感染性心内膜炎PPT课件

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1、7/1Update onInfective EndocarditisLarry Baddour,MDUniversity of Tennessee7/2Pathogenesis Disruption of the endocardial layer as a complication of abnormal blood flow associated with underlying cardiac defect Bacterium-endothelium interaction with bacterial attachment and invasion of endothelial cell

2、s7/3Epidemiology Underlying valvular abnormality predisposing to infective endocarditis rheumatic fevera common cause in the past mitral valve prolapsecurrently represents the most common underlying cardiac abnormality7/4mitral valve prolapse risk for infective ednocarditis is 5x-8x mitral regurgita

3、tion increases the risk leaflet redundancy with myxomatous degeneration is a frequent finding age 20,male accounts for 60%age 50,male accounts for 68%7/5Mitral Valve Prolapse and Infective Endocarditis0246810121416182060MaleFemaleNumber of casesRev Infect Dis 1986;8:117-1377/6Coagulase-negative Stap

4、hylococci can produce native-valve endocarditis in mitral valve prolapse usually subacute,difficult to diagnose,and disregarded as a contaminant delay in diagnosis and treatment may account for the severe complications myocardial abscess formation valvular insufficiency requiring valve surgery death

5、7/7Prosthetic Heart Valve positive 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 infection a serious complication7/8IV Drug Use Recurrent Polymicrobial Staph aureus a

6、ccounts for the majority of cases of endocarditis tricuspid valve,either alone or in combination,us most often infected7/9Predisposing Factors Polymicrobial Infective Endocarditis Iv drug useCentral lineProsthetic valvePrevious IEMurmurDental procedureRheumatic diseaseMiscellaneous7/ 10Polymicrobial

7、 Infective Endocarditisclinical features IV drug use is the predominant risk factor younger age(mean 36.5 years)2/3 were male right-sided cardiac involvement in 60%streptococci more frequent than S.aureus 1/3 of patients died mortality rate is 4x higher for pure left-sides vs pure right-sided endoca

8、rditis7/ 11Diagnostic(Duke)Criteria Definitive infective endocarditis pathologic criteria microorganisms or pathologic lesions:demonstrated by culture or histology in a vegetation,or in a vegetation that has embolized,or in an intracardiac abscess clinical criteria(see below)two major criteria,or on

9、e major and three minor criteria,or five minor criteria7/ 12Diagnostic(Duke)Criteria Possible infective endocarditis findings consistent of IE that fall short of“definite”,but not“rejected”Rejected firm alternate Dx for manifestation of IE resolution ofmanifestations of IE,with antibiotic therapy fo

10、r 4 days no pathologic evidence of IE at surgery or autopsy,after antibiotic therapy for 4 days 7/ 13Diagnostic(Duke)Criteria Major criteria positive blood culture for IE evidence of endocardial involvement Minor criteria predisposition(heart condition or IV drug use)fever of 100.40F or higher vascu

11、lar or immunologic phenomena microbiologic or echocardiographic evidence not meeting major criteria7/ 14Dukes Major Criteria positive blood culture for IE typical microorganism(strep viridans,strep bovis,HACEK group,staph aureus or enterococci in the absence of a primary locus)for endocarditis from

12、two separate blood cultures persistently positive blood culture from:blood cultures drawn more than 12 hr apart,or all of 3 or a majority of 4 or more separate blood cultures,with first and last drqwn at least 1 hr apart7/ 15Dukes Major Criteria Evidence of endocardial involvement positive echocardi

13、ogram for endocarditis oscillating intracardiac mass on valve or supporting structure,or in the path of regurgitant jets,or on implanted material,in the absence of an alternate anatomic explanation abscess new partial dehiscence of prosthetic valve new valvular regurgitation(increase or change in pr

14、e-existing murmur not sufficient)7/ 16Dukes Minor Criteria predisposition(predisposing heart condition or iv drug use)fever of 100.40F or higher vascular phenomena(major arterial emboli,septic pulmonary infarcts,mycotic aneurysm,intracranial hemorrhage,conjunctive hemorrhages,Janeway lesions)7/ 17Du

15、kes Minor Criteria immunologic phenomena(glomerulonephritis,Oslers nodes,Roth spots,rheumatoid factor)microbiologic evidence(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

16、major criteria)7/ 18Risk for Endocarditis High risk prosthetic cardiac valve prior episodes of endocarditis complex congenital cardiac defect surgically constructed systemic-pulmonary shunts or conduits7/ 19Risk for Endocarditis Moderate risk patent ductus arteriosus VSD,primum ASD coarctation of th

17、e aorta bicuspid aortic valve hypertrophic cardiomyopathy acquired valvular dysfunction MVP with mitral regurgitation7/ 20Risk for Endocarditis Low risk isolated secundum atrial septal defect ASD,VSD,or PDA 6 months past repair“innocent”heart murmur by auscultation in the pediatric population“innoce

18、nt”heart murmur by echocardiography in adult patients7/ 21Treatment Pre-antibiotic era-a death sentence Antibiotic era microbiologic cure in majority of patients7/ 22New Treatments Right-sided infective endocarditis due to methicillin-susceptible S aureus(MSSA)in IV drug users 2-wk therapy with a pe

19、nicillinase-resistant penicillin and an aminoglycoside 2-wk monotherapy with IV cloxacillin short-term therapy is inappropriate if complicated by ostomyelitis,meningitis,myocardial abscess,or concomitant left-sided involvement7/ 23New Treatments Highly penicillin-susceptible Streptococcus viridans o

20、r bovis Once-daily ceftriaxone for 4 wks cure rate 98%easily administered as outpatient,avoid hospitalization,offers significant cost savings Once-daily ceftriaxone 2 g for 2wks followed by oral amoxicillin qid for 2 wks Once-daily ceftriazone and netilmicin for 2 wks7/ 24New Treatments Prosthetic v

21、alve endocarditis due to fluconazole-susceptible Candida species many are due to bloodstream invasion chronic oral suppressive therapy with fluconazole for inoperable disease7/ 25SBE ProphylaxisStandard general prophylaxisamoxicillinUnable to take oral medsampicillinAllergic to penicilinclindamycinc

22、ephalexinazithromycinclarithromycinAllergic to penicillin and unableclindamycinto take oral medicationscefazolin7/ 26ReferencesPrevention 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

23、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