Perfectionnement

Les infections en pratique – Partie 2 «prévention et thérapie»

COVID-19, la grippe et les ­syndromes grippaux

DOI: https://doi.org/10.4414/phc-f.2021.10324
Date de publication: 06.01.2021
Prim Hosp Care Med Int Gen. 2021;21(01):16-20

Léna Dietricha,b, Marta Abreu De Azevedoa,c, Sebastian Wirza, Tobias Romera, Lisa Schmid-Thurneysena, Helmut Raschd, Michael J. Demle, Jürg Fröhlichf, Romeo Providolig, Thomas Ernsth, Muhannad Seyamh, Meliha Jusufoskaa,c, Josipa Tolica,c, Suzanne Suggsi, Caesar Gallmannj, Philipp Buschek, Bernhard Wingeierl, Lukas Schöbk, Anne Meynardm, Oliver Hausmannnn, Domenica Fluryo, Alexandra Röllinp, Helen Kovariq, Charles Béguelinr,s, Barbara Hasset, Gisela Etteru, Benedikt Huberv, Philip Tarra

a Medizinische Universitätsklinik, Infektiologie und Spitalhygiene, Kantonsspital Baselland, Bruderholz, Universität Basel; b Regionalspital Rheinfelden, Chirurgische Klinik, Gesundheitszentrum Fricktal AG; c Pharmaceutical Research Care Group, Universität Basel; d Klinik für Radiologie, Kantonsspital Baselland; e Swiss Tropical and Public Health Institute und Universität Basel; f FMH Allg. Innere Medizin, Bern; g FMH Allg. Innere Medizin, Sierre; h ­Regionalspital Rheinfelden, Medizinische Klinik, Gesundheitszentrum Fricktal AG; i Institute for Public Health and Institute for Public Communication, Università della Svizzera italiana, Lugano; j FMH Allg. Innere Medizin, Au ZH; k Klinik für Innere Medizin, Klinik Arlesheim BL; l Abteilung Pädiatrie, Klinik Arlesheim BL; m Médecine Générale FMH, Centre Médical de Lancy GE, UIGP, Faculté de medicine, Université de Genève; n Löwenpraxis und Klinik St. Anna Luzern, ADR-AC GmbH Bern; o Klinik für Infektiologie und Spitalhygiene, Kantonsspital St. Gallen; p FMH Allgemeine Innere Medizin Bern; q Zentrum für Infektionskrankheiten, Klinik im Park, Zürich; r Medizinische Klinik, Infektiologie und Spitalhygiene, Centre Hospitalier, Bienne; s Universitätsklinik für Infektiologie, Universitätsspital Bern, Universität Bern; t Klinik für Infektiologie und Spitalhygiene, Universitätsspital Zürich, Universität Zürich; u FMH Allg. Innere Medizin, Richterswil; v Klinik für Pädiatrie, Hôpital Fribourgeois, Universität Fribourg

Les mesures de distance et d’hygiène sont efficaces en termes de prévention contre la grippe et la COVID-19. Les patient.e.s COVID-19 hospitalisé.e.s souffrant de pneumonie sont actuellement traité.e.s par la dexaméthasone avec ou sans remdesivir. Les événements thromboemboliques doivent être recherchés et prévenus à bas seuil. Un vaccin efficace et sûr contre le SRAS-CoV-2 représente un énorme défi. Nous devrons probablement vivre avec le SRAS-CoV-2 pendant des années.

Série Infectiologie

Dans la pratique, les infections et les défenses immunitaires sont des thèmes centraux. Ils offrent d’ex­cellentes opportunités de ­collaboration interdisciplinaire, de vérification de concepts courants et d’intégration de méthodes des médecines complémentaires. Philip Tarr est interniste et infectiologue à ­l’hôpital cantonal de Bâle-­Campagne, et il mène un programme national de recherche PNR 74 sur le scepticisme vis-à-vis des vaccins. Il attache beaucoup d’importance à une médecine centrée sur les patients ainsi qu’à des ­articles pertinents pour la pratique, que nous allons publier régulièrement dans cette série du Primary and Hospital Care.

