Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
JAMA. 2018 Jul 3;320(1):72-83. doi: 10.1001/jama.2018.7596.
Infective endocarditis occurs in approximately 15 of 100 000 people in the United States and has increased in incidence. Clinicians must make treatment decisions with respect to prophylaxis, surgical management, specific antibiotics, and the length of treatment in the setting of emerging, sometimes inconclusive clinical research findings.
Community-associated infective endocarditis remains the predominant form of the disease; however, health care accounts for one-third of cases in high-income countries. As medical interventions are increasingly performed on older patients, the disease incidence from cardiac implanted electronic devices is also increasing. In addition, younger patients involved with intravenous drug use has increased in the past decade and with it the proportion of US hospitalization has increased to more than 10%. These epidemiological factors have led to Staphylococcus aureus being the most common cause in high-income countries, accounting for up to 40% of cases. The mainstays of diagnosis are still echocardiography and blood cultures. Adjunctive imaging such as cardiac computed tomographic and nuclear imaging can improve the sensitivity for diagnosis when echocardiography is not conclusive. Serological studies, histopathology, and polymerase chain reaction assays have distinct roles in the diagnosis of infective endocarditis when blood culture have tested negative with the highest yield obtained from serological studies. Increasing antibiotic resistance, particularly to S aureus, has led to a need for different antibiotic treatment options such as newer antibiotics and combination therapy regimens. Surgery can confer a survival benefit to patients with major complications; however, the decision to pursue surgery must balance the risks and benefits of operations in these frequently high-risk patients.
The epidemiology and management of infective endocarditis are continually changing. Guidelines provide specific recommendations about management; however, careful attention to individual patient characteristics, pathogen, and risk of sequela must be considered when making therapeutic decisions.
在美国，每 100000 人中约有 15 人发生感染性心内膜炎，其发病率一直在上升。临床医生必须根据预防措施、手术管理、特定抗生素以及在新兴的、有时结论不确定的临床研究结果的背景下治疗的持续时间做出治疗决策。
社区相关性感染性心内膜炎仍然是该病的主要形式；然而，在高收入国家，医疗保健占三分之一的病例。随着医疗干预越来越多地在老年患者中进行，心脏植入电子设备的疾病发病率也在增加。此外，过去十年中，涉及静脉内药物使用的年轻患者有所增加，因此，美国的住院比例增加到了 10%以上。这些流行病学因素导致金黄色葡萄球菌成为高收入国家最常见的病因，占病例的 40%。诊断的主要依据仍然是超声心动图和血液培养。辅助成像，如心脏计算机断层扫描和核成像，可以提高诊断的敏感性，当超声心动图不确定时。血清学研究、组织病理学和聚合酶链反应检测在血液培养阴性时在感染性心内膜炎的诊断中具有不同的作用，其中血清学研究的检出率最高。抗生素耐药性的增加，特别是金黄色葡萄球菌，导致需要不同的抗生素治疗选择，如新型抗生素和联合治疗方案。手术可以为有严重并发症的患者带来生存获益；然而，在这些经常是高危患者中，是否进行手术的决策必须权衡手术的风险和获益。
感染性心内膜炎的流行病学和管理不断变化。指南提供了关于管理的具体建议；然而，在做出治疗决策时，必须仔细考虑个体患者的特征、病原体和后遗症的风险。
