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CRITERES DE CHOIX DES ANTIBIOTIQUES (MST) 1. Efficacité 2. Sécurité 3. Coût 4. Compliance et acceptabilité 5. Disponibilit é 6.Co-infections 7.Restrictions:

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Apresentação em tema: "CRITERES DE CHOIX DES ANTIBIOTIQUES (MST) 1. Efficacité 2. Sécurité 3. Coût 4. Compliance et acceptabilité 5. Disponibilit é 6.Co-infections 7.Restrictions:"— Transcrição da apresentação:

1 CRITERES DE CHOIX DES ANTIBIOTIQUES (MST) 1. Efficacité 2. Sécurité 3. Coût 4. Compliance et acceptabilité 5. Disponibilit é 6.Co-infections 7.Restrictions: usage réservé

2 Azithromycin 1 g orally in a single dose, OR Ceftriaxone 250 mg intramuscularly (IM) in a single dose, OR Ciprofloxacin 500 mg orally twice a day for 3 days, OR Erythromycin base 500 mg orally three times a day for 7 days. CHANCRE MOU (chancroid) (CDC,2006)

3 Ciprofloxacin 500 mg orally 2 X j X 3 j, OU Erythromycine base 500 mg p os 3 X j X 7 j, OU Azithromycine 1 g p os X 1 Alternative: Ceftriaxone 250 mg intramuscularly (IM) X 1, CHANCRE MOU (chancroid) (OMS, 2004)

4 Co-trimoxazole: 160/800 mg p os x 2 x 14j Alternatives: Doxycycline 100 mg p os x 2 x 14 j Tetracycline 500 mg p os x 4 x 14 j + Streptomycine 1g IM x 1 x 14j GRANULOMA INGUINALE (WHO, 1992) (DONOVANOSE)

5 Azithromycine:1g p os x 1/j + 500mg p os x 1/j * Ou Doxycycline: 100 mg p os x 2/j * Alternatives: Erythromycine: 500 mg p os x 4 x/j * Tetracycline 500 mg p os x 4/j x 14 j * Cotrimoxazole 80mg/400 mg x 2 x 2/j x 14 j* GRANULOMA INGUINALE (WHO, 2004) (DONOVANOSE)

6 Doxycycline: 100 mg p os x 2/d x 3 weeks* Alternatives: Azithromycine: 1g p os x 1 j 3 weeks* OR Ciprofloxacine: 750 mg p os x 2/d x 3 weeks* OR Cotrimoxazole DS (800mg/160mg) p os x2/d x 3 weeks* * Up to complete healing GRANULOMA INGUINALE (CDC,2006) (DONOVANOSE)

7 LYMPHOGRANULOMA VENEREUM Doxycycline 100mg p os x 2/d Alternative: Erythromycine 500mg p os x 4/d (LGV) (CDC,2006) For 21 days

8 LYMPHOGRANULOME VENERIEN Doxycycline 100mg p os x 2 Ou Erythromycine 500mg p os x 4 Alternatives: Tetracycline 500mg p os x 4 (Nicolas et Favre) (WHO, 2004) Pendant 14 jours

9 Acyclovir 400 mg orally three times a day for days, OR Acyclovir 200 mg orally five times a day for days, OR Famciclovir 250 mg orally three times a day for days, OR Valacyclovir 1 g orally twice a day for days. HERPES GENITAL (CDC, 2006,WHO, 2004) First Clinical Episode

10 Acyclovir 400 mg orally three times a day for 5 days*, OR Acyclovir 200 mg orally five times a day for 5 days*, OR Acyclovir 800 mg orally twice a day for 5 days*, OR Famciclovir 125 mg orally twice a day for 5 days*, OR Valacyclovir 500 mg orally twice a day for 3--5 days*, OR Valacyclovir 1.0 g orally once a day for 5 days*. HERPES GENITAL Episodic Therapy for Recurrent Herpes (CDC, 2006,WHO, 2004) ( 5-10 days if HIV+, CDC)

11 Acyclovir 400 mg orally twice a day, OR Famciclovir 250 mg orally twice a day, OR Valacyclovir 500 mg orally once a day, OR Valacyclovir 1.0 gram orally once a day. HERPES GENITAL Suppressive Therapy for Recurrent Herpes (CDC, 2006,WHO, 2004)

