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1、7/98,Update onInfective Endocarditis,7/98,2,Pathogenesis,Disruption of the endocardial layer as a complication of abnormal blood flow associated with underlying cardiac defectBacterium-endothelium interaction with bacterial attachment and invasion of endothelial cells,7/98,3,Epidemiology,Underlying
2、valvular abnormality predisposing to infective endocarditisrheumatic fevera common cause in the pastmitral valve prolapsecurrently represents the most common underlying cardiac abnormality,7/98,4,mitral valve prolapse,risk for infective ednocarditis is 5x-8x mitral regurgitation increases the riskle
3、aflet redundancy with myxomatous degeneration is a frequent findingage 20,male accounts for 60%age 50,male accounts for 68%,7/98,5,Mitral Valve Prolapse and Infective Endocarditis,Male,Female,Number of cases,Rev Infect Dis 1986;8:117-137,7/98,6,Coagulase-negative Staphylococci,can produce native-val
4、ve endocarditis in mitral valve prolapseusually subacute,difficult to diagnose,and disregarded as a contaminantdelay in diagnosis and treatment may account for the severe complicationsmyocardial abscess formationvalvular insufficiency requiring valve surgerydeath,7/98,7,Prosthetic Heart Valve,positi
5、ve blood culture in hospitalized patients with underlying prosthetic valves can be a harbinger of endocarditis 43%patients with nosocomial bacteremia or fungemia had prosthetic valve infectiona serious complication,7/98,8,IV Drug Use,RecurrentPolymicrobialStaph aureus accounts for the majority of ca
6、ses of endocarditistricuspid valve,either alone or in combination,us most often infected,7/98,9,Predisposing Factors Polymicrobial Infective Endocarditis,7/98,10,Polymicrobial Infective Endocarditisclinical features,IV drug use is the predominant risk factoryounger age(mean 36.5 years)2/3 were maler
7、ight-sided cardiac involvement in 60%streptococci more frequent than S.aureus1/3 of patients died mortality rate is 4x higher for pure left-sides vs pure right-sided endocarditis,7/98,11,Diagnostic(Duke)Criteria,Definitive infective endocarditispathologic criteriamicroorganisms or pathologic lesions
8、:demonstrated by culture or histology in a vegetation,or in a vegetation that has embolized,or in an intracardiac abscessclinical criteria(see below)two major criteria,or one major and three minor criteria,or five minor criteria,7/98,12,Diagnostic(Duke)Criteria,Possible infective endocarditisfinding
9、s consistent of IE that fall short of“definite”,but not“rejected”Rejectedfirm alternate Dx for manifestation of IEresolution ofmanifestations of IE,with antibiotic therapy for 4 daysno pathologic evidence of IE at surgery or autopsy,after antibiotic therapy for 4 days,7/98,13,Diagnostic(Duke)Criteri
10、a,Major criteriapositive blood culture for IEevidence of endocardial involvementMinor criteriapredisposition(heart condition or IV drug use)fever of 100.40F or highervascular or immunologic phenomenamicrobiologic or echocardiographic evidence not meeting major criteria,7/98,14,Dukes Major Criteria,p
11、ositive blood culture for IEtypical microorganism(strep viridans,strep bovis,HACEK group,staph aureus or enterococci in the absence of a primary locus)for endocarditis from two separate blood culturespersistently positive blood culture from:blood cultures drawn more than 12 hr apart,orall of 3 or a
12、majority of 4 or more separate blood cultures,with first and last drqwn at least 1 hr apart,7/98,15,Dukes Major Criteria,Evidence of endocardial involvementpositive echocardiogram for endocarditisoscillating intracardiac mass on valve or supporting structure,or in the path of regurgitant jets,or on
13、implanted material,in the absence of an alternate anatomic explanationabscessnew partial dehiscence of prosthetic valvenew valvular regurgitation(increase or change in pre-existing murmur not sufficient),7/98,16,Dukes Minor Criteria,predisposition(predisposing heart condition or iv drug use)fever of
14、 100.40F or highervascular phenomena(major arterial emboli,septic pulmonary infarcts,mycotic aneurysm,intracranial hemorrhage,conjunctive hemorrhages,Janeway lesions),7/98,17,Dukes Minor Criteria,immunologic phenomena(glomerulonephritis,Oslers nodes,Roth spots,rheumatoid factor)microbiologic evidenc
15、e(positive blood culture not meeting major criteria or serologic evidence of active infection with organism consistent with IE)echocardiogram(consistent with IE but not meeting major criteria),7/98,18,Risk for Endocarditis,High riskprosthetic cardiac valveprior episodes of endocarditiscomplex congen
16、ital cardiac defectsurgically constructed systemic-pulmonary shunts or conduits,7/98,19,Risk for Endocarditis,Moderate riskpatent ductus arteriosusVSD,primum ASDcoarctation of the aortabicuspid aortic valvehypertrophic cardiomyopathyacquired valvular dysfunctionMVP with mitral regurgitation,7/98,20,
17、Risk for Endocarditis,Low riskisolated secundum atrial septal defectASD,VSD,or PDA 6 months past repair“innocent”heart murmur by auscultation in the pediatric population“innocent”heart murmur by echocardiography in adult patients,7/98,21,Treatment,Pre-antibiotic era-a death sentenceAntibiotic eramic
18、robiologic cure in majority of patients,7/98,22,New Treatments,Right-sided infective endocarditis due to methicillin-susceptible S aureus(MSSA)in IV drug users2-wk therapy with a penicillinase-resistant penicillin and an aminoglycoside2-wk monotherapy with IV cloxacillinshort-term therapy is inappro
19、priate if complicated by ostomyelitis,meningitis,myocardial abscess,or concomitant left-sided involvement,7/98,23,New Treatments,Highly penicillin-susceptible Streptococcus viridans or bovisOnce-daily ceftriaxone for 4 wks cure rate 98%easily administered as outpatient,avoid hospitalization,offers s
20、ignificant cost savingsOnce-daily ceftriaxone 2 g for 2wks followed by oral amoxicillin qid for 2 wksOnce-daily ceftriazone and netilmicin for 2 wks,7/98,24,New Treatments,Prosthetic valve endocarditis due to fluconazole-susceptible Candida speciesmany are due to bloodstream invasionchronic oral sup
21、pressive therapy with fluconazole for inoperable disease,7/98,25,SBE Prophylaxis,Standard general prophylaxisamoxicillinUnable to take oral medsampicillinAllergic to penicilinclindamycincephalexinazithromycinclarithromycinAllergic to penicillin and unableclindamycinto take oral medicationscefazolin,
22、7/98,26,References,Prevention of bacterial endocarditis.Recommended by the American Heart Association.Dajani AS,Taubert KA,Wilson W,et al.Circulation 1997;96:358-366New Criteria for diagnosis of infective endocarditis:Utilization of specific echocardiographic findings.Durack DT,Lukes AS,Bright DK,et al.Am J Med 1994;96:200-209Antibiotic treatment of adults with infective endocarditis due to strptococci,enterococci,staphlococci,and HACEK microorganisms.Wilson WR,Karchmer AW,Dajani AS.JAMA 1995;274:1706-1713,
