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Prise en charge des infections ostéo-articulaires sévères en réanimation

Severe bone and joint infection management in intensive care unit

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Réanimation

Résumé

Les infections ostéo-articulaires (IOA) regroupent des situations cliniques variées, se distinguant par leur site (articulation, rachis, os longs…), leur évolution (aiguë, chronique), la présence ou non de matériel étranger (prothèse articulaire, matériel d’ostéosynthèse), le(s) micro-organisme(s) impliqué(s), le terrain et la voie de contamination (hématogène, postopératoire, de contiguïté…). Ces infections sont rares en soins intensifs et concernent des patients en sepsis sévère/choc septique induits par l’IOA ou nécessitant une surveillance en période postopératoire immédiate. La gravité du tableau clinique peut être liée au terrain, aux facteurs de virulence du pathogène et à l’existence d’un abcès ou d’une bactériémie associés à l’infection ostéo-articulaire. Si le diagnostic clinique est en général aisé, le diagnostic microbiologique est souvent difficile du fait de l’urgence à instaurer un traitement antibiotique. La ponction articulaire ou d’une collection para-articulaire est alors l’examen clé pour permettre une documentation microbiologique et sera associée à la réalisation d’hémocultures. Dans ce contexte de soins intensifs, l’antibiothérapie probabiliste aura un large spectre et sera précédée si possible d’une documentation microbiologique permettant d’adapter secondairement le traitement antibiotique. La complexité des paramètres impliqués dans les choix thérapeutiques nécessite une prise en charge multidisciplinaire.

Abstract

Bone and joint infections (BJI) are characterized by various clinical presentations, according to the site of infection (joint, spine, long bones…), the evolution (acute, chronic), the presence of an implant (prosthetic joint, osteosynthesis), the causative pathogens, patient’s medical condition, and infection route (hematogenous or surgical site infection, contiguous osteomyelitis….). BJI are a rare cause of hospitalization in the intensive care unit (ICU), and patients are usually admitted for septic shock or severe sepsis management, or in post-operative period. The severity of BJI may be explained by patient’s medical condition, by virulence of the causative pathogen, or by the occurrence of abscess or bacteremia. Clinical diagnosis of severe BJI is generally easy but microbiological documentation may be compromised by the need of prompt antibiotic treatment, situation in which joint aspiration or para-articular abscess aspiration are cornerstones of microbiological analysis and must be coupled to blood cultures. In the ICU, a broad spectrum empirical antibiotic therapy must be initiated and preceded, if possible, by microbiological samples in order to target the antibiotic therapy. Parameters that guide therapeutic choices are complex, explaining why these patients must be managed by a multidisciplinary team.

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Authors and Affiliations

  1. Service universitaire de maladies infectieuses, centre de référence des infections ostéo-articulaires complexes nord-ouest, centre hospitalier de Tourcoing, Tourcoing, France

    S. Nguyen, A. Meybeck & E. Senneville

  2. Service d’orthopédie-traumatologie, centre de référence des infections ostéo-articulaires complexes nord-ouest, centre hospitalier de Tourcoing, Tourcoing, France

    E. Beltrand

  3. Hébergement septique d’orthopédie-traumatologie, centre de référence des infections ostéo-articulaires complexes nord-ouest, CHRU de Lille, Lille, France

    H. Dezeque & H. Migaud

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  1. S. Nguyen
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  2. A. Meybeck
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  3. E. Beltrand
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  6. E. Senneville
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Correspondence to S. Nguyen.

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Nguyen, S., Meybeck, A., Beltrand, E. et al. Prise en charge des infections ostéo-articulaires sévères en réanimation. Réanimation 24, 256–264 (2015). https://doi.org/10.1007/s13546-015-1057-3

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  • DOI: https://doi.org/10.1007/s13546-015-1057-3

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