12 Acyclovir mg orally twice to three times a day, OR Famciclovir 500 mg orally twice a day, OR Valacyclovir 500 mg orally twice a day. HERPES GENITAL Suppressive Therapy for Recurrent Herpes if HIV+ (CDC, 2006)

13 Benzathine-PNC-G 2.4 Millions IM x 1 Alternatives: Doxycycline 100 mg p os x 2 x 14 j Ceftriaxone 1g IM x 1 x 8-10 j Azithromycine 2g p os x 1 x 1 j SYPHILIS PRECOCE (I, II, lat < 1 an) (CDC, 2006)

14 Benzathine-PNC-G 2.4 Millions IM x 1 Alternatives: Doxycycline 100 mg p os x 2 x 14 j Tetracycline 500 mg p os x 4 x 14 j F enceintes: Erythromycine 500 mg p os x 4 x 14 j SYPHILIS PRECOCE (I, II, lat < 1 an) (WHO,2004)

15 Benzathine PNC-G: 2.4 Millions IM x q 7j x 3 SYPHILIS TARDIVE (CDC, 2006) (latente > 1an ou durée indéterminée, cardio-vasculaire, gommes)

16 Benzathine PNC-G: 2.4 Millions IM x q 7j x 3 Alternatives: Procaïne PNC-G*: 1.2 Millions IM x 1 x 20 j Doxycycline 100 mg p os x 2 x 30 j Tetracycline 500 mg p os x 4 x 30 j F. enceintes: erythromycine 500 mg p os x 4 x 30 j SYPHILIS TARDIVE (WHO,2004) (latente >1an ou durée indéterminée, cardio-vasculaire, gommes) * Non disponible en France

17 PNC-G cristalline: 3-4 Millions IV q 4 hres x j PNC-procaine*: 2-4 Millions IM x 1 x j + Probenecide: 500mg p os x 4 x j NEURO-SYPHILIS (CDC, 2006) * Non disponible en France

18 PNC-G cristalline: 2-4 Millions IV q 4 hres x 14 j PNC-procaine*: 1,2 Millions IM x 1 x j + Probenecide: 500mg p os x 4 x j Alternative si allergie: Doxycycline 200 mg p os x2 x 30 j Tetracycline 500 mg p os x4 x 30 j NEURO-SYPHILIS (WHO,2004) * Non disponible en France

19 SYPHILIS + GROSSESSE (CDC, 2006) PNC en rapport avec stade evolutif Tetracycline/Doxycycline Allergie PNC: desensibiliser ! OMS: (efficacite ?) Erythromycine 500mg p os x 4 x 30 j

20 PNC-G cristalline: 50,000 unit/kg IV q 8-12 hres x 10 j PNC-procaine*: 50,000 unit/kg IM x 1 x 10 j SYPHILIS CONGENITALE (<2ans) (WHO,2002) * Non disponible en France

21 PNC-G cristalline: 50,000 unit/kg IV q 8-12 hres x j PNC-procaine*: 50,000 unit/kg IM x 1 x j Alternative (si évaluation complète avec PL nég) Benzathine-PNC: 50,000 unit/kg IM x1 SYPHILIS CONGENITALE (CDC, 2006) * Non disponible en France

22 Résistance aux Macrolides à San Francisco, Baltimore, Dublin, Vancouver…. Retrouvée partout où cherchée Mutation 23S du gène ribosomal (rRNA) Extension rapide: 0 à 56% en 4 ans à San Francisco Reserves sur lAzithromycine dans le traitement de Syphilis (King Holmes, NEJM, 353, ,2005 )

23 Metronidazole 2g p os x 1 Ou Tinidazole 2g p os x 1 Alternative: Metronidazole 500 mg x 2 x 7j TRICHOMONASE GENITALE (CDC,2006

24 Metronidazole 2g p os x 1 Tinidazole 2g p os x 1 Alternatives: Metronidazole 500 mg x 2 x 7 j Tinidazole 500 mg x 2 x 5 j TRICHOMONASE GENITALE (WHO,2002

