fällen auch oral verabreicht werden <TextLink reference="84"></TextLink>. Die Dauer der Antibiotika-Therapie beträgt insgesamt ca. 3 Wochen.</Pgraph><Pgraph>In der Regel besteht zudem die Indikation für ein chirurgisches Vorgehen mit Sanierung des Nebenhöhlenfokus und ggf. Drainage orbitaler Abszesse. Dabei sollte das gewonnene Material mikrobiologisch untersucht und die Therapie gezielt fortgesetzt werden. Bei Kindern unter 2(–4) Jahren ohne Abszess oder mit kleinen, medial gelegenen Abszessen und normalem Visus, die rasch auf die Antibiotika-Therapie ansprechen, kann auch die alleinige konservative Therapie ausreichend sein <TextLink reference="64"></TextLink>.</Pgraph><SubHeadline>Intrakranielle Komplikationen von Sinusitiden</SubHeadline><Pgraph>Über direkte Erosion der Schädelbasis, Fortleitung über Diploe-Venen oder durch hämatogene Streuung können im Rahmen von Sinusitiden epidurale und subdurale Abszesse, Meningitis, Cerebritis und Hirnabszesse sowie septische Thrombosen des Sinus sagittalis superior oder Sinus cavernosos auftreten. Die häufigsten Erreger sind Streptokokken-Arten (v.a. Streptokokken der <Mark2>Streptococcus-anginosus</Mark2>-Gruppe) und Anaerobier, seltener Staphylokokken <TextLink reference="85"></TextLink>, <TextLink reference="86"></TextLink>, <TextLink reference="87"></TextLink>, <TextLink reference="88"></TextLink>, <TextLink reference="89"></TextLink>. Therapeutisch sind eine parenterale Antibiotika-Therapie, die chirurgische Sanierung der betroffenen Nebenhöhlen und – bei Vorliegen von Abszessen – eine neurochirurgische Abszessdrainage, jeweils mit mikrobiologischer Erregerdiagnostik, indiziert <TextLink reference="5"></TextLink>, <TextLink reference="64"></TextLink>. Als kalkulierte Therapie der ersten Wahl kommen Cefotaxim oder Ceftriaxon, jeweils in Kombination mit Metronidazol und Linezolid, in Betracht <TextLink reference="5"></TextLink>. Bei einer Allergie gegen Beta-Lactame kann als Alternative zu Cefotaxim/Ceftriaxon Levofloxacin eingesetzt werden. Die Therapiedauer beträgt 30–60 Tage.</Pgraph><SubHeadline>Ossäre Komplikationen von Sinusitiden, Stirnbeinosteomyelitis</SubHeadline><Pgraph>Die Stirnbeinosteomyelitis kann nach akuter oder chronischer Sinusitis, dentalen Infektionen des Oberkiefers oder nach Trauma auftreten. Sie tritt vornehmlich bei Jugendlichen auf und ist häufig mit intrakraniellen Komplikationen vergesellschaftet. Häufigste Erreger sind <Mark2>Staphylococcus aureus</Mark2>, <Mark2>Streptococcus pneumoniae</Mark2>, und beta-hämolysierende Streptokokken (v.a. der <Mark2>Streptococ</Mark2><TextGroup><Mark2>c</Mark2></TextGroup><Mark2>us-anginosus</Mark2>-Gruppe), <Mark2>Haemophilus influenzae</Mark2> und Anaerobier. Es wurden aber auch Infektionen beschrieben, die durch <Mark2>Pseudomonas aeruginosa</Mark2>, <Mark2>Serratia marcescens</Mark2>, <Mark2>Escherichia coli</Mark2>, <Mark2>Salmonella typhi</Mark2>, <Mark2>Pasteurella multocida</Mark2> oder Pilze (<Mark2>Aspergillus flavus</Mark2> und Mucor) verursacht worden sind <TextLink reference="90"></TextLink>, <TextLink reference="91"></TextLink>.</Pgraph><Pgraph>Die antimikrobielle Behandlung sollte initial hochdosiert mit Amoxicillin/Clavulansäure, Ampicillin/Sulbactam, Cefotaxim oder Ceftriaxon (jeweils in Kombination mit Clindamycin) oder mit Meropenem erfolgen. Bei Penicillin-Allergie kann Moxifloxacin in Kombination mit Clindamycin (CAVE: Resistenzen bei Staphylokokken) zum Einsatz kommen. </Pgraph><Pgraph>Es besteht zudem die Indikation zur operativen Sanierung der betroffenen Stirnhöhle und der Entnahme befallener Knochenregionen. Punktionsmaterial aus dem Sinus, das Sekret der chirurgischen Drainage und Blut für die mikrobiologisch Untersuchung sind unbedingt zu entnehmen. Nach dem Erhalt sollte eine den mikrobiologischen <TextGroup><PlainText>Befunden</PlainText></TextGroup> entsprechende gezielte Antibiotika-Therapie durchgeführt werden. Die Behandlung erfolgt über einen Zeitraum von etwa 6 Wochen.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Bacterial sinusitis and its complications">
<MainHeadline>Bacterial sinusitis and its complications</MainHeadline><Pgraph>Only in severe cases or without spontaneous healing should acute rhinosinusitis be treated with antibiotics, which are then administered primarily orally (recommendation grade A) <TextLink reference="63"></TextLink>, <TextLink reference="64"></TextLink>. In individual cases, indication for parenteral treatment may exist in patients with severe concomitant diseases, unusually severe progression or in the absence of improvement after oral antibiotic treatment. In such cases differential diagnostics should investigate the possibility of an invasive mycosis or non-infectious disease (such as granulomatous polyangiitis, early stage Wegener’s granulomatosis) and the indication for surgical intervention should be considered. With calculated parenteral antibiotic treatment, the most important causative agents of acute rhinosinusitis – <Mark2>Streptococcus pneumoniae</Mark2>, <Mark2>Haemophilus influenzae</Mark2>, <Mark2>Moraxella catarrhalis</Mark2>, <Mark2>Streptococcus pyogenes</Mark2>, <Mark2>Staphylococcus aureus</Mark2> and, in the case of a dentogenic cause, also various other streptococci and anaerobes <TextLink reference="64"></TextLink> should be covered. In Germany, treatment with amoxicillin/clavulanic acid, ampicillin/sulbactam, cefotaxime or ceftriaxone + clindamycin; or moxifloxacin or, in the case of poorer anaerobic activity, levofloxacin is recommended. In patients with cystic fibrosis <TextLink reference="65"></TextLink> and patients undergoing bone marrow transplantation <TextLink reference="66"></TextLink>, <Mark2>Pseudomonas aeruginosa</Mark2> must be considered a possible pathogen. In these cases, the use of piperacillin/tazobactam, ceftazidime + clindamycin or meropenem makes sense.