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Les endocardites fongiques : mise au point

Fungal endocarditis: An update

  • Mise au Point / Update
  • Published:
Réanimation

Résumé

L’épidémiologie des endocardites fongiques a été profondément modifiée au cours des dernières décennies. Rapportées principalement chez les usagers de drogues par voie intraveineuse ou au décours d’une chirurgie cardiaque dans les années 1965-1995, les endocardites fongiques affectent désormais principalement des patients immunodéprimés, et/ou porteurs d’une voie veineuse centrale, sous antibiothérapie prolongée à large spectre ou nutrition parentérale. Candida sp. est responsable de 50 à 80 % des endocardites fongiques, C. albicans restant le plus fréquent (30 à 40 % de toutes les endocardites fongiques), tandis que les endocardites à Aspergillus sp. représentent 20 à 30 % des endocardites fongiques. L’intérêt des flacons d’hémocultures spécifiques a disparu du fait de l’amélioration des performances des systèmes d’hémocultures utilisés en routine. De nouveaux outils diagnostiques sanguins–tels que la détection d’antigène galactomannane (aspergillose invasive), de mannane et d’anticorps antimannane (candidémies), et de β 1-3 D glucane (toute mycose invasive)–pourraient compenser en partie les défauts de sensibilité des hémocultures et diminuer le délai diagnostique. Le développement de nouveaux antifongiques systémiques au cours des 15 dernières années a permis des projets tangibles: 1) les échinocandines, fongicides sur la plupart des levures, semblent avoir amélioré le pronostic des endocardites à Candida sp., y compris sur prothèse valvulaire, même en l’absence de chirurgie; 2) le voriconazole, fongicide sur Aspergillus sp., a démontré sa supériorité vis-à-vis de l’amphotéricine B dans l’aspergillose invasive, même si le pronostic des endocardites à Aspergillus reste très dépendant des possibilités chirurgicales.

Abstract

While it used to affect mostly intravenous drug users and patients who underwent cardiac surgery, during the years 1965-1995’s, fungal endocarditis is currently mostly observed in severely immunocompromised patients, with chronic central venous access and/or broad-spectrum antibiotic use, or total parenteral nutrition. The requirement of specific blood culture bottles for fungus has virtually disappeared, thanks to the optimization of automated blood culture systems. Meanwhile, the advent of several blood tests for invasive mycosis–galactomannan for invasive aspergillosis, mannan/anti-mannan antibodies for candidemia and β-1,3-D glucans for any invasive mycosis–shall improve sensitivity, and reduce diagnosis delay, although limited data are available on their yield for the diagnosis of fungal endocarditis. New antifungal agents available since the early 2000s probably represent dramatic improvement for fungal endocarditis: 1) a new class, echinocandins, has the potential to improve the management of Candida sp. endocarditis, due to its fungicidal effect on yeasts, and the tolerability of increased doses; 2) voriconazole improved survival in patients with invasive aspergillosis, as compared to amphotericin B, and this achievement may apply to Aspergillus sp. endocarditis as well, although the prognosis of these latter remains dismal and largely dependent on cardiac surgery.

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  1. Maladies infectieuses et réanimation médicale, hôpital Pontchaillou, rue Le Guilloux, centre hospitalier de Rennes, université Rennes-1, F-35033, Rennes, France

    P. Fillâtre, M. Revest & P. Tattevin

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  1. P. Fillâtre
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Fillâtre, P., Revest, M. & Tattevin, P. Les endocardites fongiques : mise au point. Réanimation 25, 348–360 (2016). https://doi.org/10.1007/s13546-016-1199-y

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