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![Page 1: Prevention of acquired infections in itubated patients with combination of tow decontamination regimens. F.Bouzana DESC Réa Med Montpellier 2005 Crit Care.](https://reader035.fdocuments.us/reader035/viewer/2022070309/551d9db5497959293b8da4a5/html5/thumbnails/1.jpg)
Prevention of acquired infections in itubated patients with combination of tow decontamination regimens.
F.Bouzana
DESC Réa Med
Montpellier 2005
Crit Care Med 2005
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Introduction• La décontamination par Polymyxine et
Tobramycine (P/T) réduit les PAVM ,mais la colonisation par CG+
• La Mupirocine les infections à SAMR en chirurgie réglée
• La Chlorhéxidine le risque d’infection des cathéters en réanimation
• Mupirocine + Chlorhéxidine (M/C) PAVM à SA
Kollef.CHEST 1994 .D’Amico BMJ 1998
Perl NEJM 2002
Maki LANCET 1991
Rumbak CCM 1995
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Introduction
• Que peut être l’impact sur la survenue des infections acquises sous ventilation mécanique :
• M/C seul• P/T seul• M/C + P/T• Placebo
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Méthodes
• Multicentrique
• Randomisée
• Double aveugle
• Prospective
• 515 patients
• Avril 1996 à Octobre 1998
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Méthodes
• Critères d’inclusion• Age > 18 ans• IOT < 48 H• Une ventilation estimée à plus de 48 H• Accord famille
• Critères de non inclusion• Grossesse• Espérance de vie < 48 H• Agranulocytose• Diarrhée sévère• Patients ayant déjà reçu une décontamination
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Protocole
• 1er type de décontaminationSolution de 10 cc de polymyxine 15mg/cc +
Tobramycine 10mg/cc
Une application toute les 6 H
• 2ème type de décontaminationMupirocine pommade application toute les 8 H
Chlorhéxidine lavage corps entier toutes les 12 H
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Protocole
0 H 6 H 8 H 12 16 18 24 P/T P/T M P/T M P/T P/T M C M C C
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Protocole
• Randomisation en 4 groupes– 1- Produit actif M/C + placebo de l’autre
décontamination
– 2- Produit actif P/T + placebo
– 3- Produit actif M/C + Produit actif P/T
– 4- Placebo + Placebo
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La durée du traitement de la randomisation à 24 H après l’extubation
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Surveillance de la survenue des infections
• 2 hémoc + BU +/- ECBU à l’inclusion• T° / 4 H• La purulence des sécrétions/8 H• Cathéter /48 H• Thorax si T°> 38,5 délai 12 H• Rx sinus si T° > 72 H• Hémoc > 38,5 à 2 prises • Ablation cath + culture• ECBU 1 fois/sem• Pneumopathie infectieuse Rx + fièvre +LBAUne infection est reconnue et enregistrée comme
telle par le centre de contrôle de l’étude
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Objectifs
• 1er critère Nombres d’infections acquises depuis la
randomisation à 48 H après l’arrêt du traitement
• 2ème critères• Le pourcentage de patients non infectés en fonction du
temps
• Incidence totale des infections
• Relation infection cathéter,ventilation…
• Mortalité
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Résultats
• 325 patients soit 63% n’ont pas été infectés
• 190 patients ont été atteints par 303 infections
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Diminution significative du nombre d’infections dans le groupe double décontamination
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L’incidence totale des infections groupe double décontamination est inf à l’incidence totale de chaque groupe (significatif)
Aucune significativité concernant l’incidence liée au cath …
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Discussion
• L’association des 2 types de décontaminations réduit la survenue d’infections
• Aucun bénéfice par rapport au placebo si méthodes seules • Incidence totale + élevée selon les données du Système
nationale de surveillance des infections nosocomiales• A préciser les répercussion sur l’écologie• Colonisation ou infection? Candida• Échantillon insuffisant pour établir une différence de
mortalité• Taux de Tobramycine plasmatique
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Conclusion
• L’association de ces 2 types de décontamination parait réduire la fréquence et l’incidence totale de survenue d’infections
• Études plus forte (effectif) Mortalité