Méningites - MEDESIMBacterial Meningitis ». Clinical Microbiology and Infection: The Official...
Transcript of Méningites - MEDESIMBacterial Meningitis ». Clinical Microbiology and Infection: The Official...
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MéningitesDU Prise en charge des situations d’urgences médico-chirugicales
Pierre Jaquet
Réanimation médicale, Cochin
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Plan
• Epidémiologie
• Orientation microbactériologique
• Clinique
• Pronostic et facteurs modifiables
• Prise en charge
• Et les autres méningites
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Brouwer, Matthijs C., et Diederik van de Beek. « Epidemiology of Community-Acquired Bacterial Meningitis ». Current Opinion in Infectious Diseases, 2017
Epidémiologie des méningites bactériennes
Incidence en diminution au cours des 20 dernières années (UE, EU)
• 2 cas/ 100 000 habitants en 98-99
• 0.7-0.9 / 100 000 par an en 2004-2014
Effet de la vaccination pneumocoque, méningocoque et haemophilus influenzae
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Beek, Diederik van de « Community-Acquired Bacterial Meningitis ». Nature Reviews. 2016
Epidémiologie
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Thigpen, Michael C. et al. « Bacterial Meningitis in the United States, 1998-2007 ». The New England Journal of Medicine, 2011
Epidémiologie
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Streptocoque pneumoniae• Terrain
• Age >50ans
• FDR :• Asplénisme
• Alcoolisme
• VIH
• Diabète
• Dénutrition
• Hypogammaglobulinémie, Sd de Wiscott-Aldrich…
• Porte d’entrée : brèche méningée/pneumonie/endocardite/(Osler)
• Argument de fréquence
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Neisseria meningitidis
• Sujets jeunes
• Contage ! DO
• Antibioprophylaxie de l’entourage(rifampicine 48h, C3G monodose)
• Voyages en zones d’endémie (moyen Orient)
• Infection ORL/respiratoire associée
• Arthralgies
• Purpura fulminans
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Listeria monocytogenes
• Sujet âgés, femmes enceintes
• Immunodépression
• Subaigue
• Rhombencéphalite signes de localisation du tronc cérébral
• Méningite à PNN ou panachée
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Beek, Diederik van de, et al « Clinical Features and Prognostic Factors in Adults with Bacterial Meningitis ». The New England Journal of Medicine 2004
Clinique : Sd méningé fébrile + confusion
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Thomas, Karen E « The Diagnostic Accuracy of Kernig’s Sign, Brudzinski’s Sign, and Nuchal Rigidity in Adults with SuspectedMeningitis ». Clinical Infectious Diseases 2002
Clinique : Raideur de nuque
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Beek « Community-Acquired Bacterial Meningitis in Adults ». The New England Journal of Medicine 2006
Complications
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Beek, Diederik van de, et al « Clinical Features and Prognostic Factors in Adults with Bacterial Meningitis ». The New England Journal of Medicine 2006
Pronostic
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Weisfelt, Martijn, « Pneumococcal Meningitis in Adults: New Approaches to Management and Prevention ». The Lancet. Neurology 2006
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Que faire pour améliorer la prise en charge ?
• Seul facteur modifiable : le délai avant antibiothérapie !
• Et la corticothérapie ?
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Spilf 2008
Prise en charge pré-hospitalière
• Délai de prise en charge > 90minutes
• Purpura fulminans
Isolement respiratoire
Ceftriaxone 2g ou Claforan 2g ou Amoxicilline 2g IV ou IM
• Instabilité hémodynamique : cristalloides et antibiothérapie
• Troubles de l’hémostase (retard à la PL) : antibiothérapie
• SAMU si <20minutes et prévenir le SAU
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<1H
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Hasbun, R. « Computed Tomography of the Head before Lumbar Puncture in Adults with Suspected Meningitis ». The New England Journal of Medicine; décembre 2001
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Place de la tomodensitométrie ?
