Marr K A, Kong L, Fowler V G, Gopal A, Sexton D J, Conlon P J, Corey G R
Department of Medicine, Divisions of Infectious Diseases and Nephrology, Duke University Medical Center, Durham, North Carolina, USA.
Kidney Int. 1998 Nov;54(5):1684-9. doi: 10.1046/j.1523-1755.1998.00134.x.
Staphylococcus aureus bacteremia is frequently associated with metastatic complications and infective endocarditis (IE). The Duke criteria for the diagnosis of IE utilize echocardiographic techniques and are more sensitive than previous criteria. The documentation of IE in patients undergoing hemodialysis (HD) has become increasingly important in order to avoid the overuse of empiric vancomycin and the emergence of antibiotic resistance.
Patients who developed S. aureus bacteremia while undergoing HD at a tertiary medical center or one of four affiliated outpatient HD units were identified. Clinical outcome (death, metastatic complications, IE, and microbiologic recurrence) was assessed during hospitalization and at three months after discharge. Transthoracic and transesophageal echocardiograms were performed and the Duke criteria were used to diagnose IE. Pulse field gel electrophoresis was performed to confirm genetic similarity of recurrent isolates.
Four hundred and forty-five patients underwent hemodialysis for 5431.8 patient-months. Sixty-two developed 65 episodes of S. aureus bacteremia (1.2 episodes/100 patient-months). Complications occurred in 27 (44%) patients. Bacteremia recurred in patients who dialyzed through polytetrafluorethylene grafts (44.4% vs. 7.1%, P = 0.0.01), and there was a trend to increased recurrence in patients who received only vancomycin (19.5% vs. 7.1%, P = 0.4). IE was diagnosed in 8 patients (12%), six of whom had normal transthoracic echocardiograms.
Sensitive echocardiographic techniques and the Duke criteria for the diagnosis of IE should be used to determine the proper duration of antibiotic therapy in hemodialysis patients with S. aureus bacteremia. This diagnostic approach, coupled with early removal of hardware, may assist in improving outcomes.
金黄色葡萄球菌菌血症常伴有转移性并发症和感染性心内膜炎（IE）。用于诊断IE的杜克标准采用超声心动图技术，比以前的标准更敏感。为避免经验性使用万古霉素的过度使用和抗生素耐药性的出现，在接受血液透析（HD）的患者中记录IE变得越来越重要。
确定在一家三级医疗中心或四个附属门诊HD单位之一接受HD治疗时发生金黄色葡萄球菌菌血症的患者。在住院期间和出院后三个月评估临床结局（死亡、转移性并发症、IE和微生物复发）。进行经胸和经食管超声心动图检查，并使用杜克标准诊断IE。进行脉冲场凝胶电泳以确认复发性分离株的基因相似性。
445例患者接受了5431.8患者月的血液透析。62例患者发生了65次金黄色葡萄球菌菌血症发作（1.2次发作/100患者月）。27例（44%）患者出现并发症。通过聚四氟乙烯移植物进行透析的患者菌血症复发（44.4%对7.1%，P = 0.001），仅接受万古霉素治疗的患者复发趋势增加（19.5%对7.1%，P = 0.4）。8例患者（12%）被诊断为IE，其中6例经胸超声心动图正常。
应使用敏感的超声心动图技术和诊断IE的杜克标准来确定金黄色葡萄球菌菌血症血液透析患者抗生素治疗的适当持续时间。这种诊断方法，加上早期去除硬件，可能有助于改善结局。
