| Infective endocarditis (IE) is invasion and multiplication of microorganisms on the endocardial surface, within the endocardium, within the myocardium, or on prosthetic materials, within and around cardiac structures. It includes conditions in which structures of the heart, most frequently the valves, harbor an infective process that leads to valvar dysfunction, localized or generalized sepsis, or sites for embolism. There are multiple clinical manifestations caused with IE, such as fever,heard failure,erythra,embolic phenomenon and so on.It has been pay close attention to clinicians for so many years because of its complicacy and high mortality.Pertinent literatures have been published one after the other. Diagnositic rate and therapy of infective endocarditis have raised to some extent, along with extensive antibiotic therapy,population ageing,widespread progres of cardiac catheter and improvement of aided facilities for diagnosis&treatment.But this disease still carries a poor prognosis and a high mortality.IE is not a uniform disease,and it presents in a variety of different forms, according to the initia clinical manifestation,the underlying cardiac disease,the microorganism involved,the presence or absence of complications,and underlying patient characteristic.For these reasons,IE requires a collaborative approach.Guidelines on the prevention, diagnosis, and treatment of IE,published by the ESC in2009, had showed its diversify of characteristic about epidemiology, clinical manifestations, pathogens,but domestic reports have been rare in recent years.There were many significant investigations of IE in the Europe and USA,and several new national and international guidelines published for clinical diagnosis and treatment. Domestic investigations on the prevention, diagnosis, and treatment of IE were deficient obviously compared with that in the developed nations. Diagnostic criteria of infective endocarditis for pediatrics(on trial) published by Chinese journal of pediatrics in recent year has played an important role in standardization of diagnosis of paediatric infective endocarditis.Therapy of IE in our county refers to supplied therapeutic regimen from the Europe and USA currently. The target of antibiotic therapy is to eliminate bacterias in the vegetations,to decrease its complications and recurrence, to reduce its morbidity and mortality. Antibiotic therapy should be initiated early.And it request full dosage,enough duration and intravenous administration. Antibiotic therapeutic regimens include empirical therapy and therapeutic regimens for special pathogens. The optimal schedules should be the ones with susceptive antibiotic therapy according to positive blood cultures.IE with positive blood cultures represented85%of all IE oversea.Nevertheless, according to the data from domestic large cardiopathy centers, IE with positive blood cultures domestic represented40-60%of all IE,portion of which was blood culture-negative endocarditis. Scarce reports on antibiotic therapy for blood culture-negative IE(BCNE) have been published recent years.Mortality of IE is still high in the patients that accepted only conservative treatment, in spite of extensive administration with broad-spectrum and effective antibiotic drugs. Surgical treatment, which was used in approximately half of patients with IE because of severe complications according to reports oversea,is available approach for cases with IE which are difficult to manage.Indications of emergency or urgent surgery include progressive heart failure,uncontrolled infection and prevention embolism.On the other side surgical treatment during the active phase of the disease is associated with significant risk, accrescence of mutilation rate and mortality.Guideline of IE published by ESC recently have shown that20%-40%patients of all IE emerged neurological complications. The studies used magnetic resonance imaging have shown that acute brain embolizations are significantly more prevalent than that had been reported previously in studies based on clinical findings and CT scanning (30%of undetected events).Evidence regarding the optimal time interval between stroke and cardiac surgery is conflicting because of lack of controlled studies. The purpose of this study is to search out indications and optimal timing of surgery for IE patients.PurposeThe purpose of this study is to make clear clinical characteristic diversify of IE,to assess rationality of antibiotic therapy and to search out indications and optimal timing of surgery for IE patients by a retrospective