Maki D G, Agger W A
Department of Medicine, University of Wisconsin Medical School, Madison.
Medicine (Baltimore). 1988 Jul;67(4):248-69.
The enterococci, members of the group D streptococci and the predominant aerobic streptococci of the gastrointestinal and female genital tracts, have long been recognized as significant pathogens in infective endocarditis. Over the past 2 decades, enterococci have become increasingly important nosocomial pathogens, related to their intrinsic resistance to many antibiotics, especially the cephalosporins, and the greatly increased use of antimicrobial therapy in hospitals. Recent reports have documented an alarming increase in the frequency of high-level resistance to aminoglyclosides, and strains resistant to ampicillin by production of a beta-lactamase and to vancomycin have now been encountered. We have reviewed the clinical features and course of 153 cases of enterococcal bacteremia occurring in a university hospital over the 14-year period, 1970 to 1983, 1) to understand better the importance of enterococci as human pathogens, 2) to identify the clinical features of enterococcal bacteremia, 3) to isolate those findings that help to identify associated endocarditis, and 4) to develop guidelines for more effective antimicrobial therapy of bacteremic enterococcal infections. The annual incidence of enterococcal bacteremia in our center rose three-fold over the period reviewed. In 65 cases (42%), bacteremia was polymicrobial, caused by Enterococcus and at least 1 other microorganism, usually an aerobic gram-negative bacillus. Most bacteremias were nosocomial and derived from infections of the urinary tract (29 cases), intravenous catheters (24 cases), intra-abdominal infections or surgical wounds (46 cases), burn wounds (25 cases), or cholangitis (21 cases); only 1 case originated from a pneumonia. Endocarditis was identified in association with 12 of 35 community-acquired bacteremias, but only 1 of 118 bacteremias acquired in the hospital (P less than .001). Endocarditis was also significantly associated with pre-existent valvular heart disease and cryptogenic bacteremia, and was negatively associated with polymicrobial enterococcal bacteremia (no endocarditis in 65 cases, P less than .001). Isolated enterococcal bacteremia produced an indolent infection rarely associated with shock (3 of 64 cases evaluated, all cases due to valve destruction by endocarditis); conversely, with polymicrobial enterococcal bacteremia, primarily with gram-negative bacilli, shock or disseminated intravascular coagulation developed in 50% of cases (P less than .001).(ABSTRACT TRUNCATED AT 400 WORDS)
肠球菌是D组链球菌的成员，是胃肠道和女性生殖道中占主导地位的需氧链球菌，长期以来一直被认为是感染性心内膜炎的重要病原体。在过去20年中，肠球菌已成为日益重要的医院内病原体，这与其对许多抗生素（尤其是头孢菌素）的固有耐药性以及医院中抗菌治疗的大量增加有关。最近的报告记录了对氨基糖苷类高水平耐药频率的惊人增加，并且现已发现通过产生β-内酰胺酶对氨苄西林耐药以及对万古霉素耐药的菌株。我们回顾了1970年至1983年这14年间在一所大学医院发生的153例肠球菌血症的临床特征和病程，1）以便更好地了解肠球菌作为人类病原体的重要性，2）确定肠球菌血症的临床特征，3）找出有助于识别相关心内膜炎的那些发现，4）制定更有效的抗菌治疗肠球菌血症感染的指南。在我们中心，在所审查的期间内肠球菌血症的年发病率增加了两倍。在65例（42%）中，菌血症是多微生物性的，由肠球菌和至少1种其他微生物引起，通常是需氧革兰氏阴性杆菌。大多数菌血症是医院内感染，源自尿路感染（29例）、静脉导管感染（24例）、腹腔内感染或手术伤口感染（46例）、烧伤伤口感染（25例）或胆管炎（21例）；只有1例源自肺炎。在35例社区获得性菌血症中有12例与心内膜炎相关，但在医院获得的118例菌血症中只有1例（P<0.001）。心内膜炎也与先前存在的瓣膜性心脏病和隐源性菌血症显著相关，并且与多微生物性肠球菌血症呈负相关（65例中无心内膜炎，P<0.001）。孤立性肠球菌血症产生的感染进展缓慢，很少与休克相关（在64例评估病例中有3例，所有病例均因心内膜炎导致瓣膜破坏）；相反，对于多微生物性肠球菌血症，主要是与革兰氏阴性杆菌相关，50%的病例发生休克或弥散性血管内凝血（P<0.001）。（摘要截取自400字）
