今日の臨床サポート

感染性心内膜炎

概要・推奨   

  1. 発熱が遷延している場合、血液培養を繰り返し、心内膜炎の合併症を見逃していないか再度確認することが推奨される(推奨度1)
  1. 感染性心内膜炎疑いの患者の病歴聴取において、先天性心疾患や弁膜症、人工弁置換術の既往は重要な項目であり、聴取することが強く推奨される(推奨度1)
  1. 感染性心内膜炎疑いの患者の病歴聴取において、心内膜炎の既往は重要な項目であり、聴取することが強く推奨される(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
馳亮太 : 特に申告事項無し[2021年]
監修:山本舜悟 : 特に申告事項無し[2021年]

  1. 改訂のポイント:定期レビューを行い、感染性心内膜炎の診断におけるFDG-PET/CT検査の意義について加筆を行なった。

病態・疫学・診察

疾患情報  
  1. 感染性心内膜炎とは、弁膜や心内膜、大血管内膜に細菌、真菌、ウイルスなど感染性微生物を含む疣腫(vegetation)を形成し、菌血症、血管塞栓、心障害などさまざまな臨床症状を呈する全身性敗血症性疾患である。
  1. 感染性心内膜炎の症状は多岐にわたり、症状を呈する可能性のある臓器は、ほぼすべてといって過言でない。修正Duke基準を念頭に検査・診断を進める。血液培養と心エコーが最重要検査となる。
  1. 適切な診断と治療が行われなかった場合の予後は非常に悪い。抗菌薬治療が行われていなかった時代の致死率は100%であった。
  1. 安易な抗菌薬投与は診断を非常に困難にする。疑った場合、血液培養を複数(できれば3セット以上)、時間を空けて採取し、持続的菌血症を証明する。
  1. 好気性グラム陽性球菌など感染性心内膜炎を起こし得る菌が血液培養で陽性になった場合、常に本疾患を疑う習慣を付ける。
  1. 特に黄色ブドウ球菌の場合は、1セットのみの陽性でも25%の患者で心内膜炎が存在したとの報告もある。
問診・診察のポイント  
  1. 非特異的な症状(発熱、全身倦怠感、体重減少、腰痛など)で発症することが多く、早期診断のため積極的に疑う。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

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文献 

著者: E Bouza, A Menasalvas, P Muñoz, F J Vasallo, M del Mar Moreno, M A García Fernández
雑誌名: Medicine (Baltimore). 2001 Sep;80(5):298-307.
Abstract/Text
PMID 11552083  Medicine (Baltimore). 2001 Sep;80(5):298-307.
著者: David R Murdoch, G Ralph Corey, Bruno Hoen, José M Miró, Vance G Fowler, Arnold S Bayer, Adolf W Karchmer, Lars Olaison, Paul A Pappas, Philippe Moreillon, Stephen T Chambers, Vivian H Chu, Vicenç Falcó, David J Holland, Philip Jones, John L Klein, Nigel J Raymond, Kerry M Read, Marie Francoise Tripodi, Riccardo Utili, Andrew Wang, Christopher W Woods, Christopher H Cabell, International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators
雑誌名: Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001/archinternmed.2008.603.
Abstract/Text BACKGROUND: We sought to provide a contemporary picture of the presentation, etiology, and outcome of infective endocarditis (IE) in a large patient cohort from multiple locations worldwide.
METHODS: Prospective cohort study of 2781 adults with definite IE who were admitted to 58 hospitals in 25 countries from June 1, 2000, through September 1, 2005.
RESULTS: The median age of the cohort was 57.9 (interquartile range, 43.2-71.8) years, and 72.1% had native valve IE. Most patients (77.0%) presented early in the disease (<30 days) with few of the classic clinical hallmarks of IE. Recent health care exposure was found in one-quarter of patients. Staphylococcus aureus was the most common pathogen (31.2%). The mitral (41.1%) and aortic (37.6%) valves were infected most commonly. The following complications were common: stroke (16.9%), embolization other than stroke (22.6%), heart failure (32.3%), and intracardiac abscess (14.4%). Surgical therapy was common (48.2%), and in-hospital mortality remained high (17.7%). Prosthetic valve involvement (odds ratio, 1.47; 95% confidence interval, 1.13-1.90), increasing age (1.30; 1.17-1.46 per 10-year interval), pulmonary edema (1.79; 1.39-2.30), S aureus infection (1.54; 1.14-2.08), coagulase-negative staphylococcal infection (1.50; 1.07-2.10), mitral valve vegetation (1.34; 1.06-1.68), and paravalvular complications (2.25; 1.64-3.09) were associated with an increased risk of in-hospital death, whereas viridans streptococcal infection (0.52; 0.33-0.81) and surgery (0.61; 0.44-0.83) were associated with a decreased risk.
CONCLUSIONS: In the early 21st century, IE is more often an acute disease, characterized by a high rate of S aureus infection. Mortality remains relatively high.