analysis of prospectively collected data on a single cohort of145consecutive episodes of IE from nanfang hospital near10years,compared with domestic and overseas studies.Research Methods1.The retrospective study included all patients possible and definite IE in our hospital from October2002to September2012. Information was obtained from medical records. Clinical data included patient age and sex,visiting time,type of foundation heart disease, cardiosurgery history, symptom, signs, blood routine, urine routine, renal function,blood culture,echocardiogram,valve involved,size and number of vegetations, activity of vegetation,antibiotic therapy given and duration, Preoperative rank of heart function,type of surgery,postoperative complications,outcome of therapy and follow-up.2. Epidemiological changes were made clear after Statistics and analysis of the data,compared with domestic and overseas studies.3. Standard of embolism was obviously embolic symptom or organic embolic disease examined. All patients were grouped into embolism subgroup and non-embolism subgroup,according to embolizing or not, the association of risk factors with various embolic complication were determined by univariate analysis, and high risk factors with embolism were invested by Logistic multiple regression analysis.4. Recording antibiotic therapy and adjustment process of every case with IE, information was obtained from medical records, statistical data included type of antibiotic drugs,quoties dosage, daily dose, frequency,duration and the result of bacterial culture, rationality of antibiotic therapy was assessed by comparing with domestic and overseas studies.5. Indications and optimal timing of surgery for IE were searched out.6. Evaluating prognosisrecovery included recovery by non-operative treatment and operation. Recovery by non-operative treatment was defined as temperature normalize within4-6weeks under special antibiotic therapy,symptom improving or vanishing,spleen diminution,ascensus of akaryocyte and hemoglobin, WBC&ESR&CRP&PCT normalize,vegetation diminution or vanishing by echocardiography, negative-blood culture sampling on1,2,6weeks after antibiotic therapy.Recovery by operation was defined as hemodynamic normalize and heart function improving after the operation, reasonable correction of malformation of heart, prosthetic valvular functional normalize, non-perivalvular leakage, non-vegetation by echocardiography on1week after the operation and after the duration of antibiotic therapy.Improved criterion was defined as temperature normalize within4-6weeks under special antibiotic therapy, negative-blood culture,but one of laboratory examinations of WBC,ESR,CRP,PCT or the result of echocardiography cannot run up to cured criterion.Fatality was defined as death during in-hospital stay or after post-discharge within short time.Results1.Epidemiology The number of the male patients of145IE was105(72.4%),which of the female cases was40(27.6%).The male:female ratio was2.62:1.The average age was36.3yrs (36.3±14.5).It showed that this disease had a predilection for patients between20to40yrs.69%had several kinds of foundation heart disease, the highest incidence of which was rheumatic heart disease(26.2%), followed by congenital heart disease(25.5%) and senile valve degeneration(15.8%).31%had not any foundation heart disease,included intravenous drug users(20.7%). It was showed that proportion of rheumatic heart disease was descending,while the part of intravenous drug users was significant increasing.2.Clinical manifestations Clinical manifestations included fever(94.5%), urine routine abnormity(84%),embolic phenomenon (30.3%, cerbral infarction11%),renal functional lesion(11%),preoperative heart function Ⅲ～Ⅳ (59.3%)3. Echocardiography All cases checked out by transthoracic echocardi-ography,130patients (89.7%) had valve involved in all native valves.110had single valve involved,including43cases of MV,31of AV,31of TV,5of PV.20cases were double valves involved,which included16cases of MV+AV,2of AV+TV,1of MV+TV,1of MV+PV.131had vegetation detected on echocardiography.Vegetation was as large as from the point size to30mm,which were grouped into vegetation<10mm (70cases),vegetation10-15mm (39),vegetation>15mm(21).86(65.6%) had excursion of vegetation involved.4. Blood culture139patients had blood cultures.54(38.8%) patients of blood culture were negative, while85(61.2%) were positive.The most common causative organism was streptococcus(40patients (28.8%)),including streptococcus viridans12cases,globicatella sanguis5,streptococcus