感染性心内膜炎进展及指南课件.ppt

1、感染性心内膜炎进展感染性心内膜炎进展及指南及指南宁波市医疗中心李惠利医院周建庆2流行病学v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。v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。3病 理v3/4病人原有器质性心脏病基础。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。见下图：4图1、心内膜炎发生步骤5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

2、%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 abscess6诊 断 关键是具有高度的临床警惕

3、性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 origi

4、n 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

5、)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 7血培养方法 v抗生素应用

6、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天后多次培养。如血培养多次阴性，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。8感染性心内膜炎心超表现 v赘生物、脓肿、动脉瘤、窦道、瓣体穿孔、人工瓣分离、瓣膜关闭不全 v 敏感性 特异性 TTE 46%95%TEE 93%96%v可疑病人一定要作TEE检查9类 型 v自体瓣膜心内膜炎v人工瓣膜心内膜炎 5年发生率3%5%v 静脉吸毒者心内膜炎 右心系统好发，占总IE 10%30%，预后好v 心内膜电极心内

7、膜炎10感染性心内膜炎手术指征 TABLE 9.General indications for surgical intervention in infections endocarditisEmergency 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 peric

8、ardium.Urgent surgery(2-4 days)Presence of FC 3 or 4 CHF due to valvular dysfunction.Perivalrular abscess formation.Prosthetic valvular obstruction.Prosthetic valvular dehiscenceEarly surgery(4-10 days)Persistent fever felt due to endocarditis.Positive surveillance cultures.Recurrent septic emboli.H

9、ighly 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.11感染性心内膜炎微生物学革兰氏阳性球菌v链球菌 占IE约50%60%，儿童及年轻妇女心内

10、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12感染性心内膜炎微生物学革兰氏阳性球菌v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基础，对许多抗菌素耐药，治愈困难，病死率高。v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%。13感染性心内膜炎微生物学革兰氏阳性球菌v营养变异性链球菌（NVS）

11、占IE 2%3%，常隐匿起病，有原发心脏病基础，血培养常阴性。治疗困难，预后不良。vB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%。14感染性心内膜炎微生物学革兰氏阳性球菌v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。v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。15感染性心内膜炎微生物学革兰氏阴性杆菌v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（

12、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。16感染性心内膜炎微生物学革兰氏阴性杆菌v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。v革兰氏阳性杆菌（棒状杆菌）IE少见。17感染性心内膜炎微生物学v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%。v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办法。v其它微生物如螺旋体、立

13、克次体、衣原体及支原体等均可引起IE。18血培养阴性IE v 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 19抗微生物治疗 TABLE 10.Overview of therpy for endocarditis caused by viridans group or TABLE 10.Overview of therpy for endocarditis caused by viridans gr

14、oup or streptococcus bovis streptococcus bovisRegimen Regimen Dosage and route Duration(per type of valve)Dosage and route Duration(per type of valve)Highly penicillin-sensitive organismsHighly penicillin-sensitive organismsPenicillin G 12-18 million U/24 h either 4 weeks for native valve Penicillin

15、 G 12-18 million U/24 h either 4 weeks for native valve continuous or 4-6 doses 6 weeks for prosthetic continuous or 4-6 doses 6 weeks for prostheticORORCeftriaxone sodium 2 g/24 h IV/IM in 1 dose 4 weeks for native valveCeftriaxone sodium 2 g/24 h IV/IM in 1 dose 4 weeks for native valve 6 weeks fo

16、r prosthetic 6 weeks for prostheticORORPenicillin G plusPenicillin G plus Gentamicin Gentamicin Penicillin G 12-18 million U/24 h either 2 weeks for native valve Penicillin G 12-18 million U/24 h either 2 weeks for native valve Continuous or 6 divided doses 6 weeks for prosthetic Continuous or 6 div

17、ided doses 6 weeks for prosthetic Gentamicin 3 mg/kg per 24h IV/IM in 1 dose 2 weeks for either Gentamicin 3 mg/kg per 24h IV/IM in 1 dose 2 weeks for either20抗微生物治疗Regimen Regimen Dosage and route Duration(per type of valve)Dosage and route Duration(per type of valve)ORORCeftriaxone sodiumCeftriaxo

18、ne sodium plus gentamicin plus gentamicin Ceftriaxone 2 g/24 h IV/IM in 1 dose 2 weeks for native valve Ceftriaxone 2 g/24 h IV/IM in 1 dose 2 weeks for native valve 6 weeks for prosthetic 6 weeks for prosthetic Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 weeks for either Gentamicin 3 mg/kg per 24