</Pgraph><Pgraph>The various forms of chronic sinusitis are generally not treated with antibiotics but with topical steroids (recommendation grade A) and nasal irrigation. In the instance of primarily very pronounced cases or those that cannot be treated conservatively, surgical intervention should be considered. In the case of an odontogenic cause, the primary goal should be restoration of the dentogenic source. Concomitant oral antibiotic treatment may be useful in acute exacerbations (grade B recommendation) or with markedly purulent forms. In contrast, parenteral treatment should be reserved for patients with severe comorbidities or unusually severe progression. Since in chronic sinusitis there are numerous species of bacteria which may be the pathogen in question, treatment should be as targeted as possible. Commonly isolated pathogens include <Mark2>Staphylococcus aureus</Mark2>, streptococci, <Mark2>Haemophilus influenzae</Mark2>, various Enterobacteriaceae species (<Mark2>Escherichia coli</Mark2>, <Mark2>Klebsiella pneumoniae</Mark2>, <Mark2>Klebsiella oxytoca</Mark2>, <Mark2>Serratia marcescens</Mark2>, <Mark2>Proteus mirabilis</Mark2>), <Mark2>Pseudomonas aeruginosa</Mark2> and anaerobes <TextLink reference="67"></TextLink>, <TextLink reference="68"></TextLink>, <TextLink reference="69"></TextLink>, <TextLink reference="70"></TextLink>. In calculated treatment, piperacillin/tazobactam, ceftazidime + clindamycin or levofloxacin or moxifloxacin can be used. </Pgraph><Pgraph>The pathogen spectrum of odontogenic maxillary sinusitis is easier to calculate. Most are mixed infections caused by streptococci and anaerobes. <Mark2>Moraxella</Mark2> spp. and <Mark2>Haemophilus</Mark2> spp. are involved. Calculated treatment, which accompanies source control, is carried out either with amoxicillin/clavulanic acid, ampicillin/sulbactam or clindamycin <TextLink reference="70"></TextLink>. In addition to antibiotic treatment – at the latest after disappearance of the acute symptoms – surgical restoration pf the odontogenic cause and possibly closure of a possibly present oral antrum connection is necessary.</Pgraph><Pgraph>With a corresponding risk history, multidrug-resistant pathogens must be expected in acute as well as in chronic sinusitis. In a retrospective study by Stanford University, paranasal sinus smears were analyzed over a period of just over than 20 years. The proportion of <Mark2>Staphylococcus aureus</Mark2> grown from the smears was 7.7%. The proportion of MRSA in the <Mark2>Staphylococcus aureus</Mark2> isolates increased from 1.7% (1990–1999) to 26.8% (2006–2010) <TextLink reference="71"></TextLink>, which is specific to the US and cannot be translated to Germany. Nevertheless, the use of vancomycin or linezolid in combination with meropenem, ceftazidime or ciprofloxacin should be considered if the risk and condition are severe. </Pgraph><Pgraph>Orbital (60–75%), intracranial (15–20%) and bony complications (5–10%), which occur much more frequently as a result of acute rather than chronic rhinosinusitis, must be treated with parenteral antibiotics <TextLink reference="64"></TextLink>.</Pgraph><SubHeadline>Orbital complications of sinusitis</SubHeadline><Pgraph>Orbital complications arise either through direct spread of inflammation through the lamina papyracea or through conduction in the veins. Deviating from the long-standing division according to Chandler, in which preseptal lid phlegmons, orbital cellulitis, subperiosteal abscesses, intraorbital abscesses and septic thrombosis of the cavernous sinus were understood as a stage-related progression <TextLink reference="72"></TextLink>, the preseptal lid phlegmon and septic thrombosis of the cavernous sinus are understood today as independent entities instead <TextLink reference="64"></TextLink>.</Pgraph><Pgraph>Pure eyelid phlegmons arise mostly not as a result of sinusitis but much more often in the context of infections of the upper respiratory tract, in dacryoadenitis or skin infections. Immediate assessment by an ophthalmologist is recommended. If proptosis, restriction of bulbus motility and visual disturbances (beginning with loss of red-green discrimination) have been excluded, in cases of low illness severity outpatient treatment with oral antibiotics may be used without resorting to imaging techniques. Severe postseptal infections are much rarer than preseptal eyelid phlegmons (about 80%) with a proportion of about 20% <TextLink reference="73"></TextLink>, <TextLink reference="74"></TextLink>. In case of doubt or in the case of signs of an inflammation of the orbital contents, inpatient admission and parental antibiotic