Résumé
La prévention des infections nosocomiales est un enjeu majeur dans les services de réanimation. La colonisation cutanée bactérienne précède fréquemment la survenue de ces infections, notamment les infections à staphylocoques. La chlorhexidine est un antiseptique topique bactéricide ayant une excellente activité vis-à-vis des cocci à Gram positif, des levures et une efficacité moindre vis-à-vis des bacilles à Gram négatif. La toilette quotidienne des patients à la chlorhexidine pourrait ainsi diminuer l’incidence des infections nosocomiales en diminuant la colonisation cutanée. Les premières études observationnelles ont mis en évidence une diminution du portage cutané à staphylocoque et à entérocoque. Une diminution du taux des bactériémies sur cathéter et des bactériémies primitives a également été reportée. Les études multicentriques randomisées, plus récentes, retrouvent une diminution des bactériémies à staphylocoques à coagulase négative. La toilette à la chlorhexidine n’est pas associée à une diminution de l’incidence des pneumonies acquises sous ventilation mécanique et des infections urinaires. Cette procédure n’entraîne pas de diminution des infections acquises à bacille Gram négatif. S’il ne semble pas exister de résistance à la chlorhexidine après une période d’application de quelques mois, une utilisation plus prolongée serait associée à des augmentations des concentrations minimales inhibitrices des souches de staphylocoques vis-à-vis de cet antiseptique. La toilette à la chlorhexidine pourrait être proposée dans les services de réanimation où l’incidence des bactériémies à Staphylocoques demeure importante.
Abstract
Prevention of health care-associated infection is a major concern in the intensive care unit. Bacterial skin colonization often precedes occurrence of these infections, especially infections related to staphylococcus species. Chlorhexidine is a topical bactericidal antiseptic with a good antimicrobial activity against Gram positive cocci, fungi but a limited activity against Gram negative rods. Daily chlorhexidine bathing may reduce the occurrence of nosocomial infection by decreasing skin bacterial load. The first observational studies have reported a decrease in skin colonization with staphylococcal or enterococcal species. A decrease in the rate of catheter-related bacteremia and primitive bacteremia has been also described. Multicenter randomized studies have reported a lower incidence of bacteremia caused by coagulase-negative staphylococci. Chlorhexidine bathing was not associated with a lower occurrence of ventilator-associated pneumonia and nosocomial urinary tract infections. This procedure was not associated with a lower incidence of infections caused by Gram negative bacilli. If the use of chlorhexidine bathing for a few months was not associated with acquisition of resistance, increase in the minimal inhibitory concentrations has been described for staphylococci. Daily chlorhexidine bathing could be recommended in units where incidence of staphylococcal blood stream infections remains high.
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Références
Vincent JL, Rello J, Marshall J, et al (2009) International study of the prevalence and outcomes of infection in intensive care units. JAMA 302:2323–2329
Bueno-Cavanillas A, Delgado-Rodríguez M, López-Luque A, et al (1994) Influence of nosocomial infection on mortality rate in an intensive care unit Crit Care Med 22:55–60
de Jonge E, Schultz MJ, Spanjaard L, et al (2003) Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 27:1011–1016
Safdar N, Bradley EA (2008) The risk of infection after nasal colonization with Staphylococcus aureus. Am J Med 121:310–315
Société française d’anesthésie et de réanimation, Société de réanimation de langue française (2009) Prevention of hospitalacquired sepsis in intensive care unit. Ann Fr Anesth Reanim 28:912–920
Climo MW, Yokoe DS, Warren DK, et al (2013) Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med 368:533–542
Darouiche RO, Wall MJ Jr, Itani KM, et al (2010) Chlorhexidinealcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 362:18–26
Noorani A, Rabey N, Walsh SR, Davies RJ (2010) Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery. Br J Surg 97:1614–1620
Maki DG, Ringer M, Alvarado CJ (1991) Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet 338:339–343
O’Grady NP, Alexander M, Burns LA, et al (2011) Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 39:S1–S34
McDonnell G, Russell AD (1999) Antiseptics and disinfectants: activity, action, and resistance. Clin Microbiol Rev 12:147–179
Milstone AM, Passaretti CL, Perl TM (2008) Chlorhexidine: expanding the armamentarium for infection control and prevention. Clin Infect Dis 46:274–281
