感染性心內膜炎進展及指南第1頁/共37頁2流行病學年發病率十萬分之五，隨年齡增大發病率上升，我國年發病約5~8萬例。危險因素：人工瓣膜、風心、先心、老年退行性主動脈瓣病變、二尖瓣脫垂、介入治療、血透、牙科手術、靜脈留置。第2頁/共37頁3病理3/4病人原有器質性心臟病基礎。內皮細胞破壞，血小板及纖維蛋白積聚，細菌產生粘附基質分子，細菌粘附繁殖。見下圖：第3頁/共37頁4圖1、心內膜炎發生步驟第4頁/共37頁5表1感染性心內膜炎并發癥

Congestiveheartfailure50~60%AI＞MR＞TREmbolization20~25%Mitral＞AorticvalveCVA15%OtheremboliLimb2~3%Mesenteric2%Splenic2~3%Glomerulonephritis15~25%Anularabscess10~15%Myocoticaneurysm10~15%Conductionsysteminvolvement5~10%CNSabscess3~4%Otherlesscommoncomplications1~2%PericarditisMyocarditisMyocardialinfarctionintracardiacfistulaMetastaticabscess第5頁/共37頁6診斷

關鍵是具有高度的臨床警惕性

Table5CriteriathatshouldraisesuspicionofIE●

Highclinicalsuspision(rugentindicationforechocardiographicscreeningandpossiblyhospitaladmission)○newvalvelesion/(regurgitant)murmur○embolicenent(s)ofunknownorigin(esp.cerebralandrenalinfarction)○sepsisofunknownorigin○haematuria,goumerulonephritis,andsuspectedrenalinfarction○‘fever’plus█prostheticmaterialinsidetheheart█otherhighpredispositionsforIE█newlydevelopedventriculararrhythmiasorconductiondisturbances█firstmanifestationofCHF█positiveBCs(iftheorganismidentifiedistypicalforNVE/PVE)█cutaneous(Osler,Janeway)orophtahlmic(Roth)manifestations█multifocal/rapidchangingpulmonicinfiltrations(righyheartIE)█peripheralabscesses(renal,splenic,spine)ofunknownorigin█predispositionandrecentdiagnostic/theraputicinterventionsknowntoresultinsignificantbacteraemia第6頁/共37頁7血培養方法抗生素應用前需3次以上血培養，間隔超過1小時，每次血液20ml，動脈血陽性率較高，分2種培養基：普通，厭氧。如已短期使用抗生素，病情穩定,停藥3天后多次培養。如血培養多次陰性，骨髓培養陽性率較高，潔尿培養也有一定價值，皮膚Osler小結節、脫落的贅生物及手術標本培養陽性率較高。第7頁/共37頁8感染性心內膜炎心超表現贅生物、膿腫、動脈瘤、竇道、瓣體穿孔、人工瓣分離、瓣膜關閉不全

敏感性特異性

TTE46%95%TEE93%96%

可疑病人一定要作TEE檢查第8頁/共37頁9類型自體瓣膜心內膜炎人工瓣膜心內膜炎5年發生率3%~5%

靜脈吸毒者心內膜炎右心系統好發，占總IE10%~30%，預后好心內膜電極心內膜炎第9頁/共37頁10感染性心內膜炎手術指征

TABLE9.GeneralindicationsforsurgicalinterventionininfectionsendocarditisEmergencysurgery(24hours)Aorticinsufficiencywithevidenceforsignificant(FC3)CHF.Ruptureofsinusofvalsalvaintoanothercardiacstructure.Fistulaformationintoanothercardiacstructureorpericardium.Urgentsurgery(2-4days)PresenceofFC3or4CHFduetovalvulardysfunction.Perivalrularabscessformation.Prostheticvalvularobstruction.ProstheticvalvulardehiscenceEarlysurgery(4-10days)Persistentfeverfeltduetoendocarditis.Positivesurveillancecultures.Recurrentsepticemboli.Highlyresistantorvirulentorganism(fungi,Brucellae,Pseudomonas,antibiotic-resistantenterococci,poorlyresponsiveS.aureus)Large(＞10mm)mobilevegetations,especiallyonthemitralvalve.

