Résumé
L’évolution épidémiologique actuelle expose les réanimateurs à des infections dues à des bactéries multirésistantes, notamment les entérobactéries productrices de bêtalactamases à spectre étendu (BLSE) et les bacilles à Gram— non fermentants. L’une des conséquences est une augmentation de la consommation de carbapénèmes, à l’origine de l’émergence de souches résistantes à cette dernière classe, notamment par production de carbapénèmases. La situation devient particulièrement critique avec de véritables impasses thérapeutiques et des craintes légitimes quant à l’avenir de l’antibiothérapie. Deux molécules récentes peuvent permettre de répondre à des situations de difficulté thérapeutique tout en envisageant une épargne des carbapénèmes : le ceftolozane–tazobactam (C–T) et la témocilline. Le spectre principal de C–T concerne essentiellement les infections à Pseudomonas aeruginosa, et à certaines entérobactéries productrices de BLSE, à l’exception notable des classes B et D. Les données cliniques disponibles concernent essentiellement les infections intra-abdominales et urinaires, et des essais en cours pourraient permettre de documenter la place théorique de cette association dans la prise en charge des infections respiratoires, notamment acquises sous ventilation mécanique. Le spectre principal de la témocilline concerne les infections à entérobactéries productrices de BLSE. Cependant, les données cliniques sont anciennes, essentiellement rétrospectives et concernent peu les malades de réanimation. L’enjeu de l’utilisation de ces molécules pouvant répondre à une problématique écologique est de bien peser le pour et le contre de leur prescription, dans un contexte de contraintes budgétaires d’une part, et dans la nécessité d’une préservation de leur efficacité d’autre part, ce qui ne peut se concevoir que dans le cadre d’une politique globale d’utilisation des antibiotiques.
Abstract
Because of the actual epidemiologic evolution, intensivists must manage infections due to multidrug resistant bacteria, especially enterobacteria producing extending spectrum beta-lactamase (ESBL) and non-fermentative Gram— bacteria. This is also the cause of an increasing prescription of carbapenems, which results again in the emergence of resistance, especially by the production of carbapenemases. The emergence of such resistance makes it difficult, in fact almost impossible, to treat some infections, and justifies fears for the future of antibiotics. Two molecules can help in these therapeutic difficulties, while allowing a decrease in the use of carbapenems — ceftolozane–tazobactam (C–T) and temocillin. The spectrum of C–T includes mainly infections due to Pseudomonas aeruginosa, and to some enterobacteria producing ESBL, with the exception of B and D classes. There is available clinical data of the use of these molecules to treat intra-abdominal and urinary tract infections. Ongoing clinical trials could allow the documentation of the theoretical interest of these molecules to treat respiratory tract infections, especially ventilatory acquired pneumonia. The main spectrum of temocillin is the infections due to Enterobacteria producing ESBL. However, clinical data are quite old, retrospective, and few are about intensive care patients. The pros and cons of the use of these molecules, to respond to an ecological matter, has to be considered in the perspective of economic constraints on the one hand, and by the necessity to preserve their efficacy on the other hand. This must be included in an antimicrobial stewardship program.
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Poissy, J., Parmentier-Decrucq, E., Thieffry, C. et al. « Nouvelles » molécules anti-infectieuses. Quelle place en médecine intensive/réanimation pour ceftolozane–tazobactam et la témocilline ?. Méd. Intensive Réa 26, 224–232 (2017). https://doi.org/10.1007/s13546-017-1267-y
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DOI: https://doi.org/10.1007/s13546-017-1267-y