PMID 19273776  Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001・・・
著者: M Heiro, J Nikoskelainen, E Engblom, E Kotilainen, R Marttila, P Kotilainen
雑誌名: Arch Intern Med. 2000 Oct 9;160(18):2781-7.
Abstract/Text BACKGROUND: Many previous studies have endeavored to find appropriate means to reduce the occurrence of neurologic manifestations in patients with infective endocarditis (IE). We evaluated patients with IE-associated neurologic complications and compared them with patients with IE who did not have neurologic symptoms. Particular attention was focused on assessing the impact of cardiac surgery and the presence of potential risk factors for complications on the outcome of the patients.
METHODS: A total of 218 episodes designated as definite or possible IE according to Duke criteria and treated during the years 1980 through 1996 in a Finnish teaching hospital were retrospectively evaluated for neurologic manifestations.
RESULTS: Neurologic complications were identified in 55 episodes (25%), with an embolic event as the most frequent manifestation (23/55; 42%). In the majority (76%) of episodes, the neurologic manifestation was evident before antimicrobial treatment was started, being the first sign of IE in 47% of episodes. Only 1 recurrent cerebral embolization was observed. Neurologic complications were significantly associated with Staphylococcus aureus infection (29% vs 10%; P =.001) and with IE affecting both the aortic and the mitral valves (56% vs 23%; P<.01), but not with echocardiographic detection of vegetations or anticoagulant therapy. Death during the acute phase of IE occurred in 13 episodes (24%) with neurologic complications and in 17 episodes (10%) without neurologic complications (P<.03). In episodes with neurologic complications, the IE-associated mortality rate was 25% (10/40) in the medical treatment group and 20% (3/15) in the surgical group. No neurologic deterioration was observed in these surgically treated patients postoperatively.
CONCLUSIONS: Our results reinforce the belief that rapid diagnosis and initiation of antimicrobial therapy may still be the most effective means to prevent neurologic complications. These data underscore the importance of diagnostic alertness to the prognosis of patients with IE.

