[肠球菌性心内膜炎：76例多中心研究]

[Enterococcal endocarditis: a multicenter study of 76 cases].

作者信息

Martínez-Marcos Francisco Javier, Lomas-Cabezas José Manuel, Hidalgo-Tenorio Carmen, de la Torre-Lima Javier, Plata-Ciézar Antonio, Reguera-Iglesias José María, Ruiz-Morales Josefa, Márquez-Solero Manuel, Gálvez-Acebal Juan, de Alarcón-González Arístides

机构信息

Unidad de Enfermedades Infecciosas, Hospital Juan Ramón Jiménez, Huelva, España.

出版信息

Enferm Infecc Microbiol Clin. 2009 Dec;27(10):571-9. doi: 10.1016/j.eimc.2009.02.007. Epub 2009 May 24.

DOI:10.1016/j.eimc.2009.02.007

PMID:19477041

Abstract

BACKGROUND

Although enterococci occupy the third position among microorganisms producing infectious endocarditis (IE) following streptococci and Staphylococcus aureus, few multicenter studies have provided an in-depth analysis of enterococcal IE.

METHODS

Description of the characteristics of 76 cases of enterococcal left-sided infectious endocarditis (LSIE) (native: 59, prosthetic: 17) retrieved from the database of the Cardiovascular Infections Study Group of the Andalusian Society of Infectious Diseases, with emphasis on the comparison with non-enterococcal LSIE.

RESULTS

Enterococci were the causal agent in 76 of the 696 episodes of LSIE (11%). Compared with non-enterococcal LSIE, enterococcal LSIE was more commonly seen in patients older than 65 (47.4% vs. 27.6%, P<0.0005), and those with chronic diseases (75% vs. 54.6%, P<0.001), calcified valves (18.6% vs. 10%, P<0.05), and previous urinary (30.3% vs. 2.1%, P<0.00001) or abdominal (10.5% vs. 3.1%, P<0.01) infections, and produced a higher rate of relapses (6.6% vs. 2.3%, P<0.05). Enterococcal LSIE was associated with fewer peripheral vascular or skin manifestations (14.5% vs. 27.1%, P<0.05) and fewer immunological phenomena (10.5% vs. 24%, P<0.01). Among the total of patients with enterococcal LSIE, 36.8% underwent valve surgery during hospitalization. In-hospital mortality was 32.9% for enterococcal LSIE, 9.3% for viridans group streptococci (VGS) LSIE and 48.6% for S. aureus LSIE (enterococci vs VGS: P<0.0001; enterococci vs S. aureus: P=0.02). Enterococcal LSIE patients treated with the combination of a penicillin or vancomycin plus an aminoglycoside (n=60) and those treated with ampicillin plus ceftriaxone (n=6) showed similar in-hospital mortality (26.7% vs 33.3%, P=0.66). High-level resistance to gentamicin was detected in 5 of 38 episodes of enterococcal LSIE (13.1%).

CONCLUSIONS

Enterococcal LSIE appears in patients with well-defined clinical characteristics, and causes few peripheral vascular or skin manifestations and few immunological phenomena. The relapse rate is higher than in non-enterococcal LSIE. Mortality due to enterococcal LSIE is lower than that of S. aureus LSIE, and much higher than that of VGS LSIE. Mortality due to enterococcal LSIE is similar in patients treated with ampicillin plus ceftriaxone or with a combination of penicillin or vancomycin plus an aminoglycoside. High-level resistance to gentamicin remains uncommon in enterococci causing LSIE.

摘要

背景

尽管肠球菌在引起感染性心内膜炎（IE）的微生物中位列第三，仅次于链球菌和金黄色葡萄球菌，但很少有多中心研究对肠球菌性IE进行深入分析。

方法

描述从安达卢西亚传染病学会心血管感染研究组数据库中检索出的76例肠球菌性左侧感染性心内膜炎（LSIE）（原发性：59例，人工瓣膜性：17例）的特征，重点是与非肠球菌性LSIE进行比较。

结果

在696例LSIE发作中，肠球菌是76例（11%）的病原体。与非肠球菌性LSIE相比，肠球菌性LSIE在65岁以上患者中更常见（47.4%对27.6%，P<0.0005），在患有慢性病的患者中更常见（75%对54.6%，P<0.001），在有钙化瓣膜的患者中更常见（18.6%对10%，P<0.05），以及在既往有泌尿系统（30.3%对2.1%，P<0.00001）或腹部（10.5%对3.1%，P<0.01）感染的患者中更常见，并且复发率更高（6.6%对2.3%，P<0.05）。肠球菌性LSIE与较少的外周血管或皮肤表现（14.5%对27.1%，P<0.05）和较少的免疫现象（10.5%对24%，P<0.01）相关。在所有肠球菌性LSIE患者中，36.8%在住院期间接受了瓣膜手术。肠球菌性LSIE的住院死亡率为32.9%，草绿色链球菌（VGS）性LSIE为9.3%，金黄色葡萄球菌性LSIE为48.6%（肠球菌与VGS：P<0.0001；肠球菌与金黄色葡萄球菌：P=0.02）。接受青霉素或万古霉素联合氨基糖苷类治疗的肠球菌性LSIE患者（n=60）和接受氨苄西林联合头孢曲松治疗的患者（n=6）的住院死亡率相似（26.7%对33.3%，P=0.66）。在38例肠球菌性LSIE发作中，有5例（13.1%）检测到对庆大霉素的高水平耐药。

结论

肠球菌性LSIE出现在具有明确临床特征的患者中，引起较少的外周血管或皮肤表现和较少的免疫现象。复发率高于非肠球菌性LSIE。肠球菌性LSIE导致的死亡率低于金黄色葡萄球菌性LSIE，但远高于VGS性LSIE。接受氨苄西林联合头孢曲松或青霉素或万古霉素联合氨基糖苷类治疗的肠球菌性LSIE患者的死亡率相似。在引起LSIE的肠球菌中，对庆大霉素的高水平耐药仍然不常见。