感染性心內(nèi)膜炎英文課件

Updateon

InfectiveEndocarditisLarryBaddour,MDUniversityofTennessee7/981Updateon

InfectiveEndocarditUpdateon

InfectiveEndocarditPathogenesisDisruptionoftheendocardiallayerasacomplicationofabnormalbloodflowassociatedwithunderlyingcardiacdefectBacterium-endotheliuminteractionwithbacterialattachmentandinvasionofendothelialcells7/982PathogenesisDisruptionofthePathogenesisDisruptionoftheEpidemiologyUnderlyingvalvularabnormalitypredisposingtoinfectiveendocarditisrheumaticfever

acommoncauseinthepastmitralvalveprolapse

currentlyrepresentsthemostcommonunderlyingcardiacabnormality7/983EpidemiologyUnderlyingvalvulaEpidemiologyUnderlyingvalvulamitralvalveprolapseriskforinfectiveednocarditisis5x-8xmitralregurgitationincreasestheriskleafletredundancywithmyxomatousdegenerationisafrequentfindingage<20,femalepredominate

age>20,maleaccountsfor60%

age>50,maleaccountsfor68%7/984mitralvalveprolapseriskformitralvalveprolapseriskforMitralValveProlapse

andInfectiveEndocarditisMaleFemaleNumberofcasesRevInfectDis1986;8:117-1377/985MitralValveProlapse

andInfMitralValveProlapse

andInfCoagulase-negativeStaphylococcicanproducenative-valveendocarditisinmitralvalveprolapseusuallysubacute,difficulttodiagnose,anddisregardedasacontaminantdelayindiagnosisandtreatmentmayaccountfortheseverecomplicationsmyocardialabscessformationvalvularinsufficiencyrequiringvalvesurgerydeath7/986Coagulase-negativeStaphylococCoagulase-negativeStaphylococProstheticHeartValvepositivebloodcultureinhospitalizedpatientswithunderlyingprostheticvalvescanbeaharbingerofendocarditis43%patientswithnosocomialbacteremiaorfungemiahadprostheticvalveinfectionaseriouscomplication7/987ProstheticHeartValvepositiveProstheticHeartValvepositiveIVDrugUseRecurrentPolymicrobialStaphaureusaccountsforthemajorityofcasesofendocarditistricuspidvalve,eitheraloneorincombination,usmostofteninfected7/988IVDrugUseRecurrent7/988medslIVDrugUseRecurrent7/988medslPredisposingFactorsPolymicrobialInfectiveEndocarditis

7/989PredisposingFactorsPolymicroPredisposingFactorsPolymicroPolymicrobialInfectiveEndocarditis

