Fernández Guerrero Manuel L, Goyenechea Ana, Verdejo Carlos, Roblas Ricardo Fernández, de Górgolas Miguel
From Divisions of Infectious Diseases (Department of Medicine) and Clinical Microbiology. Fundación Jiménez Dìaz, Universidad Autónoma de Madrid, Madrid, Spain.
Medicine (Baltimore). 2007 Nov;86(6):363-377. doi: 10.1097/MD.0b013e31815d5386.
Enterococci are the third leading cause of infectious endocarditis, and despite advances in diagnosis and treatment, the mortality of enterococcal endocarditis has not changed in recent decades. Although variables such as advanced age, cardiac failure, and brain emboli have been recognized as risk factors for mortality, cooperative multi-institutional studies have not assessed the role of other variables, such as nosocomial acquisition of infection, the presence of comorbidities, or the changing antimicrobial susceptibility of enterococci, as factors determining prognosis.We conducted the current study to determine the risk factors for mortality in patients with enterococcal endocarditis in a single institution. We reviewed 47 consecutive episodes of enterococcal endocarditis in 44 patients diagnosed according to the modified Duke criteria from a retrospective cohort study of cases of infectious endocarditis. The main outcome measure was inhospital mortality. We applied stepwise logistic regression analysis to identify risk factors for mortality.Predisposing heart conditions were observed in 86.3% of patients, and 17 had prosthetic valve endocarditis. A portal of entry was suspected or determined in 38.2%; the genitourinary tract was the most common source of the infection (29.7%). Comorbidities were present in 52.2% of cases. Twelve episodes (25.5%) were acquired during hospitalization. Only 3 isolates of Enterococcus faecalis were highly resistant to gentamicin. Eighteen patients (40.9%) needed valve replacement due to cardiac failure or relapse. Comparing cases of native valve and prosthetic valve endocarditis, we found no differences regarding complications, the need for surgical treatment, or mortality. Eight of 44 (18%) episodes were fatal. Age over 70 years (p = 0.05), heart failure (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.15-2.25; p = 0.001), presence of 1 or more comorbidities (OR, 3.2; 95% CI, 1.11-9.39; p = 0.02), and nosocomial acquisition (OR, 8.05; 95% CI, 1.50-43.2; p = 0.01) were associated with mortality. In the multivariate analysis, only nosocomial acquisition increased the risk of mortality. In patients with enterococcal endocarditis, nosocomial acquisition of infection is an important factor determining outcome. As the incidence of bacteremia and the population of elderly people at risk continue to grow, the hazard of acquiring nosocomial enterococcal endocarditis may increase; hence, major emphasis must be put on prevention.
肠球菌是感染性心内膜炎的第三大主要病因，尽管在诊断和治疗方面取得了进展，但近几十年来肠球菌性心内膜炎的死亡率并未改变。虽然高龄、心力衰竭和脑栓塞等因素已被确认为死亡风险因素，但多机构合作研究尚未评估其他因素的作用，如医院获得性感染、合并症的存在或肠球菌抗菌药物敏感性的变化等对预后的影响。我们开展了本研究以确定单机构中肠球菌性心内膜炎患者的死亡风险因素。我们从一项感染性心内膜炎病例的回顾性队列研究中，根据改良的杜克标准对44例患者的47次连续性肠球菌性心内膜炎发作进行了回顾。主要结局指标是住院死亡率。我们应用逐步逻辑回归分析来确定死亡风险因素。86.3%的患者存在易患心脏疾病，17例患有人工瓣膜心内膜炎。38.2%的病例怀疑或确定了感染入口；泌尿生殖道是最常见的感染源（29.7%）。52.2%的病例存在合并症。12次发作（25.5%）是在住院期间获得的。仅3株粪肠球菌分离株对庆大霉素高度耐药。18例患者（40.9%）因心力衰竭或复发需要进行瓣膜置换。比较天然瓣膜和人工瓣膜心内膜炎病例，我们发现并发症、手术治疗需求或死亡率方面无差异。44次发作中有8次（18%）是致命的。70岁以上（p = 0.05）、心力衰竭（比值比[OR]，1.61；95%置信区间[CI]，1.15 - 2.25；p = 0.001）、存在1种或更多合并症（OR，3.2；95%CI，1.11 - 9.39；p = 0.02）以及医院获得性感染（OR，8.05；95%CI，1.50 - 43.2；p = 0.01）与死亡率相关。在多变量分析中，只有医院获得性感染增加了死亡风险。在肠球菌性心内膜炎患者中，医院获得性感染是决定预后的重要因素。随着菌血症发病率和高危老年人群数量持续增加，获得医院获得性肠球菌性心内膜炎的风险可能会增加；因此，必须高度重视预防。