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Prévention

Selon le Conseil fédéral, des mesures de distance et d’hygiène efficaces, peu limitatives et peu coûteuses doivent permettre de contrôler l’épidémie suisse de COVID-19 (tab. 1) [144]; des mesures drastiques (telles que la nouvelle fermeture d’écoles, de magasins, de restaurants, etc.) ne sont à nouveau prévues qu’en cas d’urgence et à un niveau local [144].

Tableau 1: Mesures de prévention efficaces contre la COVID-19 et la grippe dans les cabinets médicaux et les hôpitaux [154–156].
– Une combinaison de mesures est plus efficace que des mesures individuelles [157–163]
– Une communication cohérente [164]
– Désinfection régulière des mains [165]; tousser et éternuer dans un mouchoir/le coude – après désinfection des mains
– Port de masques chirurgicaux à tous les contacts <1,5 mètres [166]
 • Les patient.e.s portent un masque chirurgical lorsqu’ils quittent la chambre et lorsque le personnel entre dans la chambre
– Créer une distance suffisante avec les patient.e.s [165]
– Isolement des gouttelettes des patient.e.s hospitalisé.e.s
 • Désisolement COVID-19 après >48 heures sans fièvre et avec soulagement des symptômes [154] plus:
  • >10 jours après l’apparition des symptômes (lors du retour à domicile)
  • >14 jours après l’apparition des symptômes (lors du transfert vers une autre unité médical, un EMS, un centre de réadaptation)
  • >21 jours après l’apparition des symptômes (si le patient a été aux soins intensifs – consulter un.e infectiologue en cas d’immunosuppression)
 • Désisolement grippe après cinq jours, si les symptômes s’améliorent (pour l’immunosuppression et les patient.e.s aux soins: consulter un.e infectiologue
– Port d’un masque FFP2 lors d’activités génératrices d’aérosols* [154, 325]
 • Influenza
  • Proposer la vaccination aux employés de manière simple, peu contraignante et gratuite
  • Vaccination des patient.e.s à risque [8]
* Intubation, aspiration en circuit ouvert, bronchoscopie, ventilation non invasive, ventilation invasive par trachéotomie, expectoration induite, ventilation à haute fréquence/High Flow (Optiflow), instauration d’une trachéotomie, endoscopie gastro-intestinale supérieure, y compris CPRE.

Un mode de vie sain peut-il aider à se protéger contre la grippe ou la COVID-19?

Voir notre article dans PHC 11/2019 [145]. Les mesures immunostimulantes et donc éventuellement préventives contre le rhume et la grippe sont une durée de sommeil >7 heures [146], des gargarismes réguliers avec de l’eau [145, 147], la substitution de la vitamine D [148, 149] et la consommation prophylactique d’échinacée [150–153]. Ces mesures pourraient également protéger contre la COVID-19, mais on ne dispose pas encore de données à ce sujet.

Pendant combien de temps les patient.e.s COVID-19 sont-ils contagieux.eses?

Le SRAS-CoV-2 est le plus contagieux au début des symptômes et un ou deux jours avant – après l’apparition des symptômes, le risque d’infection et la charge virale dans le nasopharynx diminuent progressivement [346]. Les virus vivants et contagieux du SRAS-CoV-2 n’ont pas été détectés dans la culture virale après plus de neuf jours après l’apparition des symptômes (dans les cas graves jusqu’au 20e jour au maximum) [27, 117–119], même si l’ARN du virus peut encore être détecté par PCR deux à cinq semaines plus tard. Les virus vivants du SRAS-CoV-2 n’ont pratiquement jamais été détectés dans les urines, les selles ou le sang [118].

Où peut-on attraper la grippe et la COVID-19?

Le plus souvent en contact direct et étroit avec d’autres personnes malades (ménage, loisirs, travail) [38]. Environ 10 à 25% [34, 169–173] et 9 à 13% [78] (apparemment jusqu’à 50% aux États-Unis [347]) des membres d’un même ménage peuvent être infectés par le virus de la grippe ou de la COVID-19. À titre de comparaison: plus de 60 à 80% des membres non vaccinés d’un ménage sont infectés par une personne malade en cas de varicelle et de rougeole [174, 175]. Les travailleurs de la santé ne semblent pas présenter un risque accru de contracter la grippe [176] et en Suisse, ils sont rarement infectés par SRAS-Cov-2; la prévalence des anticorps du SRAS-Cov-2 chez le personnel de santé suisse n’était pas plus élevée que dans la population générale [177].

