阜外医院感染性心内膜炎300例临床特征分析
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摘要
目的:分析近4年阜外医院感染性心内膜炎患者的临床、病原微生物特点、治疗及预后,提高该疾病的临床诊疗水平。方法:回顾性分析阜外医院2013年至2016年300例住院治疗的感染性心内膜炎患者的临床资料,着重分析其基础病因、致病微生物分布及临床转归情况。并对单纯药物治疗与手术治疗的临床及流行病学特点进行对比和分析。结果:300例患者平均年龄(40.0±15.7)岁。基础病因中先天性心脏病所占比例最高,106例(35.3%),其次为非风湿性心脏瓣膜病67例(22.3%)和心脏手术及介入治疗术后31例(10.3%),风湿性心脏病仅13例(4.3%)。临床表现最常见为心脏杂音280例(93.3%)和发热253例(84.3%)。并发症最常见的是心力衰竭226例(75.3%),其次为栓塞并发症50例(16.7%)。血培养阳性118例,阳性率为52.4%,其中链球菌仍然是最常见的致病菌,90例(76.3%),其次为葡萄球菌, 13例(11.0%)。300例患者中有274例(91.3%)有阳性发现(赘生物、瓣膜穿孔、脓肿、人工瓣瓣周漏等),237例手术或病理所见与超声心动图符合。住院病死率为3.0%。外科治疗治愈好转率明显高于内科治疗(96.6%vs 48.6%,P<0.001)。结论:感染性心内膜炎患者基础心脏病因最常见的是先天性心脏病。链球菌依然是感染性心内膜炎最常见的致病菌。感染性心内膜炎血培养阳性率低,超声心动图阳性表现成为最为重要的诊断依据。早期、有效、规律的抗菌药物治疗仍是治疗基础,及时的外科治疗可降低病死率。
Objectives: To analyze the clinical features, pathogenic distribution, treatment and prognosis of patients with infective endocarditis(IE) hospitalized in Fuwai Hospital during the latest 4 years, and to improve the diagnosis and treatment of this disease.Methods: This retrospective study included a cohort of 300 IE patients hospitalized in Fuwai Hospital from 2013 to 2016. Predisposing cardiac disease,pathogenic distribution and clinical outcomes were analyzed.Clinical and epidemiological features of patients treated with medications or surgery were compared. Results: There were 228 male and 72 female patients in this cohort; the mean age was(40.0±15.7) years old. Among the IE patients, 35.3% patients had congenital heart diseases, 22.3% had non-rheumatic valve diseases, and 10.3% had history of PCI or heart surgery. Only 4.3% patients suffered from rheumatic heart diseases. Cardiac murmur(93.3%) and fever(84.3%) were the most common clinical presentations. Congestive heart failure was the most common complication(75.3%), followedby systemic and pulmonary embolism(16.7%). Incidence of positive blood culture was 52.4%.Streptococcus(76.3%) were the most common causative organisms, followed by Staphylococcus(11.0%). 91.3% IE was detected by echocardiography. In-hospital mortality rate was 3.0%. Subgroup analysis showed that the cure rate of surgical treatment group was significantly higher than that of the medical treatment group(96.6% vs 48.6%, P<0.001). Conclusion: Congenital heart disease is the main underlying disease related to IE.Streptococcus is still the primary pathogen of IE. Due to the 1 ower positive rate of blood culture, echocardiography serves as the most important diagnostic tool for infective endocarditis.Early, effective and regular antibiotic therapy is still the cornerstone of the treatment of IE. Cardiac surgery treatment can reduce the mortality rate of IE.
Objectives: To analyze the clinical features, pathogenic distribution, treatment and prognosis of patients with infective endocarditis(IE) hospitalized in Fuwai Hospital during the latest 4 years, and to improve the diagnosis and treatment of this disease.Methods: This retrospective study included a cohort of 300 IE patients hospitalized in Fuwai Hospital from 2013 to 2016. Predisposing cardiac disease,pathogenic distribution and clinical outcomes were analyzed.Clinical and epidemiological features of patients treated with medications or surgery were compared. Results: There were 228 male and 72 female patients in this cohort; the mean age was(40.0±15.7) years old. Among the IE patients, 35.3% patients had congenital heart diseases, 22.3% had non-rheumatic valve diseases, and 10.3% had history of PCI or heart surgery. Only 4.3% patients suffered from rheumatic heart diseases. Cardiac murmur(93.3%) and fever(84.3%) were the most common clinical presentations. Congestive heart failure was the most common complication(75.3%), followedby systemic and pulmonary embolism(16.7%). Incidence of positive blood culture was 52.4%.Streptococcus(76.3%) were the most common causative organisms, followed by Staphylococcus(11.0%). 91.3% IE was detected by echocardiography. In-hospital mortality rate was 3.0%. Subgroup analysis showed that the cure rate of surgical treatment group was significantly higher than that of the medical treatment group(96.6% vs 48.6%, P<0.001). Conclusion: Congenital heart disease is the main underlying disease related to IE.Streptococcus is still the primary pathogen of IE. Due to the 1 ower positive rate of blood culture, echocardiography serves as the most important diagnostic tool for infective endocarditis.Early, effective and regular antibiotic therapy is still the cornerstone of the treatment of IE. Cardiac surgery treatment can reduce the mortality rate of IE.