PMID 11025788  Arch Intern Med. 2000 Oct 9;160(18):2781-7.
著者: Xavier Duval, Bernard Iung, Isabelle Klein, Eric Brochet, Gabriel Thabut, Florence Arnoult, Laurent Lepage, Jean-Pierre Laissy, Michel Wolff, Catherine Leport, IMAGE (Resonance Magnetic Imaging at the Acute Phase of Endocarditis) Study Group
雑誌名: Ann Intern Med. 2010 Apr 20;152(8):497-504, W175. doi: 10.7326/0003-4819-152-8-201004200-00006.
Abstract/Text BACKGROUND: Neurologic complications of endocarditis can influence diagnosis, therapeutic plans, and prognosis.
OBJECTIVE: To describe how early cerebral magnetic resonance imaging (MRI) affects the diagnosis and management of endocarditis in hospitalized adults.
DESIGN: Single-center prospective study between June 2005 and October 2008. (ClinicalTrials.gov registration number: NCT00144885)
SETTING: Tertiary care university hospital in France.
PATIENTS: 130 patients with endocarditis.
INTERVENTION: Cerebral MRI with angiography performed up to 7 days after admission and before any surgical intervention.
MEASUREMENTS: 2 experts jointly established the endocarditis diagnostic classification (according to Duke-modified criteria) and therapeutic plans just before and after MRI and then compared them.
RESULTS: Endocarditis was initially classified as definite in 77 patients and possible in 50 and was excluded in 3. Sixteen patients (12%) had acute neurologic symptoms. Cerebral lesions were detected by MRI in 106 patients (82% [95% CI, 75% to 89%]), including ischemic lesions in 68, microhemorrhages in 74, and silent aneurysms in 10. Solely on the basis of MRI results and excluding microhemorrhages, diagnostic classification of 17 of 53 (32%) cases of nondefinite endocarditis was upgraded to either definite (14 patients) or possible (3 patients). Endocarditis therapeutic plans were modified for 24 (18%) of the 130 patients, including surgical plan modifications for 18 (14%). Overall, early MRI led to modifications of diagnosis or therapeutic plan in 36 patients (28% [CI, 20% to 36%]).
LIMITATION: Investigators did not assess whether the MRI-related changes in diagnosis and therapeutic plans improved patient outcomes or led to unnecessary procedures and increased costs.
CONCLUSION: Cerebral lesions were identified by MRI in many patients with endocarditis but no neurologic symptoms. The MRI findings affected both diagnostic classifications and clinical management plans.
PRIMARY FUNDING SOURCE: French Ministry of Health.

PMID 20404380  Ann Intern Med. 2010 Apr 20;152(8):497-504, W175. doi: ・・・
著者: V G Fowler, J Li, G R Corey, J Boley, K A Marr, A K Gopal, L K Kong, G Gottlieb, C L Donovan, D J Sexton, T Ryan
雑誌名: J Am Coll Cardiol. 1997 Oct;30(4):1072-8.
Abstract/Text OBJECTIVES: The purpose of this prospective study was to examine the role of echocardiography in patients with Staphylococcus aureus bacteremia (SAB).
BACKGROUND: The reported incidence of infective endocarditis (IE) among patients with SAB varies widely. Distinguishing patients with uncomplicated bacteremia from those with IE is therapeutically and prognostically important, but often difficult.
METHODS: One hundred-three consecutive patients undergoing both transthoracic (TTE) echocardiography and transesophageal (TEE) echocardiography were prospectively evaluated. All patients presented with fever and > or = 1 positive blood culture and were followed up for 12 weeks.
RESULTS: Although predisposing heart disease was present in 42 patients (41%), clinical evidence of infective endocarditis (IE) was rare (7%). TTE revealed anatomic abnormalities in 33 patients, but vegetations in only 7 (7%), and was considered indeterminate in 19 (18%). TEE identified vegetations in 22 patients (aortic valve in 5, mitral valve in 9, tricuspid valve in 4, catheter in 2 and pacemaker in 2, abscesses in 2, valve perforation in 1 and new severe regurgitation in 1; 26 total [25%]). Using Duke criteria for the diagnosis of IE, definite IE was present in 26 patients (25%). Clinical findings and predisposing heart disease did not distinguish between patients with and without IE. The sensitivity of TTE for detecting IE was 32%, and the specificity was 100%. The addition of TEE increased the sensitivity to 100%, but resulted in one false positive result (specificity 99%). TEE detected evidence of IE in 19% of patients with a negative TTE and 21% of patients with an indeterminate TTE. At follow-up, cure of staphylococcal infection occurred in a similar percentage of patients with and without IE (77% and 75%, respectively). However, death due to sepsis was significantly more likely among patients with IE (4 of 26 [15%]) than among those without IE (2 of 77 [3%]) (p = 0.03).
CONCLUSIONS: Our results suggest that IE is common among patients admitted to the hospital with SAB and is associated with an increased risk of death due to sepsis. TEE is essential to establish the diagnosis and to detect associated complications. Therefore, the test should be considered part of the early evaluation of patients with SAB.