Comment la grippe et la COVID-19 sont-ils transmis?

Les virus respiratoires sont généralement transmis principalement à l’intérieur et par des gouttelettes [178, 179]. Cela nécessite probablement un temps d’exposition ­minimum d’environ 15 minutes, sauf dans le cas des contacts particulièrement intensifs, par exemple dans des salles fermées et bondées. La musique forte favorise l’approche, la voix haute et donc la transmission du virus.

La grippe et la COVID-19 se transmettent-ils par des virus sur les surfaces?

À peine. Bien que les ARN du SRAS-CoV-2 et de la grippe puissent encore être détectés sur des surfaces après plusieurs jours, il s’agit probablement de virus non infectieux, mais seulement de leur ARN «mort» [180]. Le nombre, la viabilité et donc l’infectiosité des coronavirus et des virus de la grippe sur les surfaces diminuent considérablement en quelques heures en raison de la sécheresse et du rayonnement UV – les virus sur les surfaces ne contribuent probablement que modestement à l’infection d’autres personnes [8].

La grippe et la COVID-19 se transmettent-ils par les mains?

Oui. La transmission peut avoir lieu en contact direct et étroit avec les mains (qui sont contaminées par des sécrétions respiratoires et des virus).

Dois-je utiliser un savon antimicrobien pour me laver les mains?

Non. Dans la vie quotidienne, les savons normaux suffisent – les savons antimicrobiens n’ont pas un effet plus puissant pour réduire le risque d’infections respiratoires, de vomissements, de diarrhées et d’infections cutannées [159, 181, 182].

La grippe et la COVID-19 sont-ils transmis par des aérosols qui flottent dans l’air pendant des heures?

Les aérosols (minuscules particules de moins de 5 μm taille) [183] sont considérés beaucoup moins importants que les gouttelettes en termes de potentiel d’infection [184]. Selon les études [185] et les directives actuelles de l’OMS et de swissnoso, l’aérosolisation et donc la transmission «aérogène» des virus de la grippe n’a pas lieu, et dans le cas des virus du SRAS-CoV-2 seulement exceptionnellement [154, 325] – à savoir lorsque de nombreuses personnes se trouvent dans des pièces étroites et mal ventilées, et surtout lorsqu’elles chantent ou crient [186] et dans les hôpitaux lors d’activités génératrices d’aérosols telles que la ventilation non invasive (Tab. 1) [154, 183, 184]. Les résultats experimentaux alarmants doivent être interprétés de manière très critique: Les aérosols produits de l’homme ont une portée limitée et les virus SRAS-CoV-2 qu’ils contiennent ont une durée de vie courte [187].

Quels masques me protègent efficacement contre l’infection par la grippe ou la COVID-19?

La non-infection par COVID-19 de milliers de médecins et d’infirmières suisses en contact direct avec des patient.e.s COVID-19 montre que les masques chirurgicaux offrent une protection efficace [188]. La communication avec les autorités a été adaptée en conséquence [189]. Selon swissnoso, un masque chirurgical est suffisant pour protéger des infections par la grippe et le SRAS-CoV-2 [154]; un masque FFP2 n’est recommandé que pour les activités génératrices d’aérosols [154]. Selon l’OMS [154] et des études d’observation [190–192], les masques FFP2 ne protègent pas plus efficacement que les masques chirurgicaux contre l’infection par la grippe, le SRAS ou la COVID-19. Une nouvelle méta-analyse confirme le bon effet protecteur des masques chirurgicaux [196]. D’ailleurs, dans plus de 80 à 90% des cas, le personnel hospitalier n’attrape la grippe pas au travail mais pendant son temps libre [38, 81, 193–195]. Cela pourrait être la raison de l’efficacité similaire des masques chirurgicaux et FFP2 dans deux études randomisées parmi le personnel de santé ambulatoire [190, 191]. Comme les masques chirurgicaux ne sont pas étanches à 100%, ils permettent – selon une nouvelle hypothèse importante – le passage d’un petit nombre des virus du SRAS-CoV-2, ce qui favorise l’immunité contre le SRAS-CoV-2, mais ne suffit pas à infecter les porteurs de masque [326].

