感染性心内膜炎PPT课件.ppt

7/98,1,updateoninfectiveendocarditis,larrybaddour,mduniversityoftennessee,7/98,2,pathogenesis,disruptionoftheendocardiallayerasacomplicationofabnormalbloodflowassociatedwithunderlyingcardiacdefectbacterium-endotheliuminteractionwithbacterialattachmentandinvasionofendothelialcells,7/98,3,epidemiology,underlyingvalvularabnormalitypredisposingtoinfectiveendocarditisrheumaticfeveracommoncauseinthepastmitralvalveprolapsecurrentlyrepresentsthemostcommonunderlyingcardiacabnormality,7/98,4,mitralvalveprolapse,riskforinfectiveednocarditisis5x-8xmitralregurgitationincreasestheriskleafletredundancywithmyxomatousdegenerationisafrequentfindingage20,maleaccountsfor60%age50,maleaccountsfor68%,7/98,5,mitralvalveprolapseandinfectiveendocarditis,male,female,numberofcases,revinfectdis1986;8:117-137,7/98,6,coagulase-negativestaphylococci,canproducenative-valveendocarditisinmitralvalveprolapseusuallysubacute,difficulttodiagnose,anddisregardedasacontaminantdelayindiagnosisandtreatmentmayaccountfortheseverecomplicationsmyocardialabscessformationvalvularinsufficiencyrequiringvalvesurgerydeath,7/98,7,prostheticheartvalve,positivebloodcultureinhospitalizedpatientswithunderlyingprostheticvalvescanbeaharbingerofendocarditis43%patientswithnosocomialbacteremiaorfungemiahadprostheticvalveinfectionaseriouscomplication,7/98,8,ivdruguse,recurrentpolymicrobialstaphaureusaccountsforthemajorityofcasesofendocarditistricuspidvalve,eitheraloneorincombination,usmostofteninfected,7/98,9,predisposingfactorspolymicrobialinfectiveendocarditis,7/98,10,polymicrobialinfectiveendocarditisclinicalfeatures,ivdruguseisthepredominantriskfactoryoungerage(mean36.5years)2/3weremaleright-sidedcardiacinvolvementin60%streptococcimorefrequentthans.aureus1/3ofpatientsdiedmortalityrateis4xhigherforpureleft-sidesvspureright-sidedendocarditis,7/98,11,diagnostic(duke)criteria,definitiveinfectiveendocarditispathologiccriteriamicroorganismsorpathologiclesions:demonstratedbycultureorhistologyinavegetation,orinavegetationthathasembolized,orinanintracardiacabscessclinicalcriteria(seebelow)twomajorcriteria,oronemajorandthreeminorcriteria,orfiveminorcriteria,7/98,12,diagnostic(duke)criteria,possibleinfectiveendocarditisfindingsconsistentofiethatfallshortof“definite”,butnot“rejected”rejectedfirmalternatedxformanifestationofieresolutionofmanifestationsofie,withantibiotictherapyfor4daysnopathologicevidenceofieatsurgeryorautopsy,afterantibiotictherapyfor4days,7/98,13,diagnostic(duke)criteria,majorcriteriapositivebloodcultureforieevidenceofendocardialinvolvementminorcriteriapredisposition(heartconditionorivdruguse)feverof100.40forhighervascularorimmunologicphenomenamicrobiologicorechocardiographicevidencenotmeetingmajorcriteria,7/98,14,dukesmajorcriteria,positivebloodcultureforietypicalmicroorganism(strepviridans,strepbovis,hacekgroup,staphaureusorenterococciintheabsenceofaprimarylocus)forendocarditisfromtwoseparatebloodculturespersistentlypositivebloodculturefrom:bloodculturesdrawnmorethan12hrapart,orallof3oramajorityof4ormoreseparatebloodcultures,withfirstandlastdrqwnatleast1hrapart,7/98,15,dukesmajorcriteria,evidenceofendocardialinvolvementpositiveechocardiogramforendocarditisoscillatingintracardiacmassonvalveorsupportingstructure,orinthepathofregurgitantjets,oronimplantedmaterial,intheabsenceofanalternateanatomicexplanationabscessnewpartialdehiscenceofprostheticvalvenewvalvularregurgitation(increaseorchangeinpre-existingmurmurnotsufficient),7/98,16,dukesminorcriteria,predisposition(predisposingheartconditionorivdruguse)feverof100.40forhighervascularphenomena(majorarterialemboli,septicpulmonaryinfarcts,mycoticaneurysm,intracranialhemorrhage,conjunctivehemorrhages,janewaylesions),7/98,17,dukesminorcriteria,immunologicphenomena(glomerulonephritis,oslersnodes,rothspots,rheumatoidfactor)microbiologicevidence(positivebloodculturenotmeetingmajorcriteriaorserologicevidenceofactiveinfectionwithorganismconsistentwithie)echocardiogram(consistentwithiebutnotmeetingmajorcriteria),7/98,18,riskforendocarditis,highriskprostheticcardiacvalvepriorepisodesofendocarditiscomplexcongenitalcardiacdefectsurgicallyconstructedsystemic-pulmonaryshuntsorconduits,7/98,19,riskforendocarditis,moderateriskpatentductusarteriosusvsd,primumasdcoarctationoftheaortabicuspidaorticvalvehypertrophiccardiomyopathyacquiredvalvulardysfunctionmvpwithmitralregurgitation,7/98,20,riskforendocarditis,lowriskisolatedsecundumatrialseptaldefectasd,vsd,orpda6monthspastrepair“innocent”heartmurmurbyauscultationinthepediatricpopulation“innocent”heartmurmurbyechocardiographyinadultpatients,7/98,21,treatment,pre-antibioticera-adeathsentenceantibioticeramicrobiologiccureinmajorityofpatients,7/98,22,newtreatments,right-sidedinfectiveendocarditisduetomethicillin-susceptiblesaureus(mssa)inivdrugusers2-wktherapywithapenicillinase-resistantpenicillinandanaminoglycoside2-wkmonotherapywithivcloxacillinshort-termtherapyisinappropriateifcomplicatedbyostomyelitis,meningitis,myocardialabscess,orconcomitantleft-sidedinvolvement,7/98,23,newtreatments,highlypenicillin-susceptiblestreptococcusviridansorbovisonce-dailyceftriaxonefor4wkscurerate98%easilyadministeredasoutpatient,avoidhospitalization,offerssignificantcostsavingsonce-dailyceftriaxone2gfor2wksfollowedbyoralamoxicillinqidfor2wksonce-dailyceftriazoneandnetilmicinfor2wks,7/98,24,newtreatments,prostheticvalveendocarditisduetofluconazole-susceptiblecandidaspeciesmanyareduetobloodstreaminvasionchronicoralsuppressivetherapywithfluconazoleforinoperabledisease,7/98,25,sbeprophylaxis,standardgeneralprophylaxisamoxicillinunabletotakeoralme