treatment should be initiated immediately and a contrast-enhanced CT or MRI should be performed <TextLink reference="64"></TextLink>. </Pgraph><Pgraph>The most common pathogens are <Mark2>Staphylococcus aureus</Mark2>, streptococci of the <Mark2>Streptococcus anginosus</Mark2> group and anaerobes. <Mark2>Streptococcus pyogenes</Mark2>, <Mark2>Streptococcus pneumoniae</Mark2>, <Mark2>Haemophilus influenzae</Mark2> and <Mark2>Eikenella corrodens</Mark2> are rarely but regularly isolated. <Mark2>Pseudomonas aeruginosa</Mark2>, <Mark2>Escherichia coli</Mark2>, <Mark2>Klebsiella pneumoniae</Mark2>, <Mark2>Clostridium perfringens</Mark2> and <Mark2>Arcanobacterium haemolyticum</Mark2> are also isolated <TextLink reference="73"></TextLink>, <TextLink reference="74"></TextLink>, <TextLink reference="75"></TextLink>, <TextLink reference="76"></TextLink>, <TextLink reference="77"></TextLink>, <TextLink reference="78"></TextLink>, <TextLink reference="79"></TextLink>, <TextLink reference="80"></TextLink>, <TextLink reference="81"></TextLink>, <TextLink reference="82"></TextLink>.</Pgraph><Pgraph>Antimicrobial treatment is initially high-dose with amoxicillin/clavulanic acid, ampicillin/sulbactam (recommendation grade A) or cefotaxime or ceftriaxone + clindamycin (recommendation grade B). In cases of penicillin allergy, combination of ciprofloxacin + clindamycin (recommendation grade B) is an option. Depending on the response to the treatment, changing quickly to oral administration of the medication may be possible <TextLink reference="83"></TextLink>. Ciprofloxacin and clindamycin may also be administered orally in selected cases <TextLink reference="84"></TextLink>. The duration of antibiotic treatment is about 3 weeks in total.</Pgraph><Pgraph>In general, there is also an indication for surgical intervention with restoration of the sinus source and possibly drainage of orbital abscesses. The obtained material should be microbiologically examined and the treatment continued in a targeted manner. In children younger than 2(–4) without abscess or with small medial abscesses and normal visual acuity who are responding rapidly to antibiotic treatment, conservative treatment alone may be sufficient <TextLink reference="64"></TextLink>.</Pgraph><SubHeadline>Intracranial complications of sinusitis</SubHeadline><Pgraph>Epidural and subdural abscesses, meningitis, cerebritis and cerebral abscesses as well as septic thromboses of the superior sagittal sinus or cavernous sinus may occur in sinusitis through direct erosion of the skull base, <TextGroup><PlainText>conduction</PlainText></TextGroup> via diploic veins or by hematogenous scattering. The most common pathogens are streptococci (mainly streptococci of the <Mark2>Streptococcus anginosus</Mark2> group) and anaerobes, more rarely staphylococci <TextLink reference="85"></TextLink>, <TextLink reference="86"></TextLink>, <TextLink reference="87"></TextLink>, <TextLink reference="88"></TextLink>, <TextLink reference="89"></TextLink>. Therapeutically, parenteral treatment with antibiotics, surgical restoration of the affected sinuses and – in the presence of abscesses – neurosurgical abscess drainage, each alongside microbiological pathogen diagnostics, is indicated <TextLink reference="5"></TextLink>, <TextLink reference="64"></TextLink>. Cefotaxime or ceftriaxone, both in combination with metronidazole and linezolid, can be considered as first choice drugs in calculated treatment <TextLink reference="5"></TextLink>. Those allergic to beta-lactams may be treated with levofloxacin as an alternative to ce<TextGroup><PlainText>f</PlainText></TextGroup>otaxime/ceftriaxone. The duration of treatment is <TextGroup><PlainText>30–60 days</PlainText></TextGroup>.</Pgraph><SubHeadline>Osseous complications of sinusitis, frontal osteomyelitis</SubHeadline><Pgraph>Frontal osteomyelitis can occur after acute or chronic sinusitis, dental maxillary infections or after trauma. It occurs primarily in adolescents and is often associated with intracranial complications. The most common pathogens are <Mark2>Staphylococcus aureus</Mark2>, <Mark2>Streptococcus pneumoniae</Mark2> and beta-hemolytic streptococci (of the <Mark2>Streptococcus anginosus</Mark2> group in particular), <Mark2>Haemophilus influenzae</Mark2> and anaerobes. However, infections caused by <Mark2>Pseudomonas aeruginosa</Mark2>, <Mark2>Serratia marcescens</Mark2>, <Mark2>Escherichia coli</Mark2>, <Mark2>Salmonella typhi</Mark2>, <Mark2>Pasteurella multocida</Mark2> or fungi (<Mark2>Aspergillus flavus</Mark2> and Mucor) have also been described <TextLink reference="90"></TextLink>, <TextLink reference="91"></TextLink>.</Pgraph><Pgraph>Antimicrobial treatment should be initially high-dose with amoxicillin/clavulanic acid, ampicillin/sulbactam, cefotaxime or ceftriaxone (in combination with clindamycin) or with meropenem. In cases of penicillin allergy, moxifloxacin in combination with clindamycin is used (<TextGroup><PlainText>BEWARE</PlainText></TextGroup>: resistances in staphylococci). </Pgraph><Pgraph>There is also the indication for surgical restoration of the affected frontal sinus and the removal of infested bone regions. Sinus puncture material, surgical drainage secretion and bloods are essential for microbiological examination. Upon receipt, targeted antibiotic treatment should be performed in accordance with the microbiological findings. Treatment takes place over a period of about <TextGroup><PlainText>6 weeks</PlainText></TextGroup>.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Odontogene Infektionen mit Ausbreitungstendenz, ggf. mit lokalen oder systemischen Komplikationen">
