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Le dépistage des porteurs de bactéries multirésistantes : chez quels patients ?

Screening for multidrug resistant bacteria: For which patients?

  • Session Thématique
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Réanimation

Résumé

Le dépistage des bactéries multirésistantes (BMR) en réanimation fait l’objet de controverses persistantes, ravivées par l’arrivée de nouvelles menaces. Les recommandations disponibles sont discordantes. L’attitude vis-à-vis des BMR endémiques, en pratique le staphylocoque doré résistant à la méticilline (SARM) et les entérobactéries productrices de bêtalactamases à spectre élargi (EBLSE), est de privilégier les précautions standard, de manière adaptée à l’épidémiologie de chacune des BMR concernées : hygiène des mains et décolonisation éventuelles des porteurs pour SARM, et attention particulière à la gestion des excréta pour EBLSE. Le dépistage (associé à l’isolement) des porteurs de ces BMR n’apporte pas de bénéfice par rapport à une bonne application des précautions standard. Le dépistage est en revanche justifié pour la maîtrise de la transmission croisée des BMR hautement résistantes émergentes (BHRe), c’est-à-dire en France les entérobactéries productrices de carbapénémases et les entérocoques résistants aux glycopeptides ainsi qu’en situation endémo-épidémique ou épidémique pour les autres BMR, notamment des EBLSE autres qu’E. coli. En réanimation, les Acinetobacter résistant aux carbapénèmes doivent être pris en charge de la même manière que les BHRe. Le volet complémentaire indispensable à la maîtrise de la diffusion hospitalière des BMR, notamment pour les bacilles à gram négatif, est l’usage prudent et raisonné des antibiotiques.

Abstract

Active surveillance screening (ASC) of patients hospitalized in intensive care units (ICU) or elsewhere searching for carriers of multidrug-resistant bacteria (MDRB) remains controversial. Available guidelines are discordant. Current French recommendations emphasize standard precautions as the principal control measure against endemic MDRB, complemented by specific measures according to the epidemiology of each species, i.e., possible decontamination of methicillin-resistant Staphylococcus aureus (MRSA) carriers, and special attention to the handling of secretions and excreta for the extended-spectrum beta-lactamase producing enterobacteriaceae (ESBL-PE). In the current endemic setting which prevails in most European countries, screening and isolation of carriers of these two MDRB has no added benefit over optimal observance of standard precautions, in the absence of outbreak. Conversely, ASC is justified for the control of outbreaks and control of the highly-resistant bacteria which have recently emerged, and are still rarely encountered in most settings. In France, these highly-resistant bacteria include carbapenem-resistant enterobacteriaceae and glycopeptide-resistant enterococci. Carbapenem-resistant Acinetobacter warrant the same approach in the ICU. Infection control efforts to prevent cross-transmission must be complemented by a strict antimicrobial stewardship for optimal effectiveness of the control program.

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  1. Service de réanimation médicale et unité de contrôle, épidémiologie et prévention de l’infection, GH Henri Mondor, Assistance Publique-Hôpitaux de Paris, et Université Paris-Est Créteil, 51, avenue de Lattre de Tassigny, F-94000, Créteil, France

    C. Brun-Buisson

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Correspondence to C. Brun-Buisson.

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Cet article correspond à la conférence faite par l’auteur au congrès de la SRLF 2015 dans la session : Infections nosocomiales : les flores au centre du problème.

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Brun-Buisson, C. Le dépistage des porteurs de bactéries multirésistantes : chez quels patients ?. Réanimation 24 (Suppl 2), 304–314 (2015). https://doi.org/10.1007/s13546-014-0940-7

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