Le «grand public» doit-il porter des masques chirurgicaux?

Le port d’un masque chirurgical aux contacts <1,5 m, en particulier à l’intérieur, est une contribution importante au contrôle d’une pandémie de COVID-19 ou de grippe [160, 164]. Nous devrions appliquer le principe de précaution et porter des masques en lieu d’attendre les résultats des études randomisées [160, 182, 197–201]. Dans certains pays d’Asie orientale, les masques font partie de la vie quotidienne depuis de nombreuses années, et le nombre de cas COVID-19 est beaucoup plus bas qu’en Suisse [93]. Les masques en tissu [204] sont clairement moins efficaces que les masques chirurgicaux [205]; les travailleurs de la santé ne doivent pas les utiliser pour des raisons de sécurité [206].

Comment pouvons-nous prévenir la transmission du COVID-19 et de la grippe sans vaccination obligatoire au cabinet medical et à l’hôpital?

Le port du masque chirurgical dans tous les contacts entre le personnel et les patient.e.s a été introduit dans tous les hôpitaux suisses – la plupart du temps sans discussion et sans stigmatisation inutile [207]!

Traitement de la grippe

Un bon soulagement des symptômes (grâce aux produits naturels, aux plantes, et la médecine complémentaire [208], éventuellement l’utilisation de para­cétamol ou d’AINS), le repos et un apport hydrique adéquat sont les points clés d’un bon traitement de la grippe. Ces mesures augmentent également le bien-être grâce à une attention bienveillante. La fièvre ne doit être réduite que modérément et si l’état général est altéré, car la fièvre joue un rôle important dans la défense contre les infections. Une thérapie antivirale à l’oseltamivir est également disponible en cas de grippe. Au cours des dix dernières années, de nombreux rapports critiques sur l’oseltamivir ont été publiés, avec des références aux publications sélectives des études ayant des résultats favorables et sans preuve que l’oseltamivir réduit la mortalité chez des adultes en bonne santé habituelle [209–213, 214, 215].

Chez quels patient.e.s l’oseltamivir est-il indiqué?

Chez les patient.e.s hospitalisé.e.s et les patient.e.s à risque (tab. 2). Chez ces patient.e.s, l’oseltamivir réduit la durée des symptômes, l’utilisation d’antibiotiques et le taux d’hospitalisation [216]. Les patient.e.s en bonne santé qui peuvent être traités en ambulatoire n’ont pas besoin d’oseltamivir. On s’attend à ce qu’ils présentent une évolution bénigne et un taux de complications très faible; la durée des symptômes et l’excrétion virale ne sont que très peu réduites avec l’oseltamivir [168].

Tableau 2: Oseltamivir: les faits les plus importants en bref.
Propriétés
– Inhibiteur de la neuraminidase
– Disponible en capsules de 30, 45 et 75 mg et en poudre pour la préparation d’une suspension
– Début de la thérapie: dès que possible après l’apparition des symptômes (idéalement dans les 48 heures) [5]
Dosage
– Patient.e.s à partir de 13 ans: 75 mg 2×/j pendant 5 jours (immunosuppression: éventuellement plus longtemps)
– Il n’est plus recommandé de doubler la dose au début de la thérapie ou chez les patient.e.s obèses [222, 223]
– Dosage en cas de l’insuffisance rénale:
 • eGFR 30-60 mL/min: 30 mg 2×/j pendant 5 jours
 • eGFR 10-30 mL/min: Dosage 30 mg 1×/j pendant 5 jours
Indication
– Patient.e.s hospitalisé.e.s et patient.e.s à risque ambulatoires atteint.e.s de grippe A et B
– Aucune efficacité connue contre d’autres virus
– La résistance n’est connue que dans des cas exceptionnels
Effet
– Réduit la durée des symptômes chez:
 • les jeunes personnes en bonne santé d’environ un jour [216, 219]
 • les personnes âgées et polymorbides d’environ 2 à 3 jours [219]
 • Chez les enfants: durée plus courte des symptômes [224]; risque plus faible d’otite moyenne aiguë, surtout à l’âge de 1 à 5 ans [76, 225]
Effets indésirables
– Nausées et vomissements: environ 10% des patient.e.s [216, 225]
– Rarement: effets secondaires neuropsychiatriques (somnolence, altération de la conscience et confusion); comportement anormal [226], surtout chez les jeunes hommes [226–228]

Quelle est l’efficacité de l’oseltamivir si je ne commence à le prendre que 72 à 96 heures après l’apparition des symptômes?