<MainHeadline>Odontogene Infektionen mit Ausbreitungstendenz, ggf. mit lokalen oder systemischen Komplikationen</MainHeadline><Pgraph>Die meisten odontogenen Infektionen können erfolgreich chirurgisch ambulant, ohne Antibiotika-Einsatz, therapiert werden. Bei Ausbreitungstendenz der Infektion oder Risikofaktoren der Patienten kann eine kalkulierte orale Antibiotika-Therapie zum Einsatz kommen <TextLink reference="92"></TextLink>. Für diese unkomplizierten odontogenen Infektionen ist ein Erregernachweis in der zahnärztlichen Praxis nicht sinnvoll zu fordern <TextLink reference="93"></TextLink>. Bei schweren odontogenen Infektionen mit Ausbreitungstendenz und dem Risiko von lokalen und systemischen Komplikationen, die parenteral therapiert werden müssen, ist der Erregernachweis jedoch unverzichtbar, da die Therapie im Falle einer Ausbreitung oder Komplikation dann gezielt erfolgen kann <TextLink reference="94"></TextLink>, <TextLink reference="95"></TextLink>, <TextLink reference="96"></TextLink>. Als typische aerobe Erreger, auch geschlossener Abszesse, findet man meist Streptokokken der Mundflora, seltener Staphylokokken. Anaerobe bzw. capnophile Erreger wie <Mark2>Prevotella</Mark2> spp., Fusobakterien, Bacteroides-Arten, Veillonellen und Peptostreptokokken sind häufig <TextLink reference="97"></TextLink>, <TextLink reference="98"></TextLink>.</Pgraph><Pgraph>Die Daten der meisten, aber insgesamt wenigen Studien weisen aus, dass sich bei nicht vorbehandelten Patienten mit odontogenen Infektionen meist Erreger mit geringer Resistenzhäufigkeit gegen Penicillin und Clindamycin finden <TextLink reference="94"></TextLink>, <TextLink reference="99"></TextLink>, <TextLink reference="100"></TextLink>. Andere Autoren berichten jedoch über einen 20%-igen Anteil Penicillin-resistenter Erreger <TextLink reference="101"></TextLink>. Bei komplizierten, antibiotisch vorbehandelten odontogenen Infektionen, die der parenteralen Therapie bedürfen, wurden in 15–35% der Fälle Penicillinase-pro<TextGroup><PlainText>d</PlainText></TextGroup>uzierende Erreger <TextLink reference="102"></TextLink>, <TextLink reference="103"></TextLink>, <TextLink reference="104"></TextLink> sowie teils kritisch hohe Resistenzraten für Clindamycin von 25–45% gefunden <TextLink reference="102"></TextLink>, <TextLink reference="103"></TextLink>, <TextLink reference="104"></TextLink>, <TextLink reference="105"></TextLink>. Dabei scheint insbesondere die Antibiotika-Vorbehandlung ein Risikofaktor für das Vorkommen Penicillin-resistenter Erreger zu sein <TextLink reference="106"></TextLink>, <TextLink reference="107"></TextLink>. Bei schweren odontogenen Weichgewebeinfektionen, die bereits antibiotisch vorbehandelt wurden, muss demnach mit einem höheren Anteil von Isolaten mit Resistenz gegen Penicillin und Clindamycin gerechnet werden. Aus den oben genannten Daten ergibt sich, dass nahezu alle Erreger im odontogenen Bereich gegenüber Inhibitor-geschützten Penicillinen (z.B. Amoxicillin/Clavulansäure) empfindlich sind. Bei der Beurteilung der Resistenzsituation sollte jedoch bedacht werden, dass die pathogenetische Rolle der identifizierten Bakterien nicht geklärt ist. In lebensbedrohlichen Situationen sind Carbapeneme Mittel der Wahl zur empirischen Therapie <TextLink reference="101"></TextLink>, <TextLink reference="108"></TextLink>, <TextLink reference="109"></TextLink>. Bei Vorliegen einer Allergie auf Beta-Lactame sollte Clindamycin in Monotherapie, unter den oben genannten Einschränkungen, als etablierte Alternative eingesetzt werden. Moxifloxacin ist eine weitere mögliche Alternative <TextLink reference="105"></TextLink>, <TextLink reference="110"></TextLink>. Es wird hierzu auf die AWMF <TextGroup><PlainText>S3 L</PlainText></TextGroup>eitlinie „Odontogene Infektionen“ (Registernummer <TextGroup><PlainText>007-006</PlainText></TextGroup>) verwiesen <TextLink reference="3"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Odontogenic infections with a tendency to spread, possibly with local or systemic complications">
<MainHeadline>Odontogenic infections with a tendency to spread, possibly with local or systemic complications</MainHeadline><Pgraph>Most odontogenic infections can be successfully treated with outpatient surgery without antibiotics. If the infection spreads or in case of patients with risk factors, calculated oral antibiotic treatment may be used <TextLink reference="92"></TextLink>. It makes little sense to call for pathogen identification in dental practice in such uncomplicated odontogenic infections <TextLink reference="93"></TextLink>. In severe odontogenic infections with a tendency to spread and the risk of local and systemic complications which must be treated parenterally, pathogen identification is indispensable, since in the event of a spread or complication treatment can then be targeted <TextLink reference="94"></TextLink>, <TextLink reference="95"></TextLink>, <TextLink reference="96"></TextLink>. Mostly streptococci of the oral flora are found, more rarely staphylococci as typical aerobic pathogens, even in closed abscesses. Anaerobic or capnophilic pathogens such as <Mark2>Prevotella</Mark2> spp., Fusobacteria, Bacteroides species, Veillonella and Peptostreptococci are common <TextLink reference="97"></TextLink>, <TextLink reference="98"></TextLink>.