感染性心内膜炎进展及指南

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,感染性心内膜炎进展及指南,宁波市医疗中心李惠利医院,周建庆,1,流行病学,年发病率十万分之五，随年龄增大发病率上升，我国年发病约58万例。,危险因素：人工瓣膜、风心、先心、老年退行性主动脉瓣病变、二尖瓣脱垂、介入治疗、血透、牙科手术、静脉留置。,2,病 理,3/4病人原有器质性心脏病根底。内皮细胞破坏，血小板及纤维蛋白积聚，细菌产生粘附基质分子，细菌粘附繁殖。见以下图：,3,图1、心内膜炎发生步骤,4,表1 感染性心内膜炎并发症,Congestive heart failure 5060%,AIMR TR,Embolization 2025%,Mitral Aortic valve,CVA 15%,Other emboli,Limb 23%,Mesenteric 2%,Splenic 23%,Glomerulonephritis 1525%,Anular abscess 1015%,Myocotic aneurysm 1015%,Conduction system involvement 510%,CNS abscess 34%,Other less common complications 12%,Pericarditis,Myocarditis,Myocardial infarction,intracardiac fistula,Metastatic abscess,5,诊 断,关键是具有高度的临床警惕性,Table 5 Criteria that should raise suspicion of IE,High clinical suspision(rugent indication for echocardiographic screening,and possibly hospital admission),new valve lesion/(regurgitant)murmur,embolic enent(s)of unknown origin(esp.cerebral and renal infarction),sepsis of unknown origin,haematuria,goumerulonephritis,and suspected renal infarction,feverplus,prosthetic material inside the heart,other high predispositions for IE,newly developed ventricular arrhythmias or conduction disturbances,first manifestation of CHF,positive BCs(if the organism identified is typical for NVE/PVE),cutaneous(Osler,Janeway)or ophtahlmic(Roth)manifestations,multifocal/rapid changing pulmonic infiltrations(righy heart IE),peripheral abscesses(renal,splenic,spine)of unknown origin,predisposition and recent diagnostic/theraputic interventions known,to result in significant bacteraemia,6,血培养方法,抗生素应用前需3次以上血培养，间隔超过1小时，每次血液20ml，动脉血阳性率较高，分2种培养基：普通，厌氧。如已短期使用抗生素，病情稳定,停药3天后屡次培养。如血培养屡次阴性，骨髓培养阳性率较高，洁尿培养也有一定价值，皮肤Osler小结节、脱落的赘生物及手术标本培养阳性率较高。,7,感染性心内膜炎心超表现,赘生物、脓肿、动脉瘤、窦道、瓣体穿孔、人工瓣别离、瓣膜关闭不全,敏感性 特异性,TTE 46%95%,TEE 93%96%,可疑病人一定要作TEE检查,8,类 型,自体瓣膜心内膜炎,人工瓣膜心内膜炎 5年发生率3%5%,静脉吸毒者心内膜炎 右心系统好发，占总IE 10%30%，预后好,心内膜电极心内膜炎,9,感染性心内膜炎手术指征,TABLE 9.General indications for surgical intervention in infections endocarditis,Emergency surgery(24 hours),Aortic insufficiency with evidence for significant(FC 3)CHF.,Rupture of sinus of valsalva into another cardiac structure.,Fistula formation into another cardiac structure or pericardium.,Urgent surgery(2-4 days),Presence of FC 3 or 4 CHF due to valvular dysfunction.,Perivalrular abscess formation.,Prosthetic valvular obstruction.,Prosthetic valvular dehiscence,Early surgery(4-10 days),Persistent fever felt due to endocarditis.,Positive surveillance cultures.,Recurrent septic emboli.,Highly resistant or virulent organism(fungi,Brucellae,Pseudomonas,antibiotic-resistant enterococci,poorly responsive S.aureus),Large(10mm)mobile vegetations,especially on the mitral valve.,Immediately replase after completion of prior endocarditis treatment,.,10,感染性心内膜炎微生物学革兰氏阳性球菌,链球菌 占IE约50%60%，儿童及年轻妇女心内膜炎主要为草绿色链球菌，预后较好，90%能治愈，但30%以上可有并发症。