Au point de l’apparition des symptômes, la charge virale est la plus élevée et donc l’oseltamivir a la plus grande efficacité [5]. Si le traitement est commencé dans les cinq premiers jours, l’hospitalisation, les cas graves et les décès peuvent être réduits [216, 168, 217, 218]. Il existe donc des données qui justifient l’utilisation de l’oseltamivir >48 heures après l’apparition des symptômes [219] ou le plus tôt possible après l’hospitalisation [220, 221] chez les patient.e.s à risque et les personnes gravement malades.

Quelle est l’efficacité des produits immunostimulants comme l’échinacée?

Echinacea purpurea a une activité immunomodulatrice et peut-être aussi une activité antivirale directe contre les virus de la grippe in vitro [231, 232]. Dans une étude randomisée avec 473 patient.e.s, l’échinacée s’est révélée aussi efficace que l’oseltamivir, que le patient soit atteint de grippe ou d’un syndrôme grippal (ILI): 90% contre 85% de patient.e.s ne présentaient plus de symptômes avec l’échinacée contre l’oseltamivir au dixième jour et les effets indésirables étant légèrement moindres [225, 232].

L’oseltamivir est-il aussi efficace contre les ILI?

Un effet antiviral de l’oseltamivir contre les virus non-influenza n’est pas connu [216]. Cependant, dans une étude randomisée, les patient.e.s atteint.e.s des ILI sans influenza documenté présentaient également une durée de symptômes plus courte sous l’oseltamivir [219]. Il s’agit probablement d’un effet immunomodulateur favorable [219].

Le favipiravir est-il un médicament prometteur?

Les premiers résultats d’une étude indiquent une récupération et une chute plus rapide de l’ARN de la grippe lorsque l’oseltamivir est administré en association avec le favipiravir [233], un médicament antiviral efficace contre les virus ARN tels que la grippe et le virus ebola.

Traitement de la COVID-19

La COVID-19 est une nouvelle maladie dont les données sur les options thérapeutiques recommandées évoluent rapidement [234]. Jusqu’à présent, aucune thérapie COVID-19 hautement efficace n’a été documentée (tab. 3). En Suisse, actuellement, une thérapie antivirale précoce avec le remdesivir et une immunomodulation/-suppression avec la dexaméthasone sont utilisées pour les patient.e.s hospitalisé.e.s nécessitant une oxygénothérapie.

Vaccination contre la COVID-19

Moins d’un an après le début de la pandémie, les chercheurs ont déjà dévelopé 3 vaccins. Lors des études randomisées avec plus de 30 000 personnes chacun, les vaccins à base d’ARNm se sont révélés très efficaces et – 2 mois après la deuxième dose de vaccin – aucun effet secondaire grave n’est apparu. Selon l’OFSP, il faudra au moins jusqu’au printemps 2021 avant que la vaccination puisse être proposée à la population générale (tab. 3).