Suller MT, Russell AD (1999) Antibiotic and biocide resistance in methicillin-resistant Staphylococcus aureus and vancomycinresistant enterococcus. J Hosp Infect 43:281–291
Wootton M, Walsh TR, Davies EM, Howe RA (2009) Evaluation of the effectiveness of common hospital hand disinfectants against methicillin-resistant Staphylococcus aureus, glycopeptideintermediate S. aureus, and heterogeneous glycopeptide-intermediate S. aureus. Infect Control Hosp Epidemiol 30:226–232
McDanel JS, Murphy CR, Diekema DJ, et al (2013) Epidemiology and surveillance chlorhexidine and mupirocin susceptibilities of methicillin-resistant Staphylococcus aureus from colonized nursing home residents. Antimicrob Agents Chemother 57:552–558
Fritz SA, Hogan PG, Camins BC, et al (2013) Mupirocin and chlorhexidine resistance in Staphylococcus aureus in patients with community-onset skin and soft tissue infections. Antimicrob Agents Chemother 57:559–568
Block C, Robenshtok E, Simhon A, Shapiro M (2000) Evaluation of chlorhexidine and povidone iodine activity against methicillinresistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis using a surface test. J Hosp Infect 46:147–1452
Higgins CS, Murtough SM, Williamson E, et al (2001) Resistance to antibiotics and biocides among non-fermenting Gram negative bacteria. Clin Microbiol Infect 7:308–315
Russell AD (1999) Bacterial resistance to disinfectants: present knowledge and future problems. J Hosp Infect 43:S57–S68
Stickler DJ (2002) Susceptibility of antibiotic-resistant Gram negative bacteria to biocides: a perspective from the study of catheter biofilms. J Appl Microbiol 92:163S–170S
Popovich KJ, Lyles R, Hayes R, et al (2012) Relationship between chlorhexidine gluconate skin concentration and microbial density on the skin of critically ill patients bathed daily with chlorhexidine gluconate. Infect Control Hosp Epidemiol 33:889–896
Lee A, Harlan R, Breaud AR, et al (2011) Blood concentrations of chlorhexidine in hospitalized children undergoing daily chlorhexidine bathing. Infect Control Hosp Epidemiol 32:395–397
Silvestri DL, McEnery-Stonelake M (2013) Chlorhexidine: uses and adverse reactions. Dermatitis 24:112–118
Jee R, Nel L, Gnanakumaran G, et al (2009) Four cases of anaphylaxis to chlorhexidine impregnated central venous catheters: a case cluster or the tip of the iceberg? Br J Anaesth 103:614–615
Coello R, Glynn JR, Gaspar C, et al (1997) Risk factors for developing clinical infection with methicillin-resistant Staphylococcus aureus (MRSA) amongst hospital patients initially only colonized with MRSA. J Hosp Infect 37:39–46
Datta R, Huang SS (2008) Risk of infection and death due to methicillin-resistant Staphylococcus aureus in long-term carriers. Clin Infect Dis 47:176–181
Davis KA, Stewart JJ, Crouch HK, et al (2004) Methicillinresistant Staphylococcus aureus (MRSA) nares colonization at hospital admission and its effect on subsequent MRSA infection. Clin Infect Dis 39:776–782
Cosgrove SE, Qi Y, Kaye KS, et al (2005) The impact of methicillin resistance in Staphylococcus aureus bacteremia on patient outcomes: mortality, length of stay, and hospital charges. Infect Control Hosp Epidemiol 26:166–174
Lin MY, Hayden MK (2010) Methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus: recognition and prevention in intensive care units. Crit Care Med 38: S335–S344
Marshall C, Spelman D, Harrington G, McBryde E (2009) Daily hazard of acquisition of methicillin-resistant Staphylococcus aureus infection in the intensive care unit. Infect Control Hosp Epidemiol 30:125–129
Huang SS, Rifas-Shiman SL, Warren DK et al (2007) Centers for Disease Control and Prevention Epicenters Program. Improving methicillin-resistant Staphylococcus aureus surveillance and reporting in intensive care units. J Infect Dis 195:330–338
Song X, Srinivasan A, Plaut D, Perl TM (2003) Effect of nosocomial vancomycin-resistant enterococcal bacteremia on mortality, length of stay, and costs. Infect Control Hosp Epidemiol 24:251–256
Carmeli Y, Eliopoulos G, Mozaffari E, et al (2002) Health and economic outcomes of vancomycin-resistant enterococci. Arch Intern Med 162:2223–2228
Duckro AN, Blom DW, Lyle EA, et al (2005) Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 165:302–307
Bass P, Karki S, Rhodes D, et al (2013) Impact of chlorhexidineimpregnated washcloths on reducing incidence of vancomycinresistant enterococci colonization in hematology-oncology patients. Am J Infect Control 41:345–348
Hidron AI, Edwards JR, Patel J, et al (2008) NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infect Control Hosp Epidemiol 29: 996–1011
BEH nos 41–42. 4 Novembre 2008. Contrôle des entérocoques résistants aux glycopeptides. État des lieux en France
O’Horo JC, Silva GL, Munoz-Price LS, Safdar N (2012) The efficacy of daily bathing with chlorhexidine for reducing healthcareassociated bloodstream infections: a meta-analysis. Infect Control Hosp Epidemiol 33:257–267