agalactiae4,streptococcus pneumoniae3). The causative organisms also concluded staphylococcus aureus29cases (20.8%), enterococcus5(3.6%) and fungus3(2.2%).It was showed that streptococcus,as the most common causative organism before,was decreasing,and its subpopulation had been multipling appearance.5.Antibiotic therapy The most common antibiotic drugs of single drug therapy used for streptococcal IE were penicillins and cephalosporins,while therapeutic alliance was penicillins or cephalosporins combined with aminoglycosides or quinolones.The most common antibiotic drugs of single drug therapy for staphylococcus aureus IE were penicillins, cephalosporins and vancomycin. Therapeutic alliance for staphylococcus aureus IE was treated with vancomycin, usually combined with cephalosporins or quinolones or aminoglycosides or carbopenems. Therapeutic alliance was chosen more than single drug therapy.Antibiotic therapy for BCNE was empirical therapy.Half of BCNE were treated by single drug therapy,the other were treated by therapeutic alliance. The most common antibiotic drugs of single drug therapy for these patients were penicillins, cephalosporins and vancomycin. Therapeutic alliance was penicillins or cephalosporins combined with aminoglycosides or quinolones.It was showed that there were130effective patients of antibiotic therapy (effective rate96.3%).38patients (26.2%) accepted therapeutic alliance combined with quinolones, including streptococcal IE15cases, staphylococcus aureus IE5,BCNE14,other pathogenic IE4,and effective rate of this group was97%.All patients of the study did not appeare severe irreversible adverse reaction during antibiotic therapy.6.Surgical treatment98cases(67.6%)of all145patients with IE accepted surgical treatment.8patients,cured by antibiotic therapy, accepted surgical treatment because of presence of hemodynamic abnormality due to valval lesion or congenital anomaly,which led to enlargement of chambers heart or congestive heart failure.90patients which were active IE accepted surgical treatment. Indications for emergency surgery (performed within24h) or urgent surgery(performed within a few days) included progressive heard faulure(3cases),uncontrolled infection(5) and prevention of systemic embolism(15).53patients of active IE which needed surgical treatment anticipatablely in spite of recovery after antibiotic therapy accepted elective surgery after1week of effective antibiotic therapy because of severe valvular stenosis and/or inadequacy, rupture of chordae tendinea,valvular breakage by echocardiogram and congenital malformation of heart.The intervention of IE cases with cerebral embolism detected by CT/MRI taked place after2-4weeks(5cases).modus operandi included single valve replacement (57cases),DVR (21),TVP (3), repair of VSD or ASD (15), ligation of ductus arteriosus (3),and so on.7. Outcome There were95cases cured with positive treatment,19cases improved.21patients died(totall mortality15.6%),including7patients(operative mortality7.1%) died after surgery,14patients(non-operative mortality37.8%) died during conservative therapy.53IE patients accepted surgery after effective antibiotic treatment for1week,and in this group2patients died(mortality3.8%).the risk factors of death were lesion of MV(P=0.034) and AV(P=0.047), staphylococcus aureus as a cause(P=0.004), vegetation size≥10mm but≤15mm(P=0.049), excursional vegetation (P=0.003), congestive heart failure (P=0.036), peripheric embolism(P=0.049) and surgical treatment(P<0.0001). Surgical treatment was the opposite correlative factor of death and it became protective factor.The Main Conclusions1.The epidemiological profile of IE had some changes over last years,including predisposing factors and causative organisms.Proportion of rheumatic heart disease was descending,while the part of intravenous drug users was significant increasing. Streptococcus,as the most common causative organism before,was decreasing,but its subpopulation had been multipling appearance.2.Antibiotic therapeutic regimen for IE in our hospital was reasonable. Therapeutic alliance combined with Quinolone was effective and safe.3.It was reasonable that active IE with severe valvula leison accepted surgical treatment after effective antibiotic treatment for1week. It may be advisable to postpone valve replacement for2-4weeks in IE patients with cerebral infarction.It should decrease latency on condition of IE with progressive HF and uncontrolled infection and large vegetation,but the risk of death was significant high. |
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