Malinverni R
Medizinische Universitätspoliklinik, Inselspital Bern.
Schweiz Med Wochenschr Suppl. 1996;76:14S-20S.
The role of aminoglycosides in the treatment of infective endocarditis is well established. The combination of a beta-lactam with an aminoglycoside shortens the treatment of endocarditis due to penicillin-sensitive streptococci (MIC < or = 0.1 micrograms/mL) when compared to beta-lactams alone. Patients at higher risk (e.g. with prosthetic valves, clinical duration of symptoms > 3 months) should be treated with penicillin for 4 weeks in combination with an aminoglycoside for 2 weeks. Once-daily dosing (ODD) of aminoglycosides can be recommended in penicillin-sensitive streptococcal endocarditis. The treatment of endocarditis due to streptococci relatively and/or highly resistant to penicillin requires combined treatment with penicillin plus an aminoglycoside for a longer duration. At present ODD of aminoglycosides cannot be recommended. Enterococcal endocarditis requires combined treatment for 4 to 6 weeks. Based upon experimental data, ODD of aminoglycosides appears to be markedly inferior to q 8 h dosing. Enterococcal isolates should be screened for high-level resistance to streptomycin and gentamicin. Gentamicin is the preferred agent if susceptibility testing is not performed. Aminoglycosides are administered during the initial 3 to 5 days of treatment for staphylococcal endocarditis on native valves in order to shorten the duration of bacteremia. For staphylococcal prosthetic valve endocarditis, aminoglycosides are administered for the initial 2 weeks of treatment. However, there are no reliable clinical data for methicillin-susceptible isolates to support this recommendation. In prosthetic valve endocarditis due to coagulase-negative staphylococci combination with an aminoglycoside appears to suppress the emergence of rifampin-resistant variants during treatment. There are no data on ODD of aminoglycosides in staphylococcal endocarditis. Right-sided staphylococcal endocarditis due to methicillin-susceptible staphylococci is adequately treated with a two-week course of a beta-lactam plus an aminoglycoside. This short regimen can be recommended for low risk patients, e.g. those without significant heart failure and vegetations < 2 cm3 and with an aminoglycoside-susceptible isolate.
氨基糖苷类药物在感染性心内膜炎治疗中的作用已得到充分确立。与单独使用β-内酰胺类药物相比，β-内酰胺类药物与氨基糖苷类药物联合使用可缩短对青霉素敏感的链球菌（最低抑菌浓度≤0.1微克/毫升）所致心内膜炎的治疗时间。高危患者（如有人工瓣膜、临床症状持续时间>3个月）应接受青霉素治疗4周，并联合使用氨基糖苷类药物2周。在青霉素敏感的链球菌性心内膜炎中，可推荐氨基糖苷类药物每日一次给药。对青霉素相对和/或高度耐药的链球菌所致心内膜炎的治疗需要青霉素联合氨基糖苷类药物进行更长疗程的治疗。目前不推荐氨基糖苷类药物每日一次给药。肠球菌性心内膜炎需要联合治疗4至6周。根据实验数据，氨基糖苷类药物每日一次给药明显不如每8小时给药一次。应筛查肠球菌分离株对链霉素和庆大霉素的高水平耐药性。如果未进行药敏试验，庆大霉素是首选药物。在治疗天然瓣膜的葡萄球菌性心内膜炎时，氨基糖苷类药物在治疗的最初3至5天给药，以缩短菌血症持续时间。对于人工瓣膜葡萄球菌性心内膜炎，氨基糖苷类药物在治疗的最初2周给药。然而，对于甲氧西林敏感菌株，尚无可靠的临床数据支持这一推荐。在凝固酶阴性葡萄球菌所致的人工瓣膜心内膜炎中，联合使用氨基糖苷类药物似乎可抑制治疗期间耐利福平变异株的出现。关于葡萄球菌性心内膜炎中氨基糖苷类药物每日一次给药的数据尚无。由甲氧西林敏感葡萄球菌引起的右侧葡萄球菌性心内膜炎，采用β-内酰胺类药物加氨基糖苷类药物治疗两周即可。对于低风险患者，如无明显心力衰竭、赘生物<2立方厘米且分离株对氨基糖苷类药物敏感的患者，可推荐这种短疗程治疗方案。