Tableau 3: Situation actuelle (1/11/2020) des options thérapeutiques en cas de COVID-19.
1) Thérapie antivirale
Remdesivir
– Deux études contrôlées et randomisées montrent une efficacité modeste:
 • Réduction de la durée des symptômes si la thérapie est commencée dans les 10 jours de l’apparition des symptômes [240]
 • Réduction de la durée des symptômes (de 15 à 10 jours en moyenne) uniquement chez les patient.e.s hospitalisé.e.s sous oxygénothérapie, sans effet sur la mortalité; [241, 327]; inefficace dans les unités de soins intensifs (ventilation mécanique)
 • Inefficace dans l’étude randomisée Solidarity de l’OMS [328]
• Suisse: thérapie de cinq jours pour les patient.e.s hospitalisé.e.s dans l’unité ­normale avec besoin en oxygène
– Disponibilité limitée; commander via l’OFSP [329]
2) Thérapie immunomodulatrice
Corticostéroïdes
– La dexaméthasone (6 mg PO/IV par jour pendant 10 jours) a réduit la mortalité de 20% dans une grande étude randomisée britannique (6425 patient.e.s hospitalisé.e.s)
 • La mortalité dans cette étude était généralement >trois fois plus élevée qu’en Suisse [248]
 • Dans d’autres études, l’efficacité de la dexaméthasone était moins prononcée [330–335]
– Indication de la dexaméthasone en Suisse: patient.e.s hospitalisé.e.s sous oxygénothérapie, y compris en unité de soins intensifs
 • Relativement contre-indiqué chez les patient.e.s légèrement malades (sans oxygène ou en ambulatoire) [249]; la dexaméthasone peut augmenter la mortalité [248]
Autres thérapies immunomodulatrices:
– Tocilizumab: efficacité modeste, pas d’effet sur la mortalité [336]
– À la mi-octobre 2020, le NIH américain a lancé la grande étude randomisée de phase III ACTIV dans laquelle l’infliximab, l’abatacept et le cénicriviroc sont testés [337]
– Hydroxychloroquine: inefficace, non recommandée, même en combinasion avec l’azithromycine [338]
3) Infusion de plasma de convalescence (plasma provenant des convalescent.e.s de COVID-19)
– Pas encore d’études contrôlées [267], efficacité possible [239, 268, 269]
4) Prophylaxie de la thromboembolie veineuse / anticoagulation (un article sur ce sujet sera publié dans un futur numéro de PHC en 2021)
– Les événements thromboemboliques pourraient être plus fréquents dans les cas COVID-19 [102, 103, 270–273], les données ne sont pas uniformes [104, 274]
– L’anticoagulation thérapeutique de tous les patient.e.s COVID-19 n’est pas recommandée, en particulier pas pour les patient.e.s ambulatoires
– À l’hôpital: prophylaxie standard de la thrombose [275–277]; éventuellement prophylaxie intensifiée avec de l’héparine de bas poids moléculaire dans des situations particulières (par exemple, déxamethasone, soins intensifs, D-dimères >3 ug/ml) [278, 279]
5) Vaccination contre la COVID-19 [280, 281, 339]
– Les défis sont énormes:
 • Jamais auparavant une vaccination contre un coronavirus n’avait été développée avec succès
 • Jamais auparavant une vaccination sûre et efficace basée sur la technologie de l’ARNm n’avait été développée avec succès
 • Jamais auparavant une vaccination sûre et efficace n’avait été mise sur le marché dans un délai d’un à trois ans après le début de la recherche/le développement
– La politisation de la vaccination est déjà en cours [282]
– Une communication transparente, culturellement appropriée et linguistiquement compétente sur l’efficacité et la sécurité favorisera la confiance dans la vaccination COVID-19 [283, 340, 341]
– Une obligation de vaccination est en cours de discussion aux Etats-Unis et ailleurs [284, 285, 287], mais est hors de question en Suisse selon l’OFSP [284, 286]
Note


La partie 1 de cet article a été publiée dans le PHC 12 du 2/12/2020:

https://primary-hospital-care.ch/article/doi/phc-d.2020.10323.

Disclosure statement

OH: emploi à temps partiel chez ADR-AC GmbH à Berne, qui effectue des tests immunologiques pour le SARS-CoV-2 et autres. Tous les autres auteurs: pas de conflits d’intérêts.

Adresse de correspondance

Prof. Dr. med. Philip Tarr
Medizinische ­Universitätsklinik, ­Kantonsspital Baselland
CH-4101 Bruderholz
philip.tarr[at]unibas.ch

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Les références les plus importantes

– Recommandations actualisées sur la thérapie COVID-19 des US National Institutes of Health: https://www.COVID19treatmentguidelines.nih.gov/whats-new/

– Recommandations actualisées sur la thérapie COVID-19 du Brigham and Women’s Hospital de Boston: https://covidprotocols.org

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