Revue d'article Pyélonéphrite aigue de l'adulte  

Revue d'article Pyélonéphrite aigue de l'adulte
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ARTICLE DE REVUE
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Acute Pyelonephritis in Adults
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NEJM, JANUARY 4, 2018
DRE. MURESEANU ALEXANDRA
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10.07.2018

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Un petit rappel….
-C’est une infection urinaire sévère qui peut-être accompagnée par: EF,
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douleurs au niveau du flanc, prostatite aigue(H), cystite aigue(F), bactériémie.
Peut dégénérer en SEPSIS/SEPTIC CHOC/DECES
- Il s’agit d’une inflammation au niveau des reins
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- Le GOLD standard pour le dg reste le stix urinaire et la culture urinaire qui
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montre le microorganisme concerné (très souvent
E.Coli
ou un autre BG
-
)
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- Jusqu‘à 20% des patients ne présentent pas de symptôme urinaire ni d’EF
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- Une évolution défavorable à 24-48hObstruction(urolithiase,
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tumeur),abcès ,pyélonéphrite emphysémateuse
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- Incidence:459.000-1.138.000(EUA); 10.5-25.9mil dans le monde

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Les pathogènes
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-chez la femme en BSH: E.Coli (>90%)
-chez l’homme, la femme âgée, les patients institutionnalisés: BG-,C G+
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,Candida

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.

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Le diagnostic
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Douleur loge rénale (+/- EF) +Sédiment urinaire pathologique(pyurie,
bactériurie) ->>PYELONEPHRITE
DD: cholécystite aigue
APP
urolithiase
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syndrome musculaire paravertébral
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thrombose de la veine rénale
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PID
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prostatite aigue (hommes)
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Sepsis
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Susp. Calcul
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Ph >/= 7
IRA
Imagerie

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Traitement
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1.Le traitement symptomatique
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2.Le traitement antibiotique
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3.La recherche étiologique

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Le traitement symptomatique
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-ressuscitation hydrique
-les médicaments vasopresseurs pour les patients hospitalisés
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-l’antalgie, les anti-inflammatoires , antipyrétiques et antiémétiques

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Le traitement antibiotique
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-Doit être instauré très rapidement(après HC et culture d’urine)
-Si absence de contre-indication: les floroquinolones et le Trimethoprim-
sulfamethoxazole sont très efficaces, avec un taux de succès >90%:
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-comme traitement empirique pour des patients sans facteur de risque
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-plutôt en ambulatoire
-si résistance Abx suspectée Ceftriaxone/Gentamicine/Amikacine/Ertapenem
en ordre unique
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Pour les patients à risque( hospitalisés, dysfonction d’organe, immunocompromis):
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-le traitement empirique avec F ou TMS n’est pas recommandé, parce que la
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résistance antibiotique est importante

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La durée du traitement
(conclusion des études)
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1.Femmes( avec pathogènes sensibles)une résolution de >90% avec un
traitement de 5à 7j avec des Floroquinolones OU 14j avec TMS
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2.Hommes avec IU fébrile(avec pathogènes sensibles)même guérison avec
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14j de Ciprofloxacine que avec 28j
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3. Femmes: une durée de traitement de 10 à 14j avec céphalosporine devrait
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suffire(si résistance aux Floroquinolones //TMS)

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.

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European Association of Urology
Abx guidelines
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.
.

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Recherche étiologique
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Une évaluation à 24-48h est mandataire !!!
L’US est plus sensible que le CT pour la détection de l’hydronéphrose, mais le CT est
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plus sensible pour diagnostiquer une complication au niveau rénal (abcès,
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inflammation).
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- calculs rénaux lithotripsie ou drainage urologique
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-abcès drainage si le patient n’est pas stable
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-pyélonéphrite emphysémateuse néphrectomie partielle ou totale

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.
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2017
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Le CT est supérieur à l’US pour la détection de la PNA, particulièrement pour
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détecter l’ abcès ou la pyélonéphrite emphysémateuse

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Une population spéciale….
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PNA pdt la grossesse
-c’est une complication qui menace la vie de deux
-prise en charge optimale hospitalisation et début d’ antibiothérapie iv
Attention: toxicité pour le fétus allô Infectio
CI: aminoglycosides dans le 1ère trimestre, TMS dans le 3ème trimestre,
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Floroquinolones toute la grossesse

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.
PNA chez les greffés
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-une prédisposition de rejet de la greffe
-l’antibiothérapie prophylactique du patient doit être considérée comme
traitement empirique
PNA chez les patients avec anomalies urologiques
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-il n’y a pas un régime spécial, le traitement est identique comme pour le
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reste de la population

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Guidelines
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Infectious Diseases Society of America
&
European Society for Mycrobiology and Infectious Diseases
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-parlent seulement du traitement de la PNA, sans complication chez les
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femmes
-la culture urinaire est recommandée dans tous les cas
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Selon les études disponibles:
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-Lévofloxacine-5j (750mgx1/j)
-Ciprofloxacine -7j(b.i.d)
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-TMS -14j(b.i.d)
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-Bétalactams oraux:10-14j(b.id)

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TAKE HOME MESSAGES
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-si suspicion clinique: Stix et culture urinaire
-début d’antibiothérapie dans tous les cas(selon les guidelines CHVR)
-selon la clinique : hospitalisation ou pas
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-si mauvaise évolution à 24-48had imagerie
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-pour les populations spéciales: avis spécialisé(Infectio/Néphro/Uro/Gyneco)
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