Infections nosocomiales, de l’application orthodoxe des textes

FlickR - PhotonQ-Chemotaxis - PhotonquantiqueVoici un arrêt de la cour administrative d’appel de Nancy ((CAA Nancy, 9 avril 2009, Titeux, n°07NC01678.)) dans la plus pure tradition de la jurisprudence administrative portant sur la question récurrente de la responsabilité hospitalière du fait des infections nosocomiales. Les faits de l’espèce à l’origine du litige sont tout aussi classiques. Une patiente a subi le 16 janvier 2002 une intervention chirurgicale au centre hospitalier universitaire de Reims afin de réaliser la reprise de sa prothèse de genou gauche. Une infection est découverte le 30 octobre 2002, après que son médecin traitant eut procédé en août à l’incision d’un kyste graisseux situé au niveau du même genou.

Elle a alors demandé l’engagement de la responsabilité du centre hospitalier du fait de l’infection nosocomiale qu’elle soutient avoir contracté lors de son hospitalisation.

Que dit exactement l’arrêt ?

« Considérant qu’aux termes de l’article L. 1142-1 du code de la santé publique : (..) Les établissements, services et organismes susmentionnés sont responsables des dommages provenant d’infections nosocomiales, sauf s’ils rapportent la preuve d’une cause étrangère (..) ;

Considérant qu’il résulte de l’instruction, et notamment des termes du rapport de des experts désignés au cours de la procédure amiable suivie devant la commission régionale de conciliation et d’indemnisation des accidents médicaux de Champagne Ardenne, que, consécutivement à l’intervention chirurgicale pratiquée le 16 janvier 2002 au centre hospitalier universitaire de Reims afin de réaliser la reprise de sa prothèse de genou gauche, Mme X n’a présenté aucun épisode inflammatoire, aucune élévation de température et aucun écoulement cicatriciel qui aurait pu traduire une éventuelle infection postopératoire ;

En l’espèce, la cour se réfère au caractère nosocomial de l’infection résultant de la pose d’une prothèse qui, selon les spécialistes, peut apparaître jusqu’à un an après l’intervention, si l’on se réfère au Recueil intitulé « Les 100 recommandations pour la surveillance et la prévention des infections nosocomiales », auquel renvoie la circulaire DGS/DHOS/E2 n°645 du 29 décembre 2000.

qu’en revanche, après que son médecin traitant a, fin juillet début août 2002, procédé à l’incision d’un kyste graisseux sur une tuméfaction fluctuante molle situé au niveau de son genou gauche, un écoulement est apparu deux jours plus tard au niveau des trois fils de suture qui avaient été posés, écoulement qui persista pendant deux mois et nécessita des soins infirmiers ;

L’infection étant apparue moins d’un an après son hospitalisation, les magistrats se fondent sur l’intervention ultérieure du médecin traitant – lequel est un fait du tiers constitutif d’une cause exonératoire de responsabilité du centre hospitalier.

que, dans ces conditions, eu égard au surplus au délai écoulé entre l’hospitalisation du mois de janvier 2002 et la découverte de l’infection le 30 octobre 2002 ainsi qu’au caractère non spécifiquement hospitalier de la bactérie identifiée, le staphylocoque meticillino-sensible, l’hôpital intimé doit être regardé comme établissant l’existence d’une cause étrangère à l’infection dont a été victime Mme X de nature à l’exonérer de sa responsabilité sur le fondement des dispositions précitées du code de la santé publique ; »

Ici, on le voit, la juridiction administrative se fonde sur le long délai s’étant écoulé entre l’hospitalisation et la date de la découverte de l’infection et sur le « caractère non spécifiquement hospitalier de la bactérie identifiée » pour écarter la responsabilité de l’établissement de santé. A supposer que des hémocultures aient eu lieu quelques jours seulement après l’intervention du médecin traitant, dès l’apparition de l’écoulement, ce que rien ne laissait entendre, le lien entre l’infection et la pose de prothèse aurait été, de toute façon, très difficile à établir.

Ce faisant, les juges d’appel se fondent sur un faisceau d’indices pour écarter la repsonsabilité du centre hospitalier. La seule possibilité pour la victime serait de rechercher la responsabilité du médecin traitant. Encore faut-il pour cela apporter la preuve d’une faute commise par celui-ci. On peut penser à une faute d’asepsie, par exemple. Mais là tout se complique en ce qu’il s’agit d’une preuve extrêmement difficile à rapporter. Et la victime se retrouve, en quelque sorte et toutes proportions gardées, Gros-Jean comme devant.

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