Immediatelyreplaseaftercompletionofpriorendocarditistreatment.第10頁/共37頁11感染性心內膜炎微生物學－革蘭氏陽性球菌鏈球菌占IE約50%~60%，兒童及年輕婦女心內膜炎主要為草綠色鏈球菌，預后較好，90%能治愈，但30%以上可有并發癥。常見鏈球菌：血鏈球菌、牛鏈球菌、變異鏈球菌及腸鏈球菌第11頁/共37頁12感染性心內膜炎微生物學—革蘭氏陽性球菌腸鏈球菌（腸球菌）為消化道及前尿道正常菌群，占IE的5%~18%，常為亞急性過程。腸球菌血癥常為醫源性，多發生于尿道操作后的老年人及婦科操作后的年輕女性，40%以上病人無原發心臟病基礎，對許多抗菌素耐藥，治愈困難，病死率高。肺炎鏈球菌占IE1%~3%，常急性起病伴瓣環膿腫及急性化膿性心包炎，70%并發腦膜炎，由于急性瓣膜破壞引起血流動力學障礙，病死率高達50%。第12頁/共37頁13感染性心內膜炎微生物學—革蘭氏陽性球菌營養變異性鏈球菌（NVS）占IE2%~3%，常隱匿起病，有原發心臟病基礎，血培養常陰性。治療困難，預后不良。B族鏈球菌為口腔、生殖道、前尿道正常菌群。糖尿病、肝硬化、腫瘤等免疫力低下者為危險因素。病死率也高達50%。第13頁/共37頁14感染性心內膜炎微生物學—革蘭氏陽性球菌葡萄球菌占IE30%~40%，其中80%~90%為凝固酶陽性金葡菌，侵犯正常瓣膜，常引起急性IE,伴血行播散性膿腫，化膿性心包炎。表皮葡萄球菌常引起人工瓣IE,近年來自體瓣IE也增加，2/3為凝固酶陰性IE。第14頁/共37頁15感染性心內膜炎微生物學—革蘭氏陰性桿菌革蘭氏陰性桿菌少見，常發生于吸毒、人工瓣及肝硬化者，病程短于6周。沙門氏菌常引起左心系統心內膜炎。假單胞菌屬（包括綠膿桿菌）IE多發于吸毒者并侵犯正常瓣膜，常合并栓塞、瓣周膿腫、周圍膿腫、急性心衰等并發癥，需及早手術。第15頁/共37頁16感染性心內膜炎微生物學—革蘭氏陰性桿菌其它少見革蘭氏陰性桿菌包括嗜血桿菌、放線桿菌等，培養困難，需2~3周，臨床表現相似：大而脆的贅生物、栓塞、返流、心衰等，需換瓣手術。革蘭氏陽性桿菌（棒狀桿菌）IE少見。第16頁/共37頁17感染性心內膜炎微生物學厭氧菌主要為脆弱類桿菌IE，25%病例合并需氧菌，栓塞常見，病死率30%。霉菌IE好發于3類病人：①吸毒②心內直視手術③長期靜脈應用抗菌素。主要為ICU病人。常見為白色念珠菌及曲菌屬，病死率86%，盡早手術是治療的最好辦法。其它微生物如螺旋體、立克次體、衣原體及支原體等均可引起IE。第17頁/共37頁18血培養陰性IE

占IE5%~30%。原因為：①右心系統IE②IE晚期，病程超過2~3個月。③慢性病變伴發尿毒癥④室缺、PDA、起搏電極IE⑤致病菌生長緩慢如厭氧菌、嗜血桿菌、放線桿菌、營養變異性鏈球菌（NVS）等。⑥使用抗生素后培養⑦霉菌性IE⑧立克次體、支原體等第18頁/共37頁19抗微生物治療

TABLE10.OverviewoftherpyforendocarditiscausedbyviridansgrouporstreptococcusbovisRegimen

DosageandrouteDuration(pertypeofvalve)

Highlypenicillin-sensitiveorganismsPenicillinG12-18millionU/24heither4weeksfornativevalvecontinuousor4-6doses6weeksforprostheticORCeftriaxonesodium2g/24hIV/IMin1dose4weeksfornativevalve6weeksforprostheticORPenicillinGplusGentamicinPenicillinG12-18millionU/24heither2weeksfornativevalveContinuousor6divideddoses6weeksforprostheticGentamicin3mg/kgper24hIV/IMin1dose2weeksforeither第19頁/共37頁20抗微生物治療Regimen

DosageandrouteDuration(pertypeofvalve)ORCeftriaxonesodiumplusgentamicinCeftriaxone2g/24hIV/IMin1dose2weeksfornativevalve6weeksforprostheticGentamicin3mg/kgper24hIV/IMin1dose2weeksforeitherORVancomycin30mg/kgper24hin2equaldoses4weeksfornativevalvetomaximumof2g/24hrs6weeksforprosthetic