SPILF 2008
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Beek, D. van de, et al. « ESCMID Guideline: Diagnosis and Treatment of Acute Bacterial Meningitis ». Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases . 2016
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Glimåker, Martin et al. « Adult Bacterial Meningitis: Earlier Treatment and Improved Outcome Following Guideline RevisionPromoting Prompt Lumbar Puncture ». Clinical Infectious Diseases 2015
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Glimåker, Martin « Lumbar Puncture Performed Promptly or after Neuroimaging in Adult Bacterial Meningitis: A Prospective National Cohort Study Evaluating Different Guidelines ». Clinical Infectious Diseases. Septembre 2017
a : GCS3, ou GCS6 + mydriase, ou troubles du rythme respiratoire ou HTA+ bradycardie.
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Glimåker, Martin « Lumbar Puncture Performed Promptly or after Neuroimaging in Adult Bacterial Meningitis: A Prospective National Cohort Study Evaluating Different Guidelines ». Clinical Infectious Diseases. Septembre 2017
50% d’adhérence aux guidelines. Seulement 50% d’antibiotiques délivrés immédiatement lorsque la PL est différée…
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Prise en charge hospitalière
• PL TRAITEMENT <1h
• Hémoculture TRAITEMENT puis imagerie cérébrale
• Liquide purulent C3G (2g Cefotaxime) + DXM (10mgx4/j)
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SPILF 2008SPILF 2017
( )
+ DXM
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Autres éléments d’orientation
• Hémoculture : 2/3 positives• PCT>0.5• Scores chez l’enfant (Méningitest…)
• Dans la PL : • Binax NOW (Antigène pneumo et méningo)• PCR multiplex (dont quelques virus)• Lactate• ARN 16s
• BiopSie cutanée• Facteurs favorisants : VIH, EPS, TDM faciale, ORL.
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Bactérien ?
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SPILF 2008SPILF 2017
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CNR pneumocoques 2016
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Dexamethasone : diminue la surdité
Beek, D. van de, et al. « ESCMID Guideline: Diagnosis and Treatment of Acute Bacterial Meningitis ». Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases . 2016
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Surveillance
• En réanimation au moindre doute : risque dégradation de la vigilance, choc septique, états de mal épileptiques…
• Pas d’imagerie systématique : Si évolution défavorable (fièvre, vigilance)Si apparition de signes focaux (IRM>TDM)
• Pas de PL de contrôle systématique sauf PSDP
• Pas de prophylaxie antiépileptique
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Et si le LCR est clair ? Lymphocytaire ?
Quel traitement?
Quel examen vous permet d’orienter le diagnostic aux urgences ?
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Critères diagnostiques IDSA 20131 critère
majeur
Altération de la conscience ou troubles du comportement
≥ 24h
3 critères
mineurs
CRITÈRES CLINIQUES CRITÈRES PARACLINIQUES
Fièvre ≥ 38°C dans les 72hLCR : Nombre de leucocytes
>4éléments/mm3
Crise épileptique partielle ou
généralisée de novo
IRM : Anomalies
parenchymateuses récentes
Déficit neurologique focal récentEEG : Anomalies évocatrices
d’encéphalite
Venkatesan A. et al, Clin Infect Dis. 2013
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• Aciclovir 10mg/kg/8h à adapter à la fonction rénale.
Méningoencéphalite herpétique (HSV)
SPILF 2017
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A 48 - 72h toujours pas de documentation…
• Quel examen faut-il envisager ?
• Quel traitement faut-il envisager ?
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Méningoencéphalites
• PL : 2e PCR HSV / VZV / BK (+culture).
• Envisager BK selon clinique/contage traitement anti BK + corticothérapie
• Envisager encéphalites dysimmunitaires (ADEM, anticorps anti NMDA, encéphalites paranéoplasiques…) corticothérapie / Ig IV
• Causes infectieuses subaigues : Lyme, syphilis… => antibiothérapie
• 50% d’encéphalites jamais documentées…
SPILF 2017
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Take home message
• Urgence, dans l’heure C3G et DXM
• Rien ne doit retarder le traitement (surtout pas un scanner peu utile)
Beek, D. van de, et al. « ESCMID Guideline: Diagnosis and Treatment of Acute Bacterial Meningitis ». Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases mai 2016
• En cas de liquide clair : acyclovir et amoxicilline (apport de l’IRM)
Stahl, J. P. et al. « Guidelines on the Management of Infectious Encephalitis in Adults ». Medecine Et Maladies Infectieuses mai 2017
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Merci pour votre attention