</Pgraph><Pgraph>The data from most of the few existing studies show that pathogens with low resistance to penicillin and clinda<TextGroup><PlainText>my</PlainText></TextGroup>cin are usually found in patients with odontogenic infections who have not been previously treated <TextLink reference="94"></TextLink>, <TextLink reference="99"></TextLink>, <TextLink reference="100"></TextLink>. However, other authors report a 20% share of penicillin-resistant pathogens <TextLink reference="101"></TextLink>. In complicated odontogenic infections in patients who have been previously treated and which require parenteral treatment, in 15–35% of cases penicillinase-producing pathogens were found <TextLink reference="102"></TextLink>, <TextLink reference="103"></TextLink>, <TextLink reference="104"></TextLink> and in some cases critically high resistance rates to clindamycin of 25–45% <TextLink reference="102"></TextLink>, <TextLink reference="103"></TextLink>, <TextLink reference="104"></TextLink>, <TextLink reference="105"></TextLink>. Prior treatment with antibiotics in particular seems to be a risk factor for the occurrence of penicillin-resistant pathogens <TextLink reference="106"></TextLink>, <TextLink reference="107"></TextLink>. For severe odontogenic soft tissue infections that have already been pretreated with antibiotics, a higher proportion of isolates with resistance to penicillin and clindamycin must therefore be expected. From the above data it appears that almost all pathogens in the odontogenic region are sensitive to inhibitor-protected penicillins (such as amoxicillin/clavulanic acid). When assessing the resistance situation, however, one should bear in mind that the pathogenetic role of the identified bacteria has not been clarified. In life-threatening situations, carbapenems are the drug of choice for empirical treatment <TextLink reference="101"></TextLink>, <TextLink reference="108"></TextLink>, <TextLink reference="109"></TextLink>. If allergy to beta-lactams is present, clindamycin should be used as an established alternative in monotherapy, with the above limitations. Moxifloxacin is another possible alternative <TextLink reference="105"></TextLink>, <TextLink reference="110"></TextLink>. Note in this context the AWMF S3 guideline “Odontogenic infections” (registration number 007-006) <TextLink reference="3"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Osteomyelitis der Kiefer">
<MainHeadline>Osteomyelitis der Kiefer</MainHeadline><Pgraph>Wichtigste Formen mit bakterieller Ursache sind die akute und sekundär chronische Osteomyelitis (odontogene Infektion, pulpale und parodontale Infektion, infizierte Extraktionswunden) mit Austritt von Eiter, Fistel- und Sequesterbildung. Entsprechend findet sich ein ähnliches Erregerspektrum wie bei der odontogenen Infektion, mit einem hohen Anteil an polymikrobiellen Infektionen <TextLink reference="111"></TextLink>. Oft werden aber auch Actinomyzeten nachgewiesen <TextLink reference="112"></TextLink>, <TextLink reference="113"></TextLink>. Insbesondere bei längerer Antibiotika-Vortherapie sind auch Besiedelungen bzw. Infektionen mit multiresistenten grampositiven Erregern beschrieben <TextLink reference="114"></TextLink>, <TextLink reference="115"></TextLink>. Akute und sekundär chronische Osteomyelitiden werden sowohl chirurgisch als auch antibiotisch therapiert. Davon zu unterscheiden ist die seltenere primär chronische Osteomyelitis als nicht pustulierende und chronische Inflammation unklarer Ätiologie, wobei bei dieser Form der Osteomyelitis neben der chirurgischen Therapie Antibiotika, die hyperbare Sauerstofftherapie, nichtsteroidale Antiphlogistika und Glukokortikoide zum Einsatz kommen <TextLink reference="116"></TextLink>. </Pgraph><Pgraph>Sonderformen der Osteomyelitis, wie die infizierte Osteoradionekrose oder durch Medikamente wie Bisphosphonate, Kortikosteroide und antineoplastische Substanzen induzierte Osteomyelitiden, haben wegen ihrer Häufigkeit und Genese eine besondere Bedeutung. Die Erkrankungen werden zwar nicht primär durch Bakterien verursacht, die bakterielle Superinfektion erfordert jedoch fast immer eine möglichst gezielte, adjuvante Therapie. Wegen der Schwere des Krankheitsbildes erfolgt die initiale Antibiotika-Therapie meist intravenös <TextLink reference="117"></TextLink>. Dass Erregerspektrum weist ebenfalls Ähnlichkeit mit dem der odontogenen Infektionen auf <TextLink reference="118"></TextLink>.