PMID 9316542  J Am Coll Cardiol. 1997 Oct;30(4):1072-8.
著者: J S Li, D J Sexton, N Mick, R Nettles, V G Fowler, T Ryan, T Bashore, G R Corey
雑誌名: Clin Infect Dis. 2000 Apr;30(4):633-8. doi: 10.1086/313753. Epub 2000 Apr 3.
Abstract/Text Although the sensitivity and specificity of the Duke criteria for the diagnosis of infective endocarditis (IE) have been validated by investigators from Europe and the United States, several shortcomings of this schema remain. The Duke IE database contains records collected prospectively on >800 cases of definite and possible IE since 1984. Databases on echocardiograms and on patients with Staphylococcus aureus bacteremia at Duke University Medical Center are also maintained. Analyses of these databases, our experience with the Duke criteria in clinical practice, and analysis of the work of others have led us to propose the following modifications of the Duke schema. The category "possible IE" should be defined as having at least 1 major criterion and 1 minor criterion or 3 minor criteria. The minor criterion "echocardiogram consistent with IE but not meeting major criterion" should be eliminated, given the widespread use of transesophageal echocardiography (TEE). Bacteremia due to S. aureus should be considered a major criterion, regardless of whether the infection is nosocomially acquired or whether a removable source of infection is present. Positive Q-fever serology should be changed to a major criterion.

PMID 10770721  Clin Infect Dis. 2000 Apr;30(4):633-8. doi: 10.1086/313・・・
著者: A J Mansur, M Grinberg, P L da Luz, G Bellotti
雑誌名: Arch Intern Med. 1992 Dec;152(12):2428-32.
Abstract/Text BACKGROUND: The frequency of complications of infective endocarditis and their influence on the outcome of the patients changed in the antibiotic era. Therefore, we evaluated the complications in a recent large series of patients with infective endocarditis.
METHODS: We studied 300 episodes of endocarditis in 287 patients in a tertiary cardiology referral center. Predisposing cardiac conditions were valvular heart disease in 147 episodes, congenital heart disease in 37, other heart diseases in five, and prosthetic heart valves in 69. In 69 episodes, there was no previous heart disease. The infecting microorganisms were streptococci in 147 episodes, Staphylococcus aureus in 59, Staphylococcus epidermidis in 14, gram-negative bacteria in 16, other gram-positive bacteria in eight, and fungi in four. In 52 episodes, blood cultures were negative. Seventy-eight patients (26%) died. Complications were defined as any clinically unfavorable event occurring during treatment.
RESULTS: A total of 386 complications occurred in 223 episodes (74%); one complication occurred in 128 episodes (57%), two in 57 (26%), three in 18 (8%), four in 13 (6%), five in three (1%), and six or more in three (1%). The complications were as follows: cardiac, 100 occurrences; neurological, 72; septic, 46; associated with medical treatment, 41; renal, 27; extracranial systemic arterial embolism, 16; septic pulmonary embolism, 26; complications related to surgical treatment, 11; acute prosthetic heart valve insufficiency, six; splenic infarction or abscess, three; cardiac rhythm disturbances, three; and other, 19. The distribution of the complications relative to outcome of the patients revealed that fatality exceeded survival rates for neurologic and septic complications.
CONCLUSIONS: Complications may be common in patients with infective endocarditis. Cardiac complications were the most common ones, but fatality rates were higher for neurologic and septic complications. Hence, heart failure was replaced by neurologic and septic complications as the leading causes of death in patients with infective endocarditis.

PMID 1456853  Arch Intern Med. 1992 Dec;152(12):2428-32.
著者: E A Blumberg, N Robbins, A Adimora, F D Lowy
雑誌名: Clin Infect Dis. 1992 Dec;15(6):983-90.
Abstract/Text Fever persisting despite adequate antimicrobial therapy for endocarditis can be an ominous sign. To evaluate the significance of persistent fever in this situation, we reviewed the records of patients at three hospital affiliates of Albert Einstein College of Medicine. Twenty-six patients with 27 episodes of endocarditis and fever lasting for > or = 2 weeks despite appropriate antimicrobial therapy were identified and compared with a matched cohort of 26 patients with endocarditis but without prolonged fever. The median duration of fever in the former group was 35 days. Cardiac infection caused fever in 13 of these patients, seven of whom had myocardial abscesses. Additional causes of infection included drug treatment, nosocomial transmission of pathogens, and pulmonary emboli. Sixteen patients required cardiac surgery (seven on an emergent basis), whereas only two controls underwent such a procedure (P < .001). Twenty-two patients with persistent fever and five controls developed nosocomial complications (P < .001). Six patients with fever died, five from endocarditis-related complications. Thus persistent fever often indicates complicated endocarditis. We present an approach for the evaluation of the patients affected by this condition.

