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1、7/98Update onInfective Endocarditis7/2Pathogenesis 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 cells7/3Epidemiology Underlying valvular a
2、bnormality 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 regurgitation increases the risk leaflet redund
3、ancy 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 Staphylococci can produce native-valve end
4、ocarditis 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 death7/7Prosthetic Heart Valve positive blo
5、od 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 accounts for the majority of cases of e
6、ndocarditis 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 Infective Endocarditisclinical featur
7、es 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 endocarditis7/ 11Diagnostic(Duke)Criteria De
8、finitive 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 one major and three minor criteria,or fi
9、ve 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 for 4 days no pathologic evidence of IE
10、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 vascular or immunologic phenomena microbiol
11、ogic 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 two separate blood cultures persistent
12、ly 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 echocardiogram for endocarditis oscillating int
13、racardiac 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 pre-existing murmur not sufficient)7/ 16
14、Dukes 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/ 17Dukes Minor Criteria immunologic phenome
15、na(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 major criteria)7/ 18Risk for Endocardi
16、tis 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 the 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”h