</Pgraph><Pgraph>Das Prinzip der Osteomyelitis-Therapie besteht aus einer Eradikation des Fokus, einer Abtragung des infizierten und nekrotischen Knochens sowie einer empirischen, im Optimum erregerspezifischen Antibiotika-Therapie. Wegen des langwierigen Verlaufs ist meist eine parenterale Therapie erforderlich. Insbesondere bei der chronischen Form sind seit vielen Jahren Gentamicin enthaltende PMMA Ketten erfolgreich im Einsatz <TextLink reference="119"></TextLink>. Die adjuvante antimikrobielle Therapie sollte neben den häufig isolierten Staphylokokken das anaerobe Erregerspektrum berücksichtigen <TextLink reference="120"></TextLink>. Empfohlen werden Clindamycin oder Penicillin, nach Vorbehandlung finden sich allerdings häufiger Erreger mit Penicillin-Resistenz <TextLink reference="111"></TextLink>. Wegen des möglicherweise langen und kritischen Verlaufs sollte grundsätzlich eine Erregerdiagnostik angestrebt werden. Einige Autoren empfehlen, dass die Antibiotika-Gabe generell noch 4–6 Wochen nach der Operation oral weitergeführt werden sollte <TextLink reference="116"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Osteomyelitis of the jaw">
<MainHeadline>Osteomyelitis of the jaw</MainHeadline><Pgraph>The most important forms with a bacterial cause are acute and secondary chronic osteomyelitis (odontogenic infection, pulpal and periodontal infection, infected extraction wounds) with leakage of pus, fistula and sequestration. Accordingly, there is a similar pathogen spectrum compared to odontogenic infections, with a high proportion of polymicrobial infections <TextLink reference="111"></TextLink>. Actinomycetes are also often detected <TextLink reference="112"></TextLink>, <TextLink reference="113"></TextLink>. Colonization or infection with multidrug-resistant Gram-positive pathogens has also been described in prolonged antibiotic pretreatment <TextLink reference="114"></TextLink>, <TextLink reference="115"></TextLink>. Acute and secondary chronic osteomyelitis are treated both surgically and with antibiotics. This is to be distinguished from the rarer primary chronic osteomyelitis as a non-pustulant and chronic inflammation of unclear aetiology. In this form of osteomyelitis antibiotics, hyperbaric oxygen therapy, nonsteroidal anti-inflammatory drugs and glucocorticoids are used in addition to surgery <TextLink reference="116"></TextLink>. </Pgraph><Pgraph>Special forms of osteomyelitis, such as infected osteora<TextGroup><PlainText>d</PlainText></TextGroup>ionecrosis or osteomyelitis induced by drugs such as bisphosphonates, corticosteroids and antineoplastic substances, are of particular importance because of their frequency and origin. Although the diseases are not primarily caused by bacteria, the bacterial superinfection almost always requires the most targeted adjuvant treatment possible. Because of the severity of the disease, initial antibiotic treatment is usually intravenous <TextLink reference="117"></TextLink>. The pathogen spectrum is also similar to that of odontogenic infections <TextLink reference="118"></TextLink>.</Pgraph><Pgraph>The principle of osteomyelitis treatment consists of eradication of the source, removal of the infected and necrotic bone and empirical treatment, ideally with a pathogen-specific antibiotic. Because of the protracted progression, parenteral treatment is usually required. PMMA chains containing gentamicin have been used successfully for many years, especially in the chronic form <TextLink reference="119"></TextLink>. Adjuvant antimicrobial treatment should consider the anaerobic pathogen spectrum in addition to the commonly isolated staphylococci <TextLink reference="120"></TextLink>. Clindamycin or penicillin are recommended, however, after prior treatment pathogens with penicillin resistance are found more frequently <TextLink reference="111"></TextLink>. Because of the potentially long and critical progression, pathogen diagnosis should always be sought. Some authors recommend that antibiotics should generally be continued orally for 4–6 weeks after surgery <TextLink reference="116"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Zervikofaziale Aktinomykose">
<MainHeadline>Zervikofaziale Aktinomykose</MainHeadline><Pgraph>Die sich meist als Mischinfektion mit dem Leiterreger <Mark2>Actinomyces israeli</Mark2> präsentierende Erkrankung ist mit Antibiotika gut zu therapieren <TextLink reference="121"></TextLink>, <TextLink reference="122"></TextLink>. Je nach Befund ist zusätzlich eine chirurgische Maßnahme nötig. Wichtig ist der mikrobiologische Befund oder zumindest die histologische Sicherung der <Mark2>Actinomyces</Mark2>-Drusen. Actinomyzeten sind typischerweise Penicillin-empfindlich. Penicillin wird Initial häufig parenteral verabreicht und im Verlauf auf eine orale Therapie umgestellt. Im Fall einer Penicillin-Allergie empfiehlt sich eine orale Sequenztherapie mit Doxycyclin oder die parenterale Gabe von Clindamycin oder eines Cephalosporins. Die Bedeutung der obligat anaeroben Begleitflora ist umstritten <TextLink reference="122"></TextLink>, <TextLink reference="123"></TextLink>. Die Therapie muss, wie bei anderen chronischen Entzündungen, und wegen der schlechten Penetration in das Granulationsgewebe über lange Zeit in hoher Dosierung durchgeführt werden. Daten zur Therapiedauer sind für die zervikofaziale Form bisher nicht erhoben worden. Eine Dauer von bis zu 6 Monaten wird bei komplizierten Formen erwogen. Bei leichten Verläufen oder ausreichender chirurgischer Sanierung wird eine Therapiedauer von ca. 6 Wochen empfohlen <TextLink reference="122"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Cervicofacial actinomycosis">
