Durack D T
Am J Med. 1985 Jun 28;78(6B):149-56. doi: 10.1016/0002-9343(85)90377-8.
Prevention of infective endocarditis continues to concern health care providers in many specialties. The well-known lack of primary clinical trials in this area is not expected to change. Therefore, the evolution of recommendations and practice must be based on theoretic considerations and continuing assessment of secondary sources of information. Recent developments include a report of 52 cases in which antibiotic prophylaxis for infective endocarditis was attempted but appeared to fail. Most of these patients had undergone dental procedures after oral penicillin prophylaxis, with subsequent development of streptococcal endocarditis. In two thirds, the organism was sensitive to the antibiotic used. Notably, the most common underlying cardiac lesion among these patients was mitral valve prolapse. However, two recent independent analyses have concluded that providing endocarditis prophylaxis for all patients with mitral valve prolapse during procedures that might cause bacteremia would not be cost-effective. This is primarily because mitral valve prolapse is common and endocarditis is relatively rare, resulting in an adverse risk-benefit ratio. Parenteral prophylaxis for mitral valve prolapse might even cause a net loss of life from anaphylaxis. On the other hand, for the individual patient or physician, the reassurance provided by attempted prophylaxis with oral penicillin can be purchased at low cost and low risk. Very few cases of infective endocarditis have been reported after gastrointestinal and other endoscopic procedures; most of these do not need antibiotic coverage. Prophylactic antibiotics should be restricted to those situations in which both the procedure and the underlying cardiac condition seem to pose significant risk, for example, endoscopic sclerotherapy of esophageal varices in patients with prosthetic heart valves. Newly revised recommendations have been issued by the Medical Letter, the American Heart Association, and the American Dental Association. These regimens are shorter and simpler than earlier versions.
感染性心内膜炎的预防依旧是众多专科医疗服务提供者所关注的问题。众所周知，该领域缺乏主要的临床试验这一情况预计不会改变。因此，相关建议和实践的演变必须基于理论考量以及对二手信息来源的持续评估。近期的进展包括一份报告，其中有52例尝试进行感染性心内膜炎抗生素预防但似乎失败的病例。这些患者大多数在口服青霉素预防后接受了牙科手术，随后发生了链球菌性心内膜炎。其中三分之二的病例中，病原体对所用抗生素敏感。值得注意的是，这些患者中最常见的潜在心脏病变是二尖瓣脱垂。然而，最近两项独立分析得出结论，在可能导致菌血症的手术期间为所有二尖瓣脱垂患者提供心内膜炎预防并不具有成本效益。这主要是因为二尖瓣脱垂很常见而心内膜炎相对罕见，导致风险效益比不利。二尖瓣脱垂的胃肠外预防甚至可能因过敏反应导致生命净损失。另一方面，对于个体患者或医生而言，口服青霉素尝试性预防所带来的安心感可以以低成本和低风险获得。胃肠道及其他内镜手术后报告的感染性心内膜炎病例极少；其中大多数不需要抗生素覆盖。预防性抗生素应仅限于手术和潜在心脏状况似乎都构成重大风险的情况，例如人工心脏瓣膜患者的食管静脉曲张内镜硬化治疗。《医学通讯》、美国心脏协会和美国牙科协会已发布了新修订的建议。这些方案比早期版本更简短、更简单。