,常见链球菌：血链球菌、牛链球菌、变异链,球菌及肠链球菌,11,感染性心内膜炎微生物学革兰氏阳性球菌,肠链球菌肠球菌为消化道及前尿道正常菌群，占IE的5%18%，常为亚急性过程。肠球菌血症常为医源性，多发生于尿道操作后的老年人及妇科操作后的年轻女性，40%以上病人无原发心脏病根底，对许多抗菌素耐药，治愈困难，病死率高。,肺炎链球菌占IE 1%3%，常急性起病伴瓣环脓肿及急性化脓性心包炎，70%并发脑膜炎，由于急性瓣膜破坏引起血流动力学障碍，病死率高达50%。,12,感染性心内膜炎微生物学,革兰氏阳性球菌,营养变异性链球菌NVS占IE 2%3%，常隐匿起病，有原发心脏病根底，血培养常阴性。治疗困难，预后不良。,B族链球菌 为口腔、生殖道、前尿道正常菌群。糖尿病、肝硬化、肿瘤等免疫力低下者为危险因素。病死率也高达50%。,13,感染性心内膜炎微生物学,革兰氏阳性球菌,葡萄球菌 占IE 30%40%，其中80%90%为凝固酶阳性金葡菌，侵犯正常瓣膜，常引起急性IE,伴血行播散性脓肿，化脓性心包炎。,表皮葡萄球菌 常引起人工瓣IE,近年来自体瓣IE也增加，2/3为凝固酶阴性IE。,14,感染性心内膜炎微生物学,革兰氏阴性杆菌,革兰氏阴性杆菌少见，常发生于吸毒、人工瓣及肝硬化者，病程短于6周。沙门氏菌常引起左心系统心内膜炎。假单胞菌属包括绿脓杆菌IE多发于吸毒者并侵犯正常瓣膜，常合并栓塞、瓣周脓肿、周围脓肿、急性心衰等并发症，需及早手术。,15,感染性心内膜炎微生物学,革兰氏阴性杆菌,其它少见革兰氏阴性杆菌 包括嗜血杆菌、放线杆菌等，培养困难，需23周，临床表现相似：大而脆的赘生物、栓塞、返流、心衰等，需换瓣手术。,革兰氏阳性杆菌棒状杆菌IE少见。,16,感染性心内膜炎微生物学,厌氧菌 主要为脆弱类杆菌IE，25%病例合并需氧菌，栓塞常见，病死率30%。,霉菌IE 好发于3类病人：吸毒 心内直视手术 长期静脉应用抗菌素。主要为ICU病人。常见为白色念珠菌及曲菌属，病死率86%，尽早手术是治疗的最好方法。,其它微生物如螺旋体、立克次体、衣原体及支原体等均可引起IE。,17,血培养阴性IE,占IE 5%30%。原因为：右心系统IE IE晚期，病程超过23个月。慢性病变伴发尿毒症 室缺、PDA、起搏电极IE 致病菌生长缓慢如厌氧菌、嗜血杆菌、放线杆菌、营养变异性链球菌NVS等。使用抗生素后培养 霉菌性IE 立克次体、支原体等,18,抗微生物治疗,TABLE 10.Overview of therpy for endocarditis caused by viridans group or,streptococcus bovis,Regimen,Dosage and route Duration(per type of valve),Highly penicillin-sensitive organisms,Penicillin G 12-18 million U/24 h either 4 weeks for native valve,continuous or 4-6 doses 6 weeks for prosthetic,OR,Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose 4 weeks for native valve,6 weeks for prosthetic,OR,Penicillin G plus,Gentamicin,Penicillin G 12-18 million U/24 h either 2 weeks for native valve,Continuous or 6 divided doses 6 weeks for prosthetic,Gentamicin 3 mg/kg per 24h IV/IM in 1 dose 2 weeks for either,19,抗微生物治疗,Regimen,Dosage and route Duration(per type of valve),OR,Ceftriaxone sodium,plus gentamicin,Ceftriaxone 2 g/24 h IV/IM in 1 dose 2 weeks for native valve,6 weeks for prosthetic,Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 weeks for either,OR,Vancomycin 30mg/kg per 24 h in 2 equal doses 4 weeks for native valve,to maximum of 2 g/24 hrs 6 weeks for prosthetic,Relatively penicillin-resistant organisms,(Penicillin or ceftriaxone)plus gentamicin,Penicillin G 24million U/24 h either continuously 4 weeks for native valve,Or 4-6 equally divided dose