19、 h IV/IM in 1 dose 2 weeks for eitherORORVancomycin 30mg/kg per 24 h in 2 equal doses 4 weeks for native valveVancomycin 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 to maximum of 2 g/24 hrs 6 weeks for prosthetic Relatively penicillin-re

20、sistant organismsRelatively penicillin-resistant organisms(Penicillin or ceftriaxone)plus gentamicin(Penicillin or ceftriaxone)plus gentamicin Penicillin G 24million U/24 h either continuously 4 weeks for native valve Penicillin G 24million U/24 h either continuously 4 weeks for native valve Or 4-6

21、equally divided dose 6 weeks for prosthetic Or 4-6 equally divided dose 6 weeks for prosthetic21抗微生物治疗Regimen Regimen Dosage and route Duration(per type of valve)Dosage and route Duration(per type of valve)OROR Ceftriaxone 2 g/24 h IV/IM in 1 dose 4 weeks for native valve Ceftriaxone 2 g/24 h IV/IM

22、in 1 dose 4 weeks for native valve 6 weeks for prosthetic 6 weeks for prosthetic PLUS PLUS Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 weeks for native valve Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 weeks for native valve 6 weeks for prosthetic 6 weeks for prostheticORORVancomycin 30 mg/kg pe

23、r 24 h in 2 equal doses 4 weeks for native valveVancomycin 30 mg/kg per 24 h in 2 equal doses 4 weeks for native valve to maximum of 2 g/24 h 6 weeks for prosthetic to maximum of 2 g/24 h 6 weeks for prosthetic 22抗微生物治疗v营养变异性链球菌（NVS）及青霉素高度耐药者：万古6周+庆大6周v肺炎链球菌：青霉素4周或头孢曲松4周v耐青霉素者：头孢噻肟4周或万古4周或头孢曲松+万古4周2

24、3肠球菌治疗方案（一）vRegimen Dosage and route Duration v v Susceptible to penicillin,gentamicin,and vancomycinvAmpicillin sodium 12g/24 h IV in 6 doses 46 weeksvORvPenicillin G 18-30million U/24h either continuously or 6 doses 46 weeksv PLUSv Gentamicin 3 mg/kg per 24h IV/IM in 3 equal doses 46 weeksvOR vVan

25、comycin 30 mg/kg per 24h IV in 2 equally divided doses 6 weeksv PLUSv Gentamicin 3mg/kg per 24h IV/IM in 3 equal doses 6 weeksv Susceptible to penicillin,streptomycin,vancomycin,but resistant to gentamicinvAmipicillin sodium 12 g/24h IV in 6 doses 46 weeksvORvPenicillin G 18-30 million U/24h either

26、continuously or 6 doses 46 weeks v PLUSv Streptomycin sulfate 15mg/kg per 24h IV/IM in 2 equal doses 46 weeksvORvVancomycin 30mg/kg per 24h IV in 2 equally divided doses 6 weeksv PLUSv Streptomycin sulfate 15mg/kg per 24h IV/IM in 2 equal doses 6 weeks 24肠球菌治疗方案（二）v Regimen Dosage and route Duration

27、 v Susceptible to aminoglycosides and vancomycin but resistant to penicillinvBeta-lactamase producing strainv Ampicillin-sulbactam(舒巴坦舒巴坦)12g/24h IV in 4 doses 6 weeksv PLUSv Gentamicin 3mg/kg per 24h IV/IM in 3 equal doses 6 weeksv OR v Vancomycin 30mg/kg per 24h IV in 2 equally divided doses 6 wee

28、ksv PLUSv Gentamicin 3mg/kg per 24h IV/IM in 3 equal doses 6 weeksvIntrinsic penicillin resistancev Vancomycin 30mg/kg per 24h IV in 2 equally divided doses 6 weeksv PLUSv Gentamicin 3mg/kg per 24h IV/IM in 3 equal doses 6 weeks v vResistant to penicillin,aminoglycosides,and vanvomycinvE.faecium(屎肠球

29、菌）屎肠球菌）v Linezolid(利钠唑胺利钠唑胺)1200mg/24h IV/po in 2 equal doses 8weeksvE.faecalis(粪肠球菌）粪肠球菌）v Ceftriaxone sodium 2g/24h IV/IM in 1 doses 8weeksv PLUSv Ampicillin sodium 12g/24h IV in 6 doses 8weeks25葡萄球菌IE抗菌素应用 TABLE 12.Oerview of therapy for endocarditis caused by staphylococcus Regimen Dosage and ro