PMID 1457671  Clin Infect Dis. 1992 Dec;15(6):983-90.
著者: A Douglas, J Moore-Gillon, S Eykyn
雑誌名: Lancet. 1986 Jun 14;1(8494):1341-3.
Abstract/Text In 83 episodes of culture-positive infective endocarditis (IE) of a native valve, fever persisted or recurred in 42 (50%) despite appropriate bactericidal antibiotics. The commonest cause of fever was extensive infection of the valve ring and adjacent structures, even when the infecting organisms were viridans streptococci; urgent surgery was required. Less frequent causes were systemic and pulmonary emboli and drug hypersensitivity. Infected intravenous access sites were seldom responsible. In no case was fever due to antibiotic resistance of the infecting organism. In patients with a definite microbiological diagnosis who have been given appropriate antibiotics, the temptation to alter antibiotic therapy because of persistent or recurrent fever should be resisted unless there are features of drug hypersensitivity. When fever persists or recurs during treatment of IE, the opinions of a cardiologist and cardiac surgeon should be obtained as soon as possible; delay in valve replacement may prove fatal in patients with extensive infection.

PMID 2872468  Lancet. 1986 Jun 14;1(8494):1341-3.
著者: Sonia Jacob, Ann T Tong
雑誌名: Curr Opin Cardiol. 2002 Sep;17(5):478-85.
Abstract/Text Infective endocarditis is a life-threatening disease with significant morbidity and mortality. Accurate and early diagnosis for initiation of effective treatment is essential in improving patient outcome. Echocardiography is currently the primary modality for the detection of vegetations and cardiac complications that result from endocarditis. Technological advances in echocardiography, particularly the development of transesophageal echocardiography (TEE), have revolutionized the diagnosis and management of infective endocarditis. With the enhanced resolution provided by TEE, vegetations and paravalvular complications can be reliably detected. Transthoracic and transesophageal echocardiography provides complementary information for patient management and follow-up, and is best used in conjunction with clinical data. By means of its high sensitivity and negative predictive value, TEE is essential in the evaluation of prosthetic valve endocarditis and the paravalvular complications of IE. All patients with suspected infective endocarditis should undergo transthoracic echocardiography, and most of these patients should also undergo TEE evaluation. The role of new technology such as harmonic and three-dimensional imaging is yet to be determined.

PMID 12357123  Curr Opin Cardiol. 2002 Sep;17(5):478-85.
著者: Larry M Baddour, Walter R Wilson, Arnold S Bayer, Vance G Fowler, Imad M Tleyjeh, Michael J Rybak, Bruno Barsic, Peter B Lockhart, Michael H Gewitz, Matthew E Levison, Ann F Bolger, James M Steckelberg, Robert S Baltimore, Anne M Fink, Patrick O'Gara, Kathryn A Taubert, American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council
雑誌名: Circulation. 2015 Oct 13;132(15):1435-86. doi: 10.1161/CIR.0000000000000296. Epub 2015 Sep 15.
Abstract/Text BACKGROUND: Infective endocarditis is a potentially lethal disease that has undergone major changes in both host and pathogen. The epidemiology of infective endocarditis has become more complex with today's myriad healthcare-associated factors that predispose to infection. Moreover, changes in pathogen prevalence, in particular a more common staphylococcal origin, have affected outcomes, which have not improved despite medical and surgical advances.
METHODS AND RESULTS: This statement updates the 2005 iteration, both of which were developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It includes an evidence-based system for diagnostic and treatment recommendations used by the American College of Cardiology and the American Heart Association for treatment recommendations.
CONCLUSIONS: Infective endocarditis is a complex disease, and patients with this disease generally require management by a team of physicians and allied health providers with a variety of areas of expertise. The recommendations provided in this document are intended to assist in the management of this uncommon but potentially deadly infection. The clinical variability and complexity in infective endocarditis, however, dictate that these recommendations be used to support and not supplant decisions in individual patient management.

