Regules Jason A, Glasser Jessie S, Wolf Steven E, Hospenthal Duane R, Murray Clinton K
Brooke Army Medical Center, Fort Sam Houston, TX, USA.
Burns. 2008 Aug;34(5):610-6. doi: 10.1016/j.burns.2007.08.002. Epub 2007 Oct 29.
Burned patients are at high risk for invasive procedures, bacteremia, and other infectious complications. Previous publications describe high incidence, delayed diagnosis, and high mortality for endocarditis in burned patients, but do not address use of contemporary diagnostic criteria. Further analysis of the clinical presentation and diagnosis may aid in the earlier recognition and decreased mortality of endocarditis in burned patients.
At a 40 bed burn center, during the period from 1 January 2003 to 1 August 2006, blood culture, electronic inpatient, echocardiographic, and autopsy records were reviewed for cases of endocarditis and persistent bacteremia (blood culture positivity for the same organism separated by 24h). In addition, we reviewed cases of burn-related bacterial endocarditis published in the English language. We compared the clinical and diagnostic aspects of our identified cases with those in the published literature.
There were 90 episodes of persistent bacteremia or fungemia in 56 of 1250 patients admitted during the study period. Echocardiography was performed on 19, identifying 4 cases of endocarditis. One additional case of endocarditis was identified post-mortem. Time until echocardiography ranged from 6 to 176 days after onset of bacteremia. Case patient age ranged from 31 to 64 years, and total burn surface area ranged from 34 to 80%. Endocarditis occurred in 0.4% of burn unit admissions and in 8.9% of these patients with persistent bacteremia. Sites involved included the mitral valve (3), tricuspid valve (2), aortic valve (1), and pulmonic valve (1). Pathogens included Staphylococcus aureus, Pseudomonas aeruginosa, and one case of Enterococcus faecium. Diagnostic clues were minimal. Case mortality was 100%. A literature review revealed 17 publications describing confirmed bacterial endocarditis in burned patients. These cases revealed a predilection for infection by S. aureus and P. aeruginosa, a relative paucity of diagnostic clues prior to death, and a trend towards ante-mortem diagnosis and increased survival with use of diagnostic echocardiography.
The incidence and mortality of endocarditis in burned patients remain high. Clinical clues for endocarditis in this cohort are minimal and diagnosis may be delayed. For burned patients with persistent bacteremia, especially S. aureus or P. aeruginosa of unknown source, the diagnosis of endocarditis should be entertained and early echocardiography considered.
烧伤患者进行侵入性操作、发生菌血症及其他感染性并发症的风险很高。既往文献描述了烧伤患者心内膜炎的高发病率、诊断延迟及高死亡率，但未涉及当代诊断标准的应用。对临床表现和诊断进行进一步分析可能有助于早期识别烧伤患者的心内膜炎并降低其死亡率。
在一家拥有40张床位的烧伤中心，对2003年1月1日至2006年8月1日期间的心内膜炎和持续性菌血症（同一病原体血培养阳性且间隔24小时）病例的血培养、电子住院病历、超声心动图及尸检记录进行回顾。此外，我们还回顾了英文发表的烧伤相关细菌性心内膜炎病例。我们将所识别病例的临床和诊断方面与已发表文献中的病例进行比较。
在研究期间收治的1250例患者中，56例发生了90次持续性菌血症或真菌血症。对19例进行了超声心动图检查，确诊4例心内膜炎。另外1例心内膜炎在尸检时确诊。从菌血症发作到进行超声心动图检查的时间为6至176天。病例患者年龄在31至64岁之间，烧伤总面积在34%至80%之间。心内膜炎在烧伤病房收治患者中的发生率为0.4%，在这些发生持续性菌血症的患者中的发生率为8.9%。受累部位包括二尖瓣（3例）、三尖瓣（2例）、主动脉瓣（1例）和肺动脉瓣（1例）。病原体包括金黄色葡萄球菌、铜绿假单胞菌，还有1例粪肠球菌。诊断线索极少。病例死亡率为100%。文献回顾显示有17篇出版物描述了确诊的烧伤患者细菌性心内膜炎。这些病例显示金黄色葡萄球菌和铜绿假单胞菌感染居多，死亡前诊断线索相对较少，并且有采用诊断性超声心动图进行生前诊断及提高生存率的趋势。
烧伤患者心内膜炎的发病率和死亡率仍然很高。该队列中心内膜炎的临床线索极少，诊断可能延迟。对于发生持续性菌血症的烧伤患者，尤其是来源不明的金黄色葡萄球菌或铜绿假单胞菌感染患者，应考虑心内膜炎的诊断并尽早进行超声心动图检查。