<MainHeadline>Cervicofacial actinomycosis</MainHeadline><Pgraph>The disease, which usually presents as a mixed infection with the pathogen <Mark2>Actinomyces israeli</Mark2>, can be treated well with antibiotics <TextLink reference="121"></TextLink>, <TextLink reference="122"></TextLink>. Depending on the findings, additional surgery may be necessary. The microbiological findings or at least the histological confirmation of <Mark2>Actinomyces</Mark2> drusen is important. Actinomycetes are typically penicillin-sensitive. Penicillin is often given parenterally initially and then switched to oral therapy. In the case of a penicillin allergy, oral sequential therapy with doxycycline or parenteral administration of clindamycin or a cephalosporin is recommended. The importance of the accompanying obligate anaerobic flora is controversial <TextLink reference="122"></TextLink>, <TextLink reference="123"></TextLink>. As with other chronic inflammations and because of poor penetration into the granulation tissue, treatment must be performed over a long time in high dosage. Data on the duration of treatment have not yet been collected for the cervicofacial form. A duration of up to 6 months is considered in complicated forms. For mild progressions or with sufficient surgical restoration, treatment duration of about 6 weeks is recommended <TextLink reference="122"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Sialadenitis">
<MainHeadline>Sialadenitis</MainHeadline><Pgraph>Die Sialadenitis ist eine bakteriell oder viral bedingte Entzündung der Speicheldrüsen. Sialadenitiden treten oft als Superinfektionen nach Speicheldrüsen-Funktions<TextGroup><PlainText>s</PlainText></TextGroup>törungen auf. Meist ist die Glandula submandibularis betroffen. Sekretionsstörungen der Speichel- und Schleimdrüsen verursachen eine Viskositätszunahme des Speichels, die die Ausfällung anorganischer Substanzen unterstützt. Es bilden sich Speichelsteine aus, die eine bakterielle Kolonisierung und Infektion begünstigen können; sie sollten in der chronischen Phase entfernt werden <TextLink reference="124"></TextLink>. Es werden akute und chronische Verlaufsformen unterschieden. Die Sialadenitis bei Kindern wird häufig durch Viren (meist Mumps-Viren, Parainfluenzae-Viren, CMV), während sie bei Erwachsenen eher durch Bakterien (Staphylokokken, Streptokokken und Anaerobier) ausgelöst wird. In neueren Publikationen finden sich Hinweise auf eine erhöhte Inzidenz von Infektionen durch <Mark2>Fusobacterium necrophorum</Mark2> (14%), insbesondere bei Vorliegen von Peritonsillarabszessen (91%) <TextLink reference="125"></TextLink>, <TextLink reference="126"></TextLink>. <Mark2>Fusobacterium necrophorum</Mark2> kann das schwere Krankheitsbild des Lemierre Syndroms verursachen. In der akuten Phase steht in den meisten Fällen eine konservative Therapie im Vordergrund. Wegen der oft vorliegenden Allgemeinsymptomatik sind nicht selten eine parenterale Therapie oder auch eine chirurgische Entlastung nötig, die in der Regel einen stationären Aufenthalt erfordern. Schwere bakterielle Infektionen müssen parenteral mit Antibiotika behandelt werden. Bei leichteren Infektionen ist auch eine orale Therapie möglich. In Studien aus dem Zeitraum 1975–1985 werden alpha-hämolysierende Streptokokken und Staphylokokken als hauptsächliche Erreger beschrieben <TextLink reference="127"></TextLink>, <TextLink reference="128"></TextLink>, <TextLink reference="129"></TextLink>. In einem neueren Case Report wird auf die Bedeutung von Anaerobiern bei der eitrigen Sialadenitis hingewiesen <TextLink reference="128"></TextLink>, <TextLink reference="129"></TextLink>. Es finden sich zwar auch Empfehlungen zum Einsatz von Cephalosporinen, die sich ähnlich wie Fluorchinolone im Speichel relevant anreichern <TextLink reference="130"></TextLink>, deren Wirksamkeit gegen mögliche Anaerobier jedoch beschränkt ist. Die häufige Penicillin-Resistenz von Erregern der Sialadenitis führt zur Empfehlung, ein Aminopenicillin in Kombination mit einem Beta-Lactamase-Inhibitor oder Clindamycin einzusetzen <TextLink reference="128"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Sialadenitis">
<MainHeadline>Sialadenitis</MainHeadline><Pgraph>Sialadenitis is a bacterial or viral inflammation of the salivary glands. Sialadenitis often occurs as a superinfection after salivary gland dysfunction. Mostly the submandibular gland is affected. Secretion disorders of the salivary and mucous glands cause an increase in the viscosity of the saliva, which promotes the precipitation of inorganic substances. Saliva stones form, which can promote bacterial colonization and infection; they should be removed in the chronic phase <TextLink reference="124"></TextLink>. Acute and chronic forms are distinguished. Sialadenitis in children is often caused by viruses (mostly mumps viruses, Parainfluenzae viruses, CMV), while in adults it is more likely to be caused by bacteria (staphylococci, streptococci and anaerobes). Recent publications have found evidence of an increased incidence of infection by Fusobacterium necrophorum (14%), especially in the presence of peritonsillar abscesses (91%) <TextLink reference="125"></TextLink>, <TextLink