30、ute Duration Methicillin-susceptible organisms(native valves)Nafcillin(新青新青)or oxacillin 12g/24h IV in 4-6 doses 6 weeks With option of gentamicin Gentamicin 3mg/kg per 24h IV/IM in 2 or 3 doses 3-5 daysORCefazolin With option of gentamicin 6g/24h in 3 divided doses 6 weeks Gentamicin 3mg/kg per 24h

31、 IV/IM in 2 or 3 doses 3-5 days Methicillin-resistant organisms(native valves)Vancomycin 30mg/kg per 24h in 2 equally divided doses 6 weeks 26葡萄球菌IE抗菌素应用TABLE 12.Oerview of therapy for endocarditis caused by staphylococcus TABLE 12.Oerview of therapy for endocarditis caused by staphylococcus Regimen

32、 Dosage and route DurationRegimen Dosage and route Duration Methicillin-susceptible organisms(prosthetic material)Methicillin-susceptible organisms(prosthetic material)Nafcillinor oxacillin 12g/24h IV in 4-6 doses 6 weeksNafcillinor oxacillin 12g/24h IV in 4-6 doses 6 weeks PLUS PLUSRifampin 900mg/2

33、4h IV/PO in 3 doses 6 weeksRifampin 900mg/24h IV/PO in 3 doses 6 weeks PLUS PLUSGentamicin 3mg/kg per 24h IV/IM in 2 or 3 equal doses 2 weeks Gentamicin 3mg/kg per 24h IV/IM in 2 or 3 equal doses 2 weeks Methicillin-resistant organisms(prosthetic material)Methicillin-resistant organisms(prosthetic m

34、aterial)Vancomycin 30mg/kg per 24h in 2 equal doses to 6 weeksVancomycin 30mg/kg per 24h in 2 equal doses to 6 weeks maximum of 2g/24h maximum of 2g/24h PLUS PLUSRifampin 900mg/24h IN/PO in 3 doses 6 weeksRifampin 900mg/24h IN/PO in 3 doses 6 weeks PLUS PLUSGentamicin 3mg/kg per 24h IV/IM 2 or 3 equ

35、al doses 2 weeksGentamicin 3mg/kg per 24h IV/IM 2 or 3 equal doses 2 weeks 27沙门氏菌IE抗菌素应用 三代头孢或氨苄青霉素 6周 v +庆大霉素 2周 v 或链霉素 4周 v绿脓杆菌 妥布霉素 8周v +v 替卡西林 8周v 或v 先锋必 8周v 28流感嗜血杆菌、放线杆菌IE抗菌素应用TABLE 13.Overview of therapy for either native or prosthetic endocardiiti causedby HACEK organisems Regimen Dosage and

36、 route DurationCeftriaxone sodium 2g/24h IV/IM in 1 dose 4 weeks ORAmpicillin-sulbactam 12g per 24h IV in 4 equally 4 weeks divided doses ORCiprofloxacin 1000mg/24h PO or 800mg/24h 4 weeks for native valve IV in equal doses 6 weeks for prosthetic29霉菌性IE治疗方案 二性霉素B 12周 或 +手术 氟康唑（大扶康）术后 氟康唑利福平68周30血培养阴

37、性IE抗菌疗法 TABLE 14.Overview of therapy for culture negative native or prosthetic endocarditis Regimen Dosage and Route Duration Native valveAmpicillin-sulbactam 12g/24h IV in 4 dose 4-6 weeks PLUS Gentamicin sulfate 3mg/kg per 24h IV/IM in 3 doses 4-6 weeksORVancomycin 30mg/kg IV in 2 doses 4-6 weeks

38、PLUS Gentamicin sulfate 3mg/kg per 24h IV/IM in 3 doses 4-6 weeks PLUS Ciprofloxaxin（环丙沙星）（环丙沙星）1000mg/24h po or 800mg 4-6 weeks IV in 2 equal doses Prosthetic valve(early,1 year)Vancomycin 30mg/kg per 24h IV/IM in 2 doses 6 weeks PLUS Gentamicin sulfate 3mg/kg per 24h IV/IM in 3 doses 2 weeks PLUS

39、Cefepime 6g/24h IV in 3 doses 6 weeks PLUS Rifampin 900mg/24h PO/IV in 3 doses 6 weeks31血培养阴性IE抗菌疗法 Regimen Dosage and Route Duration Prosthetic valve(late,1 year)Suspected bartonella.culture negativeCeftriaxone sodium 2g/24h IV/IM in 1 dose 6 weeks PLUS Gentamicin sulfate 3mg/ka per 24h in 3 doses

