【医学课件】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,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,StandardgeneralprophylaxisamoxicillinUnabletotakeoral