Relativelypenicillin-resistantorganisms(Penicillinorceftriaxone)plusgentamicinPenicillinG24millionU/24heithercontinuously4weeksfornativevalveOr4-6equallydivideddose6weeksforprosthetic第20頁/共37頁21抗微生物治療Regimen

DosageandrouteDuration(pertypeofvalve)ORCeftriaxone2g/24hIV/IMin1dose4weeksfornativevalve6weeksforprostheticPLUSGentamicin3mg/kgper24hIV/IMin1dose2weeksfornativevalve6weeksforprostheticORVancomycin30mg/kgper24hin2equaldoses4weeksfornativevalvetomaximumof2g/24h6weeksforprosthetic第21頁/共37頁22抗微生物治療營養變異性鏈球菌（NVS）及青霉素高度耐藥者：萬古6周+慶大6周肺炎鏈球菌：青霉素4周或頭孢曲松4周耐青霉素者：頭孢噻肟4周或萬古4周或頭孢曲松+萬古4周第22頁/共37頁23腸球菌治療方案（一）Regimen

Dosageandroute

Duration

Susceptibletopenicillin,gentamicin,andvancomycinAmpicillinsodium12g/24hIVin6doses4~6weeksORPenicillinG18-30millionU/24heithercontinuouslyor6doses4~6weeksPLUSGentamicin3mg/kgper24hIV/IMin3equaldoses4~6weeksORVancomycin30mg/kgper24hIVin2equallydivideddoses6weeksPLUSGentamicin3mg/kgper24hIV/IMin3equaldoses6weeks

Susceptibletopenicillin,streptomycin,vancomycin,butresistanttogentamicinAmipicillinsodium12g/24hIVin6doses4~6weeksORPenicillinG18-30millionU/24heithercontinuouslyor6doses4~6weeksPLUSStreptomycinsulfate15mg/kgper24hIV/IMin2equaldoses4~6weeksORVancomycin30mg/kgper24hIVin2equallydivideddoses6weeksPLUSStreptomycinsulfate15mg/kgper24hIV/IMin2equaldoses6weeks第23頁/共37頁24腸球菌治療方案（二）

RegimenDosageandrouteDuration

SusceptibletoaminoglycosidesandvancomycinbutresistanttopenicillinBeta-lactamaseproducingstrainAmpicillin-sulbactam(舒巴坦)12g/24hIVin4doses6weeksPLUSGentamicin3mg/kgper24hIV/IMin3equaldoses6weeksORVancomycin30mg/kgper24hIVin2equallydivideddoses6weeksPLUSGentamicin3mg/kgper24hIV/IMin3equaldoses6weeksIntrinsicpenicillinresistanceVancomycin30mg/kgper24hIVin2equallydivideddoses6weeksPLUSGentamicin3mg/kgper24hIV/IMin3equaldoses6weeks

Resistanttopenicillin,aminoglycosides,andvanvomycinE.faecium

(屎腸球菌）

Linezolid(利鈉唑胺)1200mg/24hIV/poin2equaldoses≥8weeksE.faecalis(糞腸球菌）

Ceftriaxonesodium2g/24hIV/IMin1doses≥8weeksPLUSAmpicillinsodium12g/24hIVin6doses≥8weeks第24頁/共37頁25葡萄球菌IE抗菌素應用

TABLE12.Oerviewoftherapyforendocarditiscausedbystaphylococcus

RegimenDosageandrouteDuration

Methicillin-susceptibleorganisms(nativevalves)Nafcillin(新青Ⅲ)oroxacillin12g/24hIVin4-6doses6weeksWithoptionofgentamicinGentamicin3mg/kgper24hIV/IMin2or3doses3-5daysORCefazolinWithoptionofgentamicin6g/24hin3divideddoses6weeksGentamicin3mg/kgper24hIV/IMin2or3doses3-5days

Methicillin-resistantorganisms(nativevalves)Vancomycin30mg/kgper24hin2equallydivideddoses6weeks

第25頁/共37頁26葡萄球菌IE抗菌素應用TABLE12.Oerviewoftherapyforendocarditiscausedbystaphylococcus

RegimenDosageandrouteDuration

Methicillin-susceptibleorganisms(prostheticmaterial)Nafcillinoroxacillin12g/24hIVin4-6doses≥6weeksPLUSRifampin900mg/24hIV/POin3doses≥6weeksPLUSGentamicin3mg/kgper24hIV/IMin2or3equaldoses2weeks