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

7/9812Diagnostic(Duke)CriteriaPossDiagnostic(Duke)CriteriaPossDiagnostic(Duke)CriteriaMajorcriteriapositivebloodcultureforIEevidenceofendocardialinvolvementMinorcriteriapredisposition(heartconditionorIVdruguse)feverof100.40Forhighervascularorimmunologicphenomenamicrobiologicorechocardiographicevidencenotmeetingmajorcriteria7/9813Diagnostic(Duke)CriteriaMajoDiagnostic(Duke)CriteriaMajoDuke’sMajorCriteriapositivebloodcultureforIEtypicalmicroorganism(strepviridans,strepbovis,HACEKgroup,staphaureusorenterococciintheabsenceofaprimarylocus)forendocarditisfromtwoseparatebloodculturespersistentlypositivebloodculturefrom:bloodculturesdrawnmorethan12hrapart,orallof3oramajorityof4ormoreseparatebloodcultures,withfirstandlastdrqwnatleast1hrapart7/9814Duke’sMajorCriteriapositiveDuke’sMajorCriteriapositiveDuke’sMajorCriteriaEvidenceofendocardialinvolvementpositiveechocardiogramforendocarditisoscillatingintracardiacmassonvalveorsupportingstructure,orinthepathofregurgitantjets,oronimplantedmaterial,intheabsenceofanalternateanatomicexplanationabscessnewpartialdehiscenceofprostheticvalvenewvalvularregurgitation(increaseorchangeinpre-existingmurmurnotsufficient)7/9815Duke’sMajorCriteriaEvidenceDuke’sMajorCriteriaEvidenceDuke’sMinorCriteriapredisposition(predisposingheartconditionorivdruguse)feverof100.40Forhighervascularphenomena(majorarterialemboli,septicpulmonaryinfarcts,mycoticaneurysm,intracranialhemorrhage,conjunctivehemorrhages,Janewaylesions)7/9816Duke’sMinorCriteriapredisposDuke’sMinorCriteriapredisposDuke’sMinorCriteriaimmunologicphenomena(glomerulonephritis,Osler’snodes,Rothspots,rheumatoidfactor)microbiologicevidence(positivebloodculturenotmeetingmajorcriteriaorserologicevidenceofactiveinfectionwithorganismconsistentwithIE)echocardiogram(consistentwithIEbutnotmeetingmajorcriteria)7/9817Duke’sMinorCriteriaimmunologDuke’sMinorCriteriaimmunologRiskforEndocarditisHighriskprostheticcardiacvalvepriorepisodesofendocarditiscomplexcongenitalcardiacdefectsurgicallyconstructedsystemic-pulmonaryshuntsorconduits7/9818RiskforEndocarditisHighriskRiskforEndocarditisHighriskRiskforEndocarditisModerateriskpatentductusarteriosusVSD,primumASDcoarctationoftheaortabicuspidaorticvalvehypertrophiccardiomyopathyacquiredvalvulardysfunctionMVPwithmitralregurgitation7/9819RiskforEndocarditisModerateRiskforEndocarditisModerateRiskforEndocarditisLowriskisolatedsecundumatrialseptaldefectASD,VSD,orPDA>6monthspastrepair“innocent”heartmurmurbyauscultationinthepediatricpopulation“innocent”heartmurmurbyechocardiographyinadultpatients7/9820RiskforEndocarditisLowrisk7RiskforEndocarditisLowrisk7TreatmentPre-antibioticera-adeathsentenceAntibioticeramicrobiologiccureinmajorityofpatients7/9821TreatmentPre-antibioticera-TreatmentPre-antibioticera-NewTreatmentsRight-sidedinfectiveendocarditisduetomethicillin-susceptibleSaureus(MSSA)inIVdrugusers2-wktherapywithapenicillinase-resistantpenicillinandanaminoglycoside2-wkmonotherapywithIVcloxacillinshort-termtherapyisinappropriateifcomplicatedbyostomyelitis,meningitis,myocardialabscess,orconcomitantleft-sidedinvolvement7/9822NewTreatmentsRight-sidedinfeNewTreatmentsRight-sidedinfeNewTreatmentsHighlypenicillin-susceptibleStreptococcusviridansorbovisOnce-dailyceftriaxonefor4wkscurerate>98%easilyadministeredasoutpatient,avoidhospitalization,offerssignificantcostsavingsOnce-dailyceftriaxone2gfor2wksfollowedbyoralamoxicillinqidfor2wksOnce-dailyceftriazoneandnetilmicinfor2wks7/9823NewTreatmentsHighlypenicilliNewTreatmentsHighlypenicilliNewTreatmentsProstheticvalveendocarditisduetofluconazole-susceptibleCandidaspeciesmanyareduetobloodstreaminvasionchronicoralsuppressivetherapywithfluconazoleforinoperabledisease7/9824NewTreatmentsProstheticvalveNewTreatmentsProstheticvalveSBEProphylaxisStandardgeneralprophylaxis amoxicillinUnabletotakeoralmeds ampicillinAllergictopenicilin clindamycin cephalexin azithromycin clarithromycinAllergictopenicillinandunable clindamycintotakeoralmedications cefazolin7/9825SBEProphylaxisStandardgeneraSBEProphylaxisStandardgeneraReferencesPreventionofbacterialendocarditis.RecommendedbytheAmericanHeartAssociation.

DajaniAS,TaubertKA,WilsonW,etal.Circulation1997;96:358-366NewCriteriafordiagnosisofinfectiveendocarditis:Utilizationofspecificechocardiographicfindings.