25 Metronidazole 500mg p os x 2 x 7j OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days, OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days. Alternatives: Clindamycin 300 mg orally twice a day for 7 days, OR Clindamycin ovules 100 g intravaginally once at bedtime for 3 days VAGINOSE BACTERIENNE (CDC,2006)

26 Metronidazole 500mg p os x 2 x 7j Alternatives: Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days, OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days. Metronidazole 2 g orally in a single dose, OR Clindamycin 300 mg orally twice a day for 7 days, VAGINOSE BACTERIENNE (WHO,2004)

27 Secnidazole : 1 sachet en une prise Métronidazole per os : 1 g par jour pendant 7 jours En 2ème intention : ß-lactamines pendant 7 jours Traitement local anti-infectieux décevant traiter Jean-Marc Bobo, Institut Alfred Fournier

28 30 % de récidives à 4 semaines Taux de récidives au-delà de 3 mois (1) : 82 % Traitement imidazolé suppressif (2 fois/ semaine pendant 16 semaines) : 70 % de guérison mais 3 mois plus tard : 66 % de récidives (1) 1.SOBEL JD and al Am J Obstet Gynecol 2006 May; 194(5): Vaginose bactérienne Jean-Marc Bobo, Institut Alfred Fournier

29 Parce que Gardnerella vaginalis et Atopobium vaginae sont capables de produire des biofilms qui rendent laction des antibiotiques insuffisante Le traitement antibiotique est nécessaire mais insuffisant Jean-Marc Bobo, Institut Alfred Fournier

30 G. vaginalis – A. vaginae Biofilm révélé par sondes fluorescentes Cavité vaginale Epithélium vaginal Biofilm Jean-Marc Bobo, Institut Alfred Fournier

31 prébiotiques Produits acidifiants favorisant le développement des lactobacilles : Géliofil*, Saugella Intilac* : acide lactique Prévégyne* : acide ascorbique Soit en traitement isolé Soit en complément dun traitement par probiotiques Jean-Marc Bobo, Institut Alfred Fournier

32 probiotiques Lactobacilles de substitution Mais pas nimporte lesquels : Lactobacille rhamnosus : Florgynal gél*, Gynophilus*, Bactigyn gél*… Lactobacille gasseri : Florgynal tampons* Lactobacille crispatus : Mycoress gél* Voie orale : Lactobacille rhamnosus + Lactobacille reuterii : Bion flore intime* Jean-Marc Bobo, Institut Alfred Fournier

33 Cahier des charges pour probiotiques Temps nécessaire pour létablissement dun biofilm efficace : 10 9 bactéries 2 fois par semaine 1 per os ou 3 jours de suite localement 1 Posologies recommandées : localement traitement de 7 jours (ou 3 à 5 jours pendant les règles) per os : durée plus floue 1.Reid G, et al. Probiotic Lactobacillus dose required to restore and maintain a normal vaginal flora. FEMS Immunol Med Microbiol. 2001;32:37–41. Abstract Jean-Marc Bobo, Institut Alfred Fournier

34 Schéma préventif Probiotiques pendant les règles Prébiotique juste après les règles Oestrogènes en cas de signes cliniques ou biologiques dhypo-oestrogénie Jean-Marc Bobo, Institut Alfred Fournier

35 Ciprofloxacin 500 mg orally in a single dose OR Ceftriaxone 125 mg IM in a single dose, OR Cefixime 400 mg orally in a single dose, OR Spectinomycin 2g IM x 1 GONOCOCCIE (WHO,2004) (Urethre, endocol, rectum)

36 Ceftriaxone 125 mg IM in a single dose, OR Cefixime 400 mg orally in a single dose, OR Ciprofloxacin 500 mg orally in a single dose OR Ofloxacin 400 mg orally in a single dose OR Levofloxacin 250 mg orally in a single dose + Tt anti-chlamydia Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days. GONOCOCCIE (CDC,2006) (Urethre, endocol, rectum) MMWR,Apr 13, 2007

37 GONOCOCCIE (alternatives) Spectinomycine 2g IM x 1 Single-dose cephalosporin regimens (other than ceftriaxone 125 mg IM and cefixime 400 mg orally) include ceftizoxime (500 mg, administered IM), cefoxitin (2 g, administered IM with probenecid 1 g orally), and cefotaxime (500 mg, administered IM). Single-dose quinolone regimens include gatifloxacin 400 mg orally, norfloxacin 800 mg orally, and lomefloxacin 400 mg orally (Urethre, endocol, rectum) (CDC,2006) + Traitement anti-chlamydia x 7 jours MMWR,Apr 13, 2007