Karki S, Cheng AC (2012) Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review. J Hosp Infect 82:71–84
Edmiston CE Jr, Seabrook GR, Johnson CP, et al (2007) Comparative of a new and innovative 2% chlorhexidine gluconateimpregnated cloth with 4% chlorhexidine gluconate as topical antiseptic for preparation of the skin prior to surgery. Am J Infect Control 35:89–96
Cholley P, Thouverez M, Floret N, et al (2008) Contribution of tap water to patient colonisation with Pseudomonas aeruginosa in a medical intensive care unit. Intensive Care Med 34:1428–1433
Evans HL, Dellit TH, Chan J, et al (2010) Effect of chlorhexidine whole-body bathing on hospital-acquired infections among trauma patients. Arch Surg 145:240–246
Fung SK, Louie M, Simor AE (2002) Combined topical and oral antimicrobial therapy for the eradication of methicillin-resistant Staphylococcus aureus (MRSA) colonization in hospitalized patients. Can J Infect Dis 13:287–292
Gould IM, MacKenzie FM, MacLennan G, et al (2007) Topical antimicrobials in combination with admission screening and barrier precautions to control endemic methicillin-resistant Staphylococcus aureus in an Intensive Care Unit. Int J Antimicrob Agents 29:536–543
Ridenour G, Lampen R, Federspiel J, et al (2007) Selective use of intranasal mupirocin and chlorhexidine bathing and the incidence of methicillin-resistant Staphylococcus aureus colonization and infection among intensive care unit patients. Infect Control Hosp Epidemiol 28:1155–1161
Munoz-Price LS, Hota B, Stemer A, Weinstein RA (2009) Prevention of bloodstream infections by use of daily chlorhexidine baths for patients at a long-term acute care hospital. Infect Control Hosp Epidemiol 30:1031–1035
Climo MW, Sepkowitz KA, Zuccotti G, et al (2009) The effect of daily bathing with chlorhexidine on the acquisition of methicillinresistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Crit Care Med 37:1858–1865
Vernon MO, Hayden MK, Trick WE, et al (2006) Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci. Arch Intern Med 166:306–312
Bleasdale SC, Trick WE, Gonzalez IM, et al (2007) Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 167:2073–2079
Popovich KJ, Hota B, Hayes R, et al (2010) Daily skin cleansing with chlorhexidine did not reduce the rate of central-line associated bloodstream infection in a surgical intensive care unit. Intensive Care Med 36:854–858
Camus C, Bellissant E, Sebille V, et al (2005). Prevention of acquired infections in intubated patients with the combination of two decontamination regimens. Crit Care Med 33:307–314
Huang SS, Septimus E, Kleinman K, et al (2013) Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 368:2255–2265
Milstone AM, Elward A, Song X, et al (2013) Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. Lancet 381:1099–1106
Borer A, Gilad J, Porat N, et al (2007) Impact of 4% chlorhexidine whole-body washing on multidrug-resistant Acinetobacter baumannii skin colonisation among patients in a medical intensive care unit. J Hosp Infect 67:149–155
Palmore TN, Henderson DK (2013) Managing transmission of carbapenem-resistant Enterobacteriaceae in healthcare settings: a view from the trenches. Clin Infect Dis 57:1593–1599
Munoz-Price LS, Hayden MK, Lolans K, et al (2010) Successful control of an outbreak of Klebsiella pneumoniae carbapenemaseproducing K. pneumoniae at a long-term acute care hospital. Infect Control Hosp Epidemiol 31:341–347
Maragakis LL (2010) Recognition and prevention of multidrugresistant Gram negative bacteria in the intensive care unit. Crit Care Med 38:S345–S351
Wang JT, Sheng WH, Wang JL, et al (2008) Longitudinal analysis of chlorhexidine susceptibilities of nosocomial methicillinresistant Staphylococcus aureus isolates at a teaching hospital in Taiwan. J Antimicrob Chemother 62:514–517
Horner C, Mawer D, Wilcox M (2012) Reduced susceptibility to chlorhexidine in staphylococci: is it increasing and does it matter? J Antimicrob Chemother 7:2547–2559
Sangal V, Girvan EK, Jadhav S, et al (2012) Impacts of a longterm programme of active surveillance and chlorhexidine baths on the clinical and molecular epidemiology of meticillinresistant Staphylococcus aureus (MRSA) in an Intensive Care Unit in Scotland. Int J Antimicrob Agents 40:323–331
Institut de veille sanitaire (2011) Surveillance des bactéries multirésistantes dans les établissements de santé en France. Réseau BMR-RAISIN
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Georges, H., Alfandari, S., Gois, J. et al. Doit-on utiliser la décontamination cutanée par la chlorhexidine en réanimation ?. Réanimation 23, 248–255 (2014). https://doi.org/10.1007/s13546-014-0853-5
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DOI: https://doi.org/10.1007/s13546-014-0853-5