Résumé
Les pneumonies acquises sous ventilation mécanique (PAVM) augmentent de façon significative la morbidité, la mortalité et les coûts dans les services de réanimation. L’utilisation d’aérosols d’antibiotiques (AA) a du sens: le principal avantage est de délivrer directement le médicament au site infecté. Les AA peuvent générer des concentrations élevées dans le poumon, tout en réduisant les risques de toxicité systémique. L’aptitude d’une molécule à atteindre la zone cible dans le poumon dépend de plusieurs facteurs dont le type de nébuliseur et les paramètres ventilatoires. Les données les plus convaincantes sur l’utilisation des AA concernent les traitements d’entretien chez les patients atteints de mucoviscidose. En dépit du bien-fondé théorique, les données disponibles sont insuffisantes pour poser l’indication des AA en routine chez le patient sous ventilation mécanique. Les données cliniques sur l’utilisation des AA dans la prévention des PAVM sont limitées et font débat. Des données récentes envoient un message positif sur les AA dans le traitement de trachéobronchite acquise sous respirateur. Les données cliniques sur l’utilisation des AA dans le traitement des PAVM sont insuffisantes, et plusieurs groupes de consensus se prononcent contre leur utilisation. Une association d’antibiotiques par voie parentérale et en aérosols peut cependant être considérée chez des patients porteurs de bactéries multirésistantes (BMR) ne répondant pas au traitement classique. De larges études cliniques bien construites, contrôlées, avec des antibiotiques ciblés donnés pendant une courte période semblent urgentes.
Abstract
Ventilator-associated pneumonia (VAP) significantly increases intensive care unit morbidity, mortality, and costs. The rationale for using aerosolized antibiotics (AA) makes sense: the main advantage is the targeted drug delivery to the site of infection. AA can yield high concentrations in the lung while minimizing systemic toxicity. The ability of a drug to effectively reach the targeted area in the lung depends on a number of variables, including the type of nebulizer and the ventilator settings. The most convincing data to support the use of aerosolized antimicrobials has been generated for maintenance treatment in patients with cystic fibrosis. Although the theory is sound, there are limited data available to support the routine use of AA in mechanically ventilated patients. Clinical evidence for AA to prevent VAP is limited and conflicting. Recent data send a positive message to treat tracheobronchitis-associated pneumonia with AA. Clinical evidence that AA can treat VAP remains insufficient and multiple consensus groups recommend against treating VAP with AA. A combination of aerosolized and systematic treatment may be considered for patients with multi-drug resistance bacteria unresponsive to standard therapy. Large, appropriately designed and controlled trials with targeted antibiotics given for a short period appear to be urgently needed.
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Clavel, M. Indications des aérosols d’antibiotiques chez les patients sous ventilation mécanique. Réanimation 23, 271–277 (2014). https://doi.org/10.1007/s13546-014-0861-5
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DOI: https://doi.org/10.1007/s13546-014-0861-5
Mots clés
- Aérosol
- Antibiotique
- Ventilation mécanique
- Pneumonie acquise sous ventilation mécanique
- Trachéobronchite acquise sous ventilation mécanique