38 Ceftriaxone 125mg IM x 1 Ciprofloxacine 500mg p os x 1 + Tt anti-chlamydia si diagnostic non éliminé Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice daily for 7 days. GONOCOCCIE PHARYNGEE (CDC, 2006) MMWR,Apr 13, 2007

39 Ceftriaxone 125mg IM x 1 Spectinomycine 2g IM x 1 GONOCOCCIE + GROSSESSE (CDC,2006) + Traitement anti-chlamydia: Azithromycine: 1 g p os x 1 j Ou Amoxicilline: 500 mg per os x3/j x 7j

40 Azithromycine 1 g p os x 1 j Doxyxycline 100mg p os x 2 x 7j Erythromycin base 500 mg orally four times a day for 7 days, OR Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days, OR Ofloxacin 300 mg twice a day for 7 days, OR Levofloxacin 500 mg once daily for 7 days. INFECTION A CHLAMYDIA (CDC, 2006) (Urethre, endocol, rectum)

41 Azithromycine 1 g p os x 1 j Or Doxycycline 100mg p os x 2 x 7j Alternatives: Amoxicilline 500 mg x3 x 7 j Erythromycin base 500 mg orally four times a day for 7 days, OR Tetracycline, 500 mg p os x4 x 7j OR Ofloxacin 300 mg twice a day for 7 days, INFECTION A CHLAMYDIA (WHO,2004) (Urethre, endocol, rectum)

42 SYNDROME INFLAMMATOIRE PELVIEN Cefotetan 2g IV q 12 hres + Doxycycline 100mg p os q 12 hres Cefoxitin 2g IV q 6hres + Doxycycline 100mg p os q 12 hres Clindamycine 900mg IV q 8 hres + Gentamycine 2mg/kg IV stat 1.5mg/kg IV q 8 hres Doxycycline 100mg p os x 2 x 10-14jours (CDC, 2006) Pendant 48 heures au moins Apres Exeat (PID)-CAS HOSPITALISES

43 Ceftriaxone 250mg IM x1 + Doxycycline* 100mg p os x 2 x 10-14j ± Metronidazole 500mg p os x2/j x 14 j Cefoxitin 2g IM x 1 + Probenecide 1g p os x 1 + Doxycycline* 100mg p os x 2 x 10-14j ± Metronidazole 500mg p os x2/j x 14j Ou Traitement entièrement oral : Levofloxacin 500 mg per os x1/j x 14j Ou Ofloxacin 400 mg p os x 1/j x 7 j ± Metronidazole 500mg p os x2/j x 14j SYNDROME INFLAMMATOIRE PELVIEN (CDC, 2006) * ou tetracycline ou erythromycine (PID)-Traitement ambulatoire

44 Podofilox 0.5% solution or gel. The safety of podofilox during pregnancy has not been established. OR Imiquimod 5% cream. The safety of imiquimod during pregnancy has not been established. Podophyllin resin 10%--25% in a compound tincture of benzoin. The safety of podophyllin during pregnancy has not been established. OR Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%--90%. repeated weekly, if necessary. OR Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery. Cryotherapie par Azote liquide: vegetations vaginales ou meatiques vegetations anales ou orales Azote liquide ou cryocautere: vegetations genitales externes vegetations perianales CONDYLOMES VENERIENS (CDC, 2002) (Papillomes veneriens/Cretes de Coq)

45 CONDYLOMES VENERIENS (CDC, 2002) (Papillomes veneriens/Cretes de Coq) Podophylline 10-20% (+teinture de benjoin) Acide trichloro-acetique 80-90% Electrocoagulation/Fulguration Excision chirurgicale Laser surgery FEMMES ENCEINTES

46 (CDC)

47 Gabriele Riedner, M.D., Ph.D., Mary Rusizoka, Dipl.Med., Jim Todd, M.Sc. et al Single-Dose Azithromycin versus Penicillin G Benzathine for the Treatment of Early Syphilis. N Engl J Med 2005;353: (Mbeya Tanzania

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