引文
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[9]张抒扬,严晓伟,金兰.感染性心内膜炎的临床变迁[J].中华内科杂志,1994,33(5):317-319.DOI:10.3760/j.issn:0578-1426.1994.05.012.
[10]熊长明,程显声,杨方伦.215例感染性心内膜炎临床分析[J].中国循环杂志,2001,16(03):203-204.DOI:10.3321/j.issn:1000-3614.2001.03.018.
[11]王鹏,卢静海,王贺玲,等.感染性心内膜炎368例临床分析[J].中华心血管病杂志,2014,42(2):140-144.DOI:10.3760/cma.j.issn.0253-3758.2014.02.009.
[12]Castillo FJ,Anguita M,Castillo JC,et al.Changes in clinical profile,epidemiology and prognosis of left-sided native-valve infective endocarditis without predisposing heart conditions[J].Rev Esp Cardiol(Engl Ed),2015,68(5):445-448.DOI:10.1016/j.rec.2014.12.014.
[13]李坑,张富恩,王爱萍,等.感染性心内膜炎的临床特点及病原菌分析[J].中华内科杂志,2016,55(10):774-778.DOI:10.3760/cma.j.issn.0578-1426.2016.10.010.
[14]王星星,陈帆,乔慧捷,等.223例感染性心内膜炎临床分析[J].南京医科大学学报(自然科学版),2015,14(07):1026-1030.DOI:10.7655/NYDXBNS20150725.
[15]崔敏,张真路,王纯,等.868例感染性心内膜炎感染部位与病原菌分析[J].华中科技大学学报(医学版),2010,39(3):427-428.DOI:10.3870/j.issn.1672-0741.2010.03.035.
[16]Yew HS,Murdoch DR.Global trends in infective endocarditis epidemiology[J].Curr Infect Dis Rep,2012,14(4):367-372.DOI:10.1007/s11908-012-0265-5.
[17]Fefer P,Raveh D,Rudensky B,et al.Changing epidemiology of infective endocarditis:a retrospective survey of 108 cases,1990-1999[J].Eur J Clin Microbiol Infect Dis,2002,21(6):432-437.DOI:10.1007/s10096-002-0740-2.
[18]Devlin RK,Andrews MM,von Reyn CF.Recent trends in infective endocarditis:influence of case definitions[J].Curr Opin Cardiol,2004,19(2):134-139.DOI:10.1039/b401882f.
[19]Murdoch DR,Corey GR,Hoen B,et al.Clinical presentation,etiology,and outcome of infective endocarditis in the 21st century:the International Collaboration on Endocarditis-Prospective Cohort Study[J].Arch Intern Med,2009,169(5):463-473.DOI:10.1001/archinternmed.2008.603.
[20]吴伟春,王浩,赵星,等.超声心动图对感染性心内膜炎患者的赘生物及其他常见并发症的研究[J].中华医学超声杂志(电子版),2011,8(03):558-563.DOI:10.3877/cma.j.issn.1672-6448.2011.03.018.
[21]Southwick FS.Infectious diseases:a clinical short course(Sencond Edition)[M].McGraw-Hill,2011.166.
[22]Wang A,Athan E,Pappas PA,et al.Contemporary clinical profile and outcome of prosthetic valve endocarditis[J].JAMA,2007,297(12):1354-1361.DOI:10.1001/jama.297.12.1354.
[2]Dayer MJ,Jones S,Prendergast B,et al.Incidence of infective endocarditis in England,2000-13:a secular trend,interrupted timeseries analysis[J].Lancet,2015,385(9974):1219-1228.DOI:10.1016/S0140-6736(14)62007-9.
[3]Korem M,Israel S,Gilon D,et al.Epidemiology of infective endocarditis in a tertiary-center in Jerusalem:a 3-year prospective survey[J].Eur J Intern Med,2014,25(6):550-555.DOI:10.1016/j.ejim.2014.05.011.
