感染性心内膜炎英文课件

Updateon

InfectiveEndocarditisLarryBaddour,MDUniversityofTennessee7/981PathogenesisDisruptionoftheendocardiallayerasacomplicationofabnormalbloodflowassociatedwithunderlyingcardiacdefectBacterium-endotheliuminteractionwithbacterialattachmentandinvasionofendothelialcells7/982EpidemiologyUnderlyingvalvularabnormalitypredisposingtoinfectiveendocarditisrheumaticfever

acommoncauseinthepastmitralvalveprolapse

currentlyrepresentsthemostcommonunderlyingcardiacabnormality7/983mitralvalveprolapseriskforinfectiveednocarditisis5x-8xmitralregurgitationincreasestheriskleafletredundancywithmyxomatousdegenerationisafrequentfindingage<20,femalepredominate

age>20,maleaccountsfor60%

age>50,maleaccountsfor68%7/984MitralValveProlapse

andInfectiveEndocarditisMaleFemaleNumberofcasesRevInfectDis1986;8:117-1377/985Coagulase-negativeStaphylococcicanproducenative-valveendocarditisinmitralvalveprolapseusuallysubacute,difficulttodiagnose,anddisregardedasacontaminantdelayindiagnosisandtreatmentmayaccountfortheseverecomplicationsmyocardialabscessformationvalvularinsufficiencyrequiringvalvesurgerydeath7/986ProstheticHeartValvepositivebloodcultureinhospitalizedpatientswithunderlyingprostheticvalvescanbeaharbingerofendocarditis43%patientswithnosocomialbacteremiaorfungemiahadprostheticvalveinfectionaseriouscomplication7/987IVDrugUseRecurrentPolymicrobialStaphaureusaccountsforthemajorityofcasesofendocarditistricuspidvalve,eitheraloneorincombination,usmostofteninfected7/988PredisposingFactors

PolymicrobialInfectiveEndocarditis

7/989PolymicrobialInfectiveEndocarditis

clinicalfeaturesIVdruguseisthepredominantriskfactoryoungerage(mean36.5years)2/3weremaleright-sidedcardiacinvolvementin>60%streptococcimorefrequentthanS.aureus1/3ofpatientsdiedmortalityrateis4xhigherforpureleft-sidesvspureright-sidedendocarditis7/9810Diagnostic(Duke)CriteriaDefinitiveinfectiveendocarditispathologiccriteriamicroorganismsorpathologiclesions:demonstratedbycultureorhistologyinavegetation,orinavegetationthathasembolized,orinanintracardiacabscessclinicalcriteria(seebelow)twomajorcriteria,oronemajorandthreeminorcriteria,orfiveminorcriteria7/9811Diagnostic(Duke)CriteriaPossibleinfectiveendocarditisfindingsconsistentofIEthatfallshortof“definite”,butnot“rejected”RejectedfirmalternateDxformanifestationofIEresolutionofmanifestationsofIE,withantibiotictherapyfor4daysnopathologicevidenceofIEatsurgeryorautopsy,afterantibiotictherapyfor4days

7/9812Diagnostic(Duke)CriteriaMajorcriteriapositivebloodcultureforIEevidenceofendocardialinvolvementMinorcriteriapredisposition(heartconditionorIVdruguse)feverof100.40Forhighervascularorimmunologicphenomenamicrobiologicorechocardiographicevidencenotmeetingmajorcriteria7/9813Duke’sMajorCriteriapositivebloodcultureforIEtypicalmicroorganism(strepviridans,strepbovis,HACEKgroup,staphaureusorenterococciintheabsenceofaprimarylocus)forendocarditisfromtwoseparatebloodculturespersistentlypositivebloodculturefrom:bloodculturesdrawnmorethan12hrapart,orallof3oramajorityof4ormoreseparatebloodcultures,withfirstandlastdrqwnatleast1hrapart7/9814Duke’sMajorCriteriaEvidenceofendocardialinvolvementpositiveechocardiogramforendocarditisoscillatingintracardiacmassonvalveorsupportingstructure,orinthepathofregurgitantjets,oronimplantedmaterial,intheabsenceofanalternateanatomicexplanationabscessnewpartialdehiscenceofprostheticvalvenewvalvularregurgitation(increaseorchangeinpre-existingmurmurnotsufficient)7/9815Duke’sMinorCriteriapredisposition(predisposingheartconditionorivdruguse)feverof100.40Forhighervascularphenomena(majorarterialemboli,septicpulmonaryinfarcts,mycoticaneurysm,intracranialhemorrhage,conjunctivehemorrhages,Janewaylesions)7/9816Duke’sMinorCriteriaimmunologicphenomena(glomerulonephritis,Osler’snodes,Rothspots,rheumatoidfactor)microbiologicevidence(positivebloodculturenotmeetingmajorcriteriaorserologicevidenceofactiveinfectionwithorganismconsistentwithIE)echocardiogram(consistentwithIEbutnotmeetingmajorcriteria)7/9817RiskforEndocarditisHighriskprostheticcardiacvalvepriorepisodesofendocarditiscomplexcongenitalcardiacdefectsurgicallyconstructedsystemic-pulmonaryshuntsorconduits7/9818RiskforEndocarditisModerateriskpatentductusarteriosusVSD,primumASDcoarctationoftheaortabicuspidaorticvalvehypertrophiccardiomyopathyacquiredvalvulardysfunctionMVPwithmitralregurgitation7/9819RiskforEndocarditisLowriskisolatedsecundumatrialseptaldefectASD,VSD,orPDA>6monthspastrepair“innocent”heartmurmurbyauscultationinthepediatricpopulation“innocent”heartmurmurbyechocardiographyinadultpatients7/9820TreatmentPre-antibioticera-adeathsentenceAntibioticeramicrobiologiccureinmajorityofpatients7/9821NewTreatmentsRight-sidedinfectiveendocarditisduetomethicillin-susceptibleSaureus(MSSA)inIVdrugusers2-wktherapywithapenicillinase-resistantpenicillinandanaminoglycoside2-wkmonotherapywithIVcloxacillinshort-termtherapyisinappropriateifcomplicatedbyostomyelitis,meningitis,myocardialabscess,orconcomitantleft-sidedinvolvement7/9822NewTreatmentsHighlypenicillin-susceptibleStreptococcusviridansorbovisOnce-dailyceftriaxonefor4wkscurerate>98%easilyadministeredasoutpatient,avoidhospitalization,offerssignificantcostsavingsOnce-dailyceftriaxone2gfor2wksfollowedbyoralamoxicillinqidfor2wksOnce-dailyceftriazoneandnetilmicinfor2wks7/9823NewTreatmentsProstheticvalveendocarditisduetofluconazole-susceptibleCandidaspeciesmanyareduetobloodstreaminvasionchronicoralsuppressivetherapywithfluconazoleforinoperabledisease7/9824SBEProphylaxisStandardgeneralprophylaxis amoxicillinUnabletotakeoralmeds

ampicillinAllergictopenicilin

clindamyc