Schaffner A
Departement für Innere Medizin, Universitätsspital Zürich.
Schweiz Med Wochenschr. 1994 Jun 25;124(25):1083-9.
The diagnosis of infective endocarditis remains a challenge to physicians providing primary care. On one hand this type of infection will be rarely encountered in primary care, but on the other hand this disease carries an enormous detrimental potential. Furthermore infective endocarditis, particularly in its initial phase, often has an uncharacteristic presentation with findings and symptoms shared with many much more frequent and often harmless diseases. To confront these difficulties, which are responsible for the often delayed diagnosis of infective endocarditis, strict rules must be applied. In patients at risk for infectious endocarditis no antibiotic therapy should be instituted without prior cultures. Also, in all other patients aimless, "blind" antibiotic therapy without diagnosis of a bacterial infection should be avoided. In patients with uncharacteristic symptoms and findings compatible with the diagnosis of infective endocarditis that persist for more than 5 days, blood cultures prior to any antibiotic therapy are warranted in addition to other clinical exams and tests. The sensitivity of echocardiography in detecting infective endocarditis is frequently overestimated. Furthermore, transesophageal echocardiography in endocarditis high-risk patients requires antibiotic prophylaxis which would obscure bacteriological diagnosis. For these reasons echocardiography should not be used as first test method when considering the diagnosis of infective endocarditis.
对于提供初级医疗服务的医生而言，感染性心内膜炎的诊断仍然是一项挑战。一方面，这种感染在初级医疗中很少见，但另一方面，这种疾病具有极大的潜在危害。此外，感染性心内膜炎，尤其是在其初始阶段，通常表现不典型，其症状和体征与许多更常见且往往无害的疾病相同。为应对这些导致感染性心内膜炎诊断常常延迟的困难，必须应用严格的规则。对于有感染性心内膜炎风险的患者，未经预先培养不得开始抗生素治疗。同样，在所有其他患者中，应避免在未诊断出细菌感染的情况下进行无目的的“盲目”抗生素治疗。对于有与感染性心内膜炎诊断相符的不典型症状和体征且持续超过5天的患者，除进行其他临床检查和检测外，在任何抗生素治疗前进行血培养是必要的。超声心动图检测感染性心内膜炎的敏感性常常被高估。此外，对于心内膜炎高危患者，经食管超声心动图需要使用抗生素预防，这会掩盖细菌学诊断。出于这些原因，在考虑感染性心内膜炎的诊断时，超声心动图不应作为首选检测方法。