DurackDT,LukesAS,BrightDK,etal.AmJMed1994;96:200-209Antibiotictreatmentofadultswithinfectiveendocarditisduetostrptococci,enterococci,staphlococci,andHACEKmicroorganisms.WilsonWR,KarchmerAW,DajaniAS.JAMA1995;274:1706-17137/9826ReferencesPreventionofbacterReferencesPreventionofbacterUpdateon

InfectiveEndocarditisLarryBaddour,MDUniversityofTennessee7/9827Updateon

InfectiveEndocarditUpdateon

InfectiveEndocarditPathogenesisDisruptionoftheendocardiallayerasacomplicationofabnormalbloodflowassociatedwithunderlyingcardiacdefectBacterium-endotheliuminteractionwithbacterialattachmentandinvasionofendothelialcells7/9828PathogenesisDisruptionofthePathogenesisDisruptionoftheEpidemiologyUnderlyingvalvularabnormalitypredisposingtoinfectiveendocarditisrheumaticfever

acommoncauseinthepastmitralvalveprolapse

currentlyrepresentsthemostcommonunderlyingcardiacabnormality7/9829EpidemiologyUnderlyingvalvulaEpidemiologyUnderlyingvalvulamitralvalveprolapseriskforinfectiveednocarditisis5x-8xmitralregurgitationincreasestheriskleafletredundancywithmyxomatousdegenerationisafrequentfindingage<20,femalepredominate

age>20,maleaccountsfor60%

age>50,maleaccountsfor68%7/9830mitralvalveprolapseriskformitralvalveprolapseriskforMitralValveProlapse

andInfectiveEndocarditisMaleFemaleNumberofcasesRevInfectDis1986;8:117-1377/9831MitralValveProlapse

andInfMitralValveProlapse

andInfCoagulase-negativeStaphylococcicanproducenative-valveendocarditisinmitralvalveprolapseusuallysubacute,difficulttodiagnose,anddisregardedasacontaminantdelayindiagnosisandtreatmentmayaccountfortheseverecomplicationsmyocardialabscessformationvalvularinsufficiencyrequiringvalvesurgerydeath7/9832Coagulase-negativeStaphylococCoagulase-negativeStaphylococProstheticHeartValvepositivebloodcultureinhospitalizedpatientswithunderlyingprostheticvalvescanbeaharbingerofendocarditis43%patientswithnosocomialbacteremiaorfungemiahadprostheticvalveinfectionaseriouscomplication7/9833ProstheticHeartValvepositiveProstheticHeartValvepositiveIVDrugUseRecurrentPolymicrobialStaphaureusaccountsforthemajorityofcasesofendocarditistricuspidvalve,eitheraloneorincombination,usmostofteninfected7/9834IVDrugUseRecurrent7/988medslIVDrugUseRecurrent7/9834medsPredisposingFactorsPolymicrobialInfectiveEndocarditis

7/9835PredisposingFactorsPolymicroPredisposingFactorsPolymicroPolymicrobialInfectiveEndocarditis

clinicalfeaturesIVdruguseisthepredominantriskfactoryoungerage(mean36.5years)2/3weremaleright-sidedcardiacinvolvementin>60%streptococcimorefrequentthanS.aureus1/3ofpatientsdiedmortalityrateis4xhigherforpureleft-sidesvspureright-sidedendocarditis7/9836PolymicrobialInfectiveEndocaPolymicrobialInfectiveEndocaDiagnostic(Duke)CriteriaDefinitiveinfectiveendocarditispathologiccriteriamicroorganismsorpathologiclesions:demonstratedbycultureorhistologyinavegetation,orinavegetationthathasembolized,orinanintracardiacabscessclinicalcriteria(seebelow)twomajorcriteria,oronemajorandthreeminorcriteria,orfiveminorcriteria7/9837Diagnostic(Duke)CriteriaDefiDiagnostic(Duke)CriteriaDefiDiagnostic(Duke)CriteriaPossibleinfectiveendocarditisfindingsconsistentofIEthatfallshortof“definite”,butnot“rejected”RejectedfirmalternateDxformanifestationofIEresolutionofmanifestationsofIE,withantibiotictherapyfor4daysnopathologicevidenceofIEatsurgeryorautopsy,afterantibiotictherapyfor4days

