Fernández Guerrero Manuel L, González López Julio J, Goyenechea Ana, Fraile Julián, de Górgolas Miguel
From the Division of Infectious Diseases (Department of Medicine) and Department of Cardiac Surgery. Fundación Jiménez Díaz. Universidad Autónoma de Madrid, Spain.
Medicine (Baltimore). 2009 Jan;88(1):1-22. doi: 10.1097/MD.0b013e318194da65.
Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis.Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status.Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications.Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE.The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively).Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18).S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE.
金黄色葡萄球菌是感染性心内膜炎的主要病因,尽管随着时间推移诊断和治疗方法有所改进,但其死亡率仍然很高。我们对一家三级医疗中心在22年间收治的133例确诊的金黄色葡萄球菌性心内膜炎病例进行了回顾性研究,以评估该感染的流行病学、发病率变化、临床表现、预后、死亡危险因素以及心脏手术对预后的影响。患者分为两组:1)右侧心内膜炎(64例)和2)左侧心内膜炎(69例)。左侧心内膜炎的病例数每10000例入院患者中保持在1 - 3例稳定水平,而右侧心内膜炎的发病率在20世纪90年代初达到峰值后,于2001年下降至几乎消失。在右侧心内膜炎病例中,我们发现了两组具有不同临床特征和预后的患者:第一组包括53例静脉注射吸毒者,第二组包括11例与导管相关的金黄色葡萄球菌菌血症和心内膜炎患者。51例患者为人类免疫缺陷病毒(HIV)阳性吸毒者,其中大多数(80.3%)患有右侧心内膜炎。我们未发现HIV阳性和阴性个体之间的死亡率差异;死亡率似乎更多地取决于心脏受累部位而非HIV状态。在左侧心内膜炎病例中,二尖瓣比主动脉瓣更常受累(61%对30%)。总体而言,74%的左侧心内膜炎患者发生了1种或更多种心脏或心脏外并发症。相比之下,只有23.4%的右侧心内膜炎患者发生了并发症。人工瓣膜心内膜炎(PVE)比天然瓣膜心内膜炎(NVE)更常为医院获得性。与NVE患者相比,PVE患者在诊断前症状持续时间较短,出现心脏杂音或发展为心脏杂音的频率较低。心力衰竭(49%)、肾衰竭(43%)和中枢神经系统(CNS)事件(35%)在PVE和NVE患者中均很常见。与NVE患者相比,PVE患者更频繁且更迅速地需要进行瓣膜置换。右侧心内膜炎患者的总体死亡率为17%。注射吸毒者中右侧心内膜炎的死亡率为3.7%,而与感染的静脉导管相关的右侧心内膜炎患者的死亡率为82%(优势比[OR],0.01;95%置信区间[CI],0.001 - 0.07)。左侧心内膜炎的死亡率为38%,NVE或PVE患者之间无显著差异(OR,0.65;95% CI,0.23 - 1.87)。CNS并发症在NVE(OR,6.55;95% CI,1.78 - 24.04)和PVE(OR,32;95% CI,2.63 - 465.40)中均与死亡率相关。发生2种或3种并发症与死亡风险增加相关(分别为2种并发症与1种并发症相比的OR,5.59;95% CI,1.08 - 28.80以及3种并发症与2种并发症相比的OR,9.25;95% CI,1.36 - 62.72)。手术治疗对NVE病例的死亡率没有显著影响(OR,3.19;95% CI,0.76 - 13.38),但显著改善了PVE患者的预后(OR,69;95% CI,2.89 - 1647.18)。金黄色葡萄球菌性心内膜炎是一种侵袭性的、通常致命的感染。本研究结果表明瓣膜置换将改善感染的预后,特别是在PVE患者中。