[4]Fernandez-Hidalgo N,Almirante B,Tornos P,et al.Immediate and long-term outcome of left-sided infective endocarditis.A 12-year prospective study from a contemporary cohort in a referral hospital[J].Clin Microbiol Infect,2012,18(12):E522-E530.DOI:10.1111/1469-0691.12033.
[5]Li JS,Sexton DJ,Mick N,et al.Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis[J].Clin Infect Dis,2000,30(4):633-638.DOI:10.1086/313753.
[6]Mckinsey DS,Ratts TE,Bisno A L.Underlying cardiac lesions in adults with infective endocarditis.The changing spectrum[J].Am JMed,1987,82(4):681-688.DOI:10.1016/0002-9343(87)90001-5.
[7]Martinez-Selles M,Munoz P,Estevez A,et al.Long-term outcome of infective endocarditis in non-intravenous drug users[J].Mayo Clin Proc,2008,83(11):1213-1217.DOI:10.4065/83.11.1213.
[8]Werdan K,Dietz S,Loffler B,et al.Mechanisms of infective endocarditis:pathogen-host interaction and risk states[J].Nat Rev Cardiol,2014,11(1):35-50.DOI:10.1038/nrcardio.2013.174.
[9]张抒扬,严晓伟,金兰.感染性心内膜炎的临床变迁[J].中华内科杂志,1994,33(5):317-319.DOI:10.3760/j.issn:0578-1426.1994.05.012.
[10]熊长明,程显声,杨方伦.215例感染性心内膜炎临床分析[J].中国循环杂志,2001,16(03):203-204.DOI:10.3321/j.issn:1000-3614.2001.03.018.
[11]王鹏,卢静海,王贺玲,等.感染性心内膜炎368例临床分析[J].中华心血管病杂志,2014,42(2):140-144.DOI:10.3760/cma.j.issn.0253-3758.2014.02.009.
[12]Castillo FJ,Anguita M,Castillo JC,et al.Changes in clinical profile,epidemiology and prognosis of left-sided native-valve infective endocarditis without predisposing heart conditions[J].Rev Esp Cardiol(Engl Ed),2015,68(5):445-448.DOI:10.1016/j.rec.2014.12.014.
[13]李坑,张富恩,王爱萍,等.感染性心内膜炎的临床特点及病原菌分析[J].中华内科杂志,2016,55(10):774-778.DOI:10.3760/cma.j.issn.0578-1426.2016.10.010.
[14]王星星,陈帆,乔慧捷,等.223例感染性心内膜炎临床分析[J].南京医科大学学报(自然科学版),2015,14(07):1026-1030.DOI:10.7655/NYDXBNS20150725.
[15]崔敏,张真路,王纯,等.868例感染性心内膜炎感染部位与病原菌分析[J].华中科技大学学报(医学版),2010,39(3):427-428.DOI:10.3870/j.issn.1672-0741.2010.03.035.
[16]Yew HS,Murdoch DR.Global trends in infective endocarditis epidemiology[J].Curr Infect Dis Rep,2012,14(4):367-372.DOI:10.1007/s11908-012-0265-5.
[17]Fefer P,Raveh D,Rudensky B,et al.Changing epidemiology of infective endocarditis:a retrospective survey of 108 cases,1990-1999[J].Eur J Clin Microbiol Infect Dis,2002,21(6):432-437.DOI:10.1007/s10096-002-0740-2.
[18]Devlin RK,Andrews MM,von Reyn CF.Recent trends in infective endocarditis:influence of case definitions[J].Curr Opin Cardiol,2004,19(2):134-139.DOI:10.1039/b401882f.
[19]Murdoch DR,Corey GR,Hoen B,et al.Clinical presentation,etiology,and outcome of infective endocarditis in the 21st century:the International Collaboration on Endocarditis-Prospective Cohort Study[J].Arch Intern Med,2009,169(5):463-473.DOI:10.1001/archinternmed.2008.603.
[20]吴伟春,王浩,赵星,等.超声心动图对感染性心内膜炎患者的赘生物及其他常见并发症的研究[J].中华医学超声杂志(电子版),2011,8(03):558-563.DOI:10.3877/cma.j.issn.1672-6448.2011.03.018.
[21]Southwick FS.Infectious diseases:a clinical short course(Sencond Edition)[M].McGraw-Hill,2011.166.
[22]Wang A,Athan E,Pappas PA,et al.Contemporary clinical profile and outcome of prosthetic valve endocarditis[J].JAMA,2007,297(12):1354-1361.DOI:10.1001/jama.297.12.1354.