7/9838Diagnostic(Duke)CriteriaPossDiagnostic(Duke)CriteriaPossDiagnostic(Duke)CriteriaMajorcriteriapositivebloodcultureforIEevidenceofendocardialinvolvementMinorcriteriapredisposition(heartconditionorIVdruguse)feverof100.40Forhighervascularorimmunologicphenomenamicrobiologicorechocardiographicevidencenotmeetingmajorcriteria7/9839Diagnostic(Duke)CriteriaMajoDiagnostic(Duke)CriteriaMajoDuke’sMajorCriteriapositivebloodcultureforIEtypicalmicroorganism(strepviridans,strepbovis,HACEKgroup,staphaureusorenterococciintheabsenceofaprimarylocus)forendocarditisfromtwoseparatebloodculturespersistentlypositivebloodculturefrom:bloodculturesdrawnmorethan12hrapart,orallof3oramajorityof4ormoreseparatebloodcultures,withfirstandlastdrqwnatleast1hrapart7/9840Duke’sMajorCriteriapositiveDuke’sMajorCriteriapositiveDuke’sMajorCriteriaEvidenceofendocardialinvolvementpositiveechocardiogramforendocarditisoscillatingintracardiacmassonvalveorsupportingstructure,orinthepathofregurgitantjets,oronimplantedmaterial,intheabsenceofanalternateanatomicexplanationabscessnewpartialdehiscenceofprostheticvalvenewvalvularregurgitation(increaseorchangeinpre-existingmurmurnotsufficient)7/9841Duke’sMajorCriteriaEvidenceDuke’sMajorCriteriaEvidenceDuke’sMinorCriteriapredisposition(predisposingheartconditionorivdruguse)feverof100.40Forhighervascularphenomena(majorarterialemboli,septicpulmonaryinfarcts,mycoticaneurysm,intracranialhemorrhage,conjunctivehemorrhages,Janewaylesions)7/9842Duke’sMinorCriteriapredisposDuke’sMinorCriteriapredisposDuke’sMinorCriteriaimmunologicphenomena(glomerulonephritis,Osler’snodes,Rothspots,rheumatoidfactor)microbiologicevidence(positivebloodculturenotmeetingmajorcriteriaorserologicevidenceofactiveinfectionwithorganismconsistentwithIE)echocardiogram(consistentwithIEbutnotmeetingmajorcriteria)7/9843Duke’sMinorCriteriaimmunologDuke’sMinorCriteriaimmunologRiskforEndocarditisHighriskprostheticcardiacvalvepriorepisodesofendocarditiscomplexcongenitalcardiacdefectsurgicallyconstructedsystemic-pulmonaryshuntsorconduits7/9844RiskforEndocarditisHighriskRiskforEndocarditisHighriskRiskforEndocarditisModerateriskpatentductusarteriosusVSD,primumASDcoarctationoftheaortabicuspidaorticvalvehypertrophiccardiomyopathyacquiredvalvulardysfunctionMVPwithmitralregurgitation7/9845RiskforEndocarditisModerateRiskforEndocarditisModerateRiskforEndocarditisLowriskisolatedsecundumatrialseptaldefectASD,VSD,orPDA>6monthspastrepair“innocent”heartmurmurbyauscultationinthepediatricpopulation“innocent”heartmurmurbyechocardiographyinadultpatients7/9846RiskforEndocarditisLowrisk7RiskforEndocarditisLowrisk7TreatmentPre-antibioticera-adeathsentenceAntibioticeramicrobiologiccureinmajorityofpatients7/9847TreatmentPre-antibioticera-TreatmentPre-antibioticera-NewTreatmentsRight-sidedinfectiveendocarditisduetomethicillin-susceptibleSaureus(MSSA)inIVdrugusers2-wktherapywithapenicillinase-resistantpenicillinandanaminoglycoside2-wkmonotherapywithIVcloxacillinshort-termtherapyisinappropriateifcomplicatedbyostomyelitis,meningitis,myocardialabs