reference="126"></TextLink>. Fusobacterium necrophorum can cause the serious clinical presentation of Lemierre syndrome. In the acute phase, in most cases, the focus is on conservative treatment. Because of the general symptoms which are often present, parenteral treatment or surgical relief is often required, which usually requires hospitalization. Serious bacterial infections must be treated parenterally with antibiotics. For mild infections, oral treatment is also possible. Studies from the period 1975–1985 described alpha-hemolytic streptococci and staphylococci as the main pathogens <TextLink reference="127"></TextLink>, <TextLink reference="128"></TextLink>, <TextLink reference="129"></TextLink>. A recent case report highlights the importance of anaerobes in purulent sialadenitis <TextLink reference="128"></TextLink>, <TextLink reference="129"></TextLink>. There are also recommendations for the use of cephalosporins, which, similar to fluoroquinolones, accumulate in the saliva <TextLink reference="130"></TextLink> but their effectiveness against possible anaerobes is limited. The frequent penicillin resistance of sialadenitis pathogen leads to the recommendation to use aminopenicillin in combination with a beta-lactamase inhibitor or clindamycin <TextLink reference="128"></TextLink>.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Übersicht der Empfehlungen">
<MainHeadline>Übersicht der Empfehlungen</MainHeadline><Pgraph>In Tabelle 1 <ImgLink imgNo="1" imgType="table"/> werden die Therapieempfehlungen zusammenfassend dargestellt.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Summary of recommendations">
<MainHeadline>Summary of recommendations</MainHeadline><Pgraph>Table 1 <ImgLink imgNo="1" imgType="table"/> summarizes the treatment recommendations.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Anmerkung">
<MainHeadline>Anmerkung</MainHeadline><Pgraph>Dies ist das sechste Kapitel der von der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) herausgegebenen S2k Leitlinie „Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen – Update 2018“ in der 2. aktualisierten Fassung.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Note">
<MainHeadline>Note</MainHeadline><Pgraph>This is the sixth chapter of the guideline “Calculated initial parenteral treatment of bacterial infections in adults – update 2018” in the 2<Superscript>nd</Superscript> updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemothe<TextGroup><PlainText>r</PlainText></TextGroup>apie e.V. (PEG) has been translated to address an international audience.</Pgraph></TextBlock>
<TextBlock language="de" linked="yes" name="Interessenkonflikte">
<MainHeadline>Interessenkonflikte</MainHeadline><Pgraph>Die Autoren erklären, dass sie keine Interessenkonflikte in Zusammenhang mit diesem Artikel haben.</Pgraph></TextBlock>
<TextBlock language="en" linked="yes" name="Competing interests">
<MainHeadline>Competing interests</MainHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock>
<References linked="yes">
<Reference refNo="1">
<RefAuthor>Deutsche Gesellschaft für Mund-</RefAuthor>
<RefAuthor>Kiefer- und Gesichtschirurgie</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2008</RefYear>
<RefBookTitle>Osteomyelitis. Leitlinie. AWMF-Registernummer 007-045</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Deutsche Gesellschaft für Mund-, Kiefer- und Gesichtschirurgie. Osteomyelitis. Leitlinie. AWMF-Registernummer 007-045. AWMF; 2008.</RefTotal>
</Reference>
<Reference refNo="2">
<RefAuthor>Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde</RefAuthor>
<RefAuthor>Kopf- und Hals-Chirurgie</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2008</RefYear>
<RefBookTitle>Antibiotikatherapie der Infektionen an Kopf und Hals. Leitlinie. AWMF-Registernummer 017-066</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie. Antibiotikatherapie der Infektionen an Kopf und Hals. Leitlinie. AWMF-Registernummer 017-066. AWMF; 2008.</RefTotal>
</Reference>
<Reference refNo="3">
<RefAuthor>Deutsche Gesellschaft für Mund-Kiefer-Gesichtschirurgie</RefAuthor>
<RefAuthor> Deutsche Gesellschaft für Zahn-</RefAuthor>
<RefAuthor>Mund- und Kieferheilkunde (DGZMK)</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2016</RefYear>
<RefBookTitle>Odontogene Infektionen. S3-Leitlinie. AWMF-Registernummer 007-006</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Deutsche Gesellschaft für Mund-Kiefer-Gesichtschirurgie; Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK). Odontogene Infektionen. S3-Leitlinie. AWMF-Registernummer 007-006. 2016. Available from: http://www.awmf.org/uploads/tx_szleitlinien/007-006l_S3_Odontogene_Infektionen_2017-12.pdf</RefTotal>
<RefLink>http://www.awmf.org/uploads/tx_szleitlinien/007-006l_S3_Odontogene_Infektionen_2017-12.pdf</RefLink>
</Reference>
<Reference refNo="4">
<RefAuthor>Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde</RefAuthor>
<RefAuthor> Deutscher Berufsverband der Hals-Nasen-Ohrenärzte</RefAuthor>
<RefAuthor> Deutsche Gesellschaft für Kinder- und Jugendmedizin</RefAuthor>
<RefAuthor> Deutsche Gesellschaft für Pädiatrische Infektiologie</RefAuthor>
<RefTitle></RefTitle>
<RefYear></RefYear>
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