40、2 weeks OPTINAL Doxycycline 200mg/24h IV/PO in 2 doses 6 weeksDocumented bartonella.culture positive Doxycycline 200mg/24h IV/PO in 2 doses 6 weeks PLUS Gentamicin sulfate 3mg/kg per 24h IV/IM in 3 doses 2 weeks OR Rifampin 600mg/24h IV/PO in 2 doses 2 weeks32预防 v高危患者：人工瓣膜、曾是IE患者、紫绀型先心病、主肺动脉分流术后v中危患

41、者：其它先心、获得型瓣膜病、肥厚性心肌病、二尖瓣脱垂、主动脉瓣退行性变33预 防vTABLE 15.Prophylactic regimens for dental,oral,respiratory tract,or esophageal procedures(follow-up dose no longer redcommended)v Standard general prophylaxis for patients at risk:v Amoxicillin:Adults,2.0g(children,50mg/kg)given orally 1 hour before peocedure

42、.v Unable to take oral medications:v Ampicillin:Adults,2.0 g (children,50mg/kg)given IM or IV within 30 minutes beforev procedure.v Amoxicillin/ampicillin/penicillin allergic patients:v Clindamycin(克林霉素克林霉素):Adults,600mg(children,20mg/kg)given orally 1 hour before v peocedure.v -OR-v Cephalexin*(头孢氨

43、苄头孢氨苄)or Cefadroxil*（头孢羟氨苄）（头孢羟氨苄）:Adults,2.0 g(children 50mg/kg)v orally 1 hour before peocedure.v Amoxicillin/ampicillin/penicillin allergic patients unable to take oral medications：v Clindamycin(克林霉素克林霉素):Adults,600mg(children,20mg/kg)IV within 30 minutes before v peocedure.-OR-v Cefazolin*：Adult

44、s,1.0 g(children 25 mg/kg)IM or IV within 30 minutes before procedure.v34预 防TABLE 16.Prophylactic regimens for genitourinary/gastrointestinal procedures.High-risk patients:Ampicillin plus gentamicin:Ampicillin(adults,2.0g;chikdren 50mg/kg)plus gentamicin 1.5mg/kg(for both adults and children,not to

45、exceed 120 mg)IM or IV within 30 minutes before starting peocedure.6 hours later,ampicillin(adults,1.0g;children,25 mg/kg)IM or IV,or amoxilillin(adults,1.0g;children,25mg/kg)orally.High-risk patients allergic to ampicillin/amoxicillin:Vancomycin plus gentamixcin 1.5mg/kg(for both adults and childre

46、n,not to exceed 120 mg)IM or IV.Complete injection/infusion within 30 minutes before starting procedure.Modetare-risk patients:Amoxicillin:Adults,2.0g(children 50mg/kg)orally 1 hour before procedure-OR-Ampicillin:Aduuls,2.0g(children 50mg/kg)IM or IV within 30 minutes before starting procedure.Moder

47、ate-risk patients allergic to ampicillin/amoxicillin:Vancomycin:adults,1.0g(children 20mg/kg)IV over 1-2 hours.Complete infusion within 30 minutes of starting the procedure.35参考文献1.Baddour LM,Wilson WR,Bayer AS,et,al.AHA Scientific Statement:Infective endocarditis:diagnosis,antimicrobial therapy,and

48、 management of complications:a statement for health-care professionals from the committee on Rheumatic Fever,Endocarditis,and Kawasaki Disease,Council on Clinical Cardiology,Stroke,and Cardiovascular surgery and anesthesia,American Heart Associationececutive summary:endorsed by the Infectious Diseas

49、es Society of America.1.Circulation 2005;111(23):3167-84.2.The Task Force Members,Dieter Horstkotte,Ferenc Follath,Erno Gutschik,et,al.Guidelines on Prevention,Diagnosis and Treatment of Infective EndocarditisExecutive Summary.Europe Heart Journal2004;25(3):267-276.3.Thomas M.Bashore,Christopher Cab

50、ell,Vacne Fowler.Update on Infective Endocarditis.Current problems in Cardiology.2006,31(4):265-352.36 谢 谢！lM$sNxt-hjW5whyX65ZvqufCrBY(b+0YEC8EASr+sQeIgIL6XTDFUY5pN$dQ6jhgLQJ!CK8CZbDWHZ9E1mnw-RH-DVqd61!dcCw+0BtZwR*lGuVsypPqRqHl0zcrm#Hncp$lV4$el!YdN81wDA10vatM8zM2Bd*)MR8gaIJ3f!)y*OldM&daxGVVFjceFKgIF