感染性心内膜炎ppt课件.ppt

7 98 1 UpdateonInfectiveEndocarditis LarryBaddour MDUniversityofTennessee 天马行空官方博客 7 98 2 Pathogenesis DisruptionoftheendocardiallayerasacomplicationofabnormalbloodflowassociatedwithunderlyingcardiacdefectBacterium endotheliuminteractionwithbacterialattachmentandinvasionofendothelialcells 天马行空官方博客 7 98 3 Epidemiology Underlyingvalvularabnormalitypredisposingtoinfectiveendocarditisrheumaticfeveracommoncauseinthepastmitralvalveprolapsecurrentlyrepresentsthemostcommonunderlyingcardiacabnormality 7 98 4 mitralvalveprolapse riskforinfectiveednocarditisis 5x 8xmitralregurgitationincreasestheriskleafletredundancywithmyxomatousdegenerationisafrequentfindingage20 maleaccountsfor60 age 50 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 sidedcardiacinvolvementin 60 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 withantibiotictherapyfor 4daysnopathologicevidenceofIEatsurgeryorautopsy afterantibiotictherapyfor 4days 7 98 13 Diagnostic Duke Criteria MajorcriteriapositivebloodcultureforIEevidenceofendocardialinvolvementMinorcriteriapredisposition heartconditionorIVdruguse feverof100 40Forhighervascularorimmunologicphenomenamicrobiologicorechocardiographicevidencenotmeetingmajorcriteria 7 98 14 Duke sMajorCriteria positivebloodcultureforIEtypicalmicroorganism strepviridans strepbovis HACEKgroup staphaureusorenterococciintheabsenceofaprimarylocus forendocarditisfromtwoseparatebloodculturespersistentlypositivebloodculturefrom bloodculturesdrawnmorethan12hrapart orallof3oramajorityof4ormoreseparatebloodcultures withfirstandlastdrqwnatleast1hrapart 7 98 15 Duke sMajorCriteria Evidenceofendocardialinvolvementpositiveechocardiogramforendocarditisoscillatingintracardiacmassonvalveorsupportingstructure orinthepathofregurgitantjets oronimplantedmaterial intheabsenceofanalternateanatomicexplanationabscessnewpartialdehiscenceofprostheticvalvenewvalvularregurgitation increaseorchangeinpre existingmurmurnotsufficient 7 98 16 Duke sMinorCriteria predisposition predisposingheartconditionorivdruguse feverof100 40Forhighervascularphenomena majorarterialemboli septicpulmonaryinfarcts mycoticaneurysm intracranialhemorrhage conjunctivehemorrhages Janewaylesions 7 98 17 Duke sMinorCriteria immunologicphenomena glomerulonephritis Osler snodes Rothspots rheumatoidfactor microbiologicevidence positivebloodculturenotmeetingmajorcriteriaorserologicevidenceofactiveinfectionwithorganismconsistentwithIE echocardiogram consistentwithIEbutnotmeetingmajorcriteria 7 98 18 RiskforEndocarditis Highriskprostheticcardiacvalvepriorepisodesofendocarditiscomplexcongenitalcardiacdefectsurgicallyconstructedsystemic pulmonaryshuntsorconduits 7 98 19 RiskforEndocarditis ModerateriskpatentductusarteriosusVSD primumASDcoarctationoftheaortabicuspidaorticvalvehypertrophiccardiomyopathyacquiredvalvulardysfunctionMVPwithmitralregurgitation 7 98 20 RiskforEndocarditis LowriskisolatedsecundumatrialseptaldefectASD VSD orPDA 6monthspastrepair 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 dailyceftriaxonefor4wkscurerate 98 easilyadministeredasoutpatient avoidhospitalization offerssignificantcostsavingsOnce dailyceftriaxone2gfor2wksfollowedbyoralamoxicillinqidfor2wksOnce dailyceftriazoneandnetilmicinfor2wks 7 98 24 NewTreatments Prostheticvalveendocarditisduetofluconazole susceptibleCandidaspeciesmanyareduetobloodstreaminvasionchronicoralsuppressivetherapywithfluconazoleforinoperabledisease 7 98 25 SBEProphylaxis StandardgeneralprophylaxisamoxicillinUnabletotakeor