Methicillin-resistantorganisms(prostheticmaterial)Vancomycin30mg/kgper24hin2equaldosesto≥6weeksmaximumof2g/24hPLUSRifampin900mg/24hIN/POin3doses≥6weeksPLUSGentamicin3mg/kgper24hIV/IM2or3equaldoses2weeks

第26頁/共37頁27沙門氏菌IE抗菌素應用

三代頭孢或氨芐青霉素6周

+慶大霉素2周或鏈霉素4周綠膿桿菌妥布霉素8周

+

替卡西林8周或先鋒必8周

第27頁/共37頁28流感嗜血桿菌、放線桿菌IE抗菌素應用TABLE13.OverviewoftherapyforeithernativeorprostheticendocardiiticausedbyHACEKorganisemsRegimenDosageandrouteDurationCeftriaxonesodium2g/24hIV/IMin1dose4weeksORAmpicillin-sulbactam12gper24hIVin4equally4weeksdivideddosesORCiprofloxacin1000mg/24hPOor800mg/24h4weeksfornativevalveIVinequaldoses6weeksforprosthetic第28頁/共37頁29霉菌性IE治療方案

二性霉素B1~2周或+手術氟康唑（大扶康）

術后氟康唑＋利福平6～8周第29頁/共37頁30血培養陰性IE抗菌療法

TABLE14.Overviewoftherapyforculturenegativenativeorprostheticendocarditis

RegimenDosageandRouteDuration

NativevalveAmpicillin-sulbactam12g/24hIVin4dose4-6weeksPLUSGentamicinsulfate3mg/kgper24hIV/IMin3doses4-6weeksORVancomycin30mg/kgIVin2doses4-6weeksPLUSGentamicinsulfate3mg/kgper24hIV/IMin3doses4-6weeksPLUSCiprofloxaxin（環丙沙星）1000mg/24hpoor800mg4-6weeksIVin2equaldoses

Prostheticvalve(early,＜1year)Vancomycin30mg/kgper24hIV/IMin2doses6weeksPLUSGentamicinsulfate3mg/kgper24hIV/IMin3doses2weeksPLUSCefepime6g/24hIVin3doses6weeksPLUSRifampin900mg/24hPO/IVin3doses6weeks第30頁/共37頁31血培養陰性IE抗菌療法

RegimenDosageandRouteDuration

Prostheticvalve(late,＞1year)Suspectedbartonella.culturenegativeCeftriaxonesodium2g/24hIV/IMin1dose6weeksPLUSGentamicinsulfate3mg/kaper24hin3doses2weeksOPTINALDoxycycline200mg/24hIV/POin2doses6weeksDocumentedbartonella.culturepositiveDoxycycline200mg/24hIV/POin2doses6weeksPLUSGentamicinsulfate3mg/kgper24hIV/IMin3doses2weeksORRifampin600mg/24hIV/POin2doses2weeks第31頁/共37頁32預防高危患者：人工瓣膜、曾是IE患者、紫紺型先心病、主肺動脈分流術后中危患者：其它先心、獲得型瓣膜病、肥厚性心肌病、二尖瓣脫垂、主動脈瓣退行性變第32頁/共37頁33預防TABLE15.Prophylacticregimensfordental,oral,respiratorytract,oresophagealprocedures(follow-updosenolongerredcommended)

ⅠStandardgeneralprophylaxisforpatientsatrisk:Amoxicillin:Adults,2.0g(children,50mg/kg)givenorally1hourbeforepeocedure.ⅡUnabletotakeoralmedications:Ampicillin:Adults,2.0g(children,50mg/kg)givenIMorIVwithin30minutesbeforeprocedure.ⅢAmoxicillin/ampicillin/penicillinallergicpatients:Clindamycin(克林霉素):Adults,600mg(children,20mg/kg)givenorally1hourbeforepeocedure.-OR-Cephalexin*(頭孢氨芐)orCefadroxil*（頭孢羥氨芐）:Adults,2.0g(children50mg/kg)orally1hourbeforepeocedure.ⅣAmoxicillin/ampicillin/penicillinallergicpatientsunabletotakeoralmedications：

Clindamycin(克林霉素):Adults,600mg(children,20mg/kg)IVwithin30minutesbeforepeocedure.-OR-Cefazolin*：Adults,1.0g(children25mg/kg)IMorIVwithin30minutesbeforeprocedure.

第33頁/共37頁34預防TABLE16.Prophylacticregimensforgenitourinary/gastrointestinalproceduresⅠ.High-riskpatients:Ampicillinplusgentamicin:Ampi