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Infections à Clostridium difficile : aspects cliniques épidémiologiques et thérapeutiques

Clostridium difficile infection: clinical, epidemiological and therapeutic aspects

  • Enseignement Supérieur en Réanimation
  • Médecin
  • Published:
Réanimation

Résumé

Clostriduim difficile est un bacille à Gram positif anaérobie, sporulé, responsable de 15 à 25 % des diarrhées postantibiotiques et de plus de 95 % des cas de colites pseudomembraneuses (CPM). C. difficile représente une des causes majeures de diarrhées associées aux soins. Les principaux facteurs de risque d’infections liées à C. difficile (ICD) sont l’âge supérieur à 65 ans, l’administration d’antibiotiques (notamment de céphalosporines de troisième génération, d’amoxicilline + acide clavulanique, de clindamycine et de fluoroquinolones) et les antécédents d’hospitalisation. La réponse immunitaire joue un rôle majeur dans la physiopathologie des ICD et des récidives. Ces dernières années ont été marquées par la dissémination mondiale d’une souche épidémique (027/NAP1/BI) responsable d’infections sévères et d’une mortalité plus importante. Des recommandations américaines et européennes pour le traitement des ICD ont été récemment publiées. Le métronidazole (500 mg × 3/jour, 10 jours) per os reste toujours la molécule de choix pour le traitement des formes peu à modérément sévères d’ICD. La vancomycine (125 mg × 4/jour, 10 jours) per os (ou par voie rectale en cas d’iléus) est réservée aux formes sévères d’infections. Il n’y a pas de consensus pour le traitement des récidives multiples, mais l’administration de doses dégressives et intermittentes de vancomycine est une stratégie fréquemment utilisée. De nouveaux traitements, telles la fidaxomixine, l’immunothérapie passive ou la vaccination, sont en cours d’évaluation.

Abstract

Clostridium difficile is a gram-positive spore-forming anaerobic enteropathogen. This bacillus is responsible for more than 95% of cases of pseudomembranous colitis and for 15 to 25% of cases of antibiotic-associated diarrhoea. C. difficile has emerged as the major cause of healthcare-associated diarrhoea. Risk factors for C. difficile infection (CDI) include age above 65 years, previous hospitalization, and recent antibiotic therapy (third-generation cephalosporins, amoxicillinclavulanate, clindamycin, and new fluoroquinolones). Serum immunity plays a key role in the development of CDI and relapses. Since 2003, a new hypervirulent strain (027/NAP1/BI) has emerged and spread rapidly worldwide. This epidemic strain is responsible for outbreaks with increased mortality and severity in North America and Europe. Recent American and European guidelines have been published for the treatment of CDI. Oral metronidazole (500 mg three times a day, for 10 days) is still the drug of choice for the initial episode of mild to moderate CDI. Vancomycin (125 mg four times a day, for 10 days) should be given orally (or per rectum if ileus is present) in case of severe CDI. There is no consensus for the treatment of multiple relapses; however, vancomycin therapy using a tapered and pulse regimen is the preferred next strategy. New developments including new drugs (fidaxomixin recently approved by the FDA) or passive or active immunization are currently evaluated.

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Authors and Affiliations

  1. Laboratoire Clostridium difficile associé au CNR des bactéries anaérobies et du botulisme, faculté de médecine Saint-Antoine, laboratoire de bactériologie, 27, rue de Chaligny, F-75571, Paris cedex 12, France

    F. Barbut & C. Eckert

  2. UHLIN, hôpital Saint-Antoine, Assistance publique-Hôpitaux de Paris, Paris, France

    F. Barbut

  3. Service de microbiologie, centre hospitalier André-Mignot, Versailles, France

    A. Le Monnier

  4. EA 4043, USC Inra, écosystème microbien digestif et santé, université Paris-Sud, Châtenay-Malabry, France

    F. Barbut, A. Le Monnier & C. Eckert

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  1. F. Barbut
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  2. A. Le Monnier
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  3. C. Eckert
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Correspondence to F. Barbut.

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Cet article correspond à la conférence faite par l’auteur au congrès de la SRLF 2012 dans la session : Colites graves.

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Barbut, F., Le Monnier, A. & Eckert, C. Infections à Clostridium difficile : aspects cliniques épidémiologiques et thérapeutiques. Réanimation 21 (Suppl 2), 373–383 (2012). https://doi.org/10.1007/s13546-011-0341-4

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  • DOI: https://doi.org/10.1007/s13546-011-0341-4

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