© 2015 American Heart Association, Inc.
PMID 26373316  Circulation. 2015 Oct 13;132(15):1435-86. doi: 10.1161/・・・
著者: Raphael Abegão de Camargo, Marcio Sommer Bitencourt, José Claudio Meneghetti, Jose Soares, Luís Fernando Tonello Gonçalves, Carlos Alberto Buchpiguel, Milena Ribeiro Paixão, Marilia Francesconi Felicio, Alexandre de Matos Soeiro, Tania Mara Varejão Strabelli, Alfredo Jose Mansur, Flavio Tarasoutchi, Mucio Tavares de Oliveira, Jussara Bianchi Castelli, Danielle Menosi Gualandro, Lucas Zoboli Pocebon, Ron Blankstein, Abass Alavi, John Edmund Moore, Beverley Cherie Millar, Rinaldo Focaccia Siciliano
雑誌名: Clin Infect Dis. 2020 Feb 3;70(4):583-594. doi: 10.1093/cid/ciz267.
Abstract/Text BACKGROUND: 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) has emerged as a useful diagnostic tool for suspected infective endocarditis (IE) in patients with prosthetic valves or implantable devices. However, there is limited evidence regarding use of 18F-FDG-PET/CT for the diagnosis of native valve endocarditis (NVE).
METHODS: Between 2014 and 2017, 303 episodes of left-sided suspected IE (188 prosthetic valves/ascending aortic prosthesis and 115 native valves) were studied. 18F-FDG-PET/CT accuracy was determined in the subgroups of patients with NVE and prosthetic valve endocarditis (PVE)/ascending aortic prosthesis infection (AAPI). Associations between inflammatory infiltrate patterns and 18F-FDG-PET/CT uptake were investigated in an exploratory ad hoc histological analysis.
RESULTS: Among 188 patients with PVE/AAPI, the sensitivity, specificity, and positive and negative predictive values of 18F-FDG-PET/CT focal uptake were 93%, 90%, 89%, and 94%, respectively, while among 115 patients with NVE, the corresponding values were 22%, 100%, 100%, and 66%. The inclusion of abnormal 18F-FDG cardiac uptake as a major criterion at admission enabled a recategorization of 76% (47/62) of PVE/AAPI cases initially classified as "possible" to "definite" IE. In the histopathological analysis, a predominance of polymorphonuclear cell inflammatory infiltrate and a reduced extent of fibrosis were observed in the PVE group only.
CONCLUSIONS: Use of 18F-FDG-PET/CT at the initial presentation of patients with suspected PVE increases the diagnostic capability of the modified Duke criteria. In patients who present with suspected NVE, the use of 18F-FDG-PET/CT is less accurate and could only be considered a complementary diagnostic tool for a specific population of patients with NVE.

© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.
PMID 30949690  Clin Infect Dis. 2020 Feb 3;70(4):583-594. doi: 10.1093・・・
著者: Imad M Tleyjeh, James M Steckelberg, Hani S Murad, Nandan S Anavekar, Hassan M K Ghomrawi, Zaur Mirzoyev, Sherif E Moustafa, Tanya L Hoskin, Jayawant N Mandrekar, Walter R Wilson, Larry M Baddour
雑誌名: JAMA. 2005 Jun 22;293(24):3022-8. doi: 10.1001/jama.293.24.3022.
Abstract/Text CONTEXT: Limited data exist regarding population-based epidemiologic changes in incidence of infective endocarditis (IE).
OBJECTIVE: To evaluate temporal trends in the incidence and clinical characteristics of IE.
DESIGN, SETTING, AND PATIENTS: Population-based survey using the resources of the Rochester Epidemiology Project of Olmsted County, Minnesota. One hundred seven IE episodes occurred in 102 Olmsted County residents between 1970 and 2000. The modified Duke criteria were used to validate the diagnosis of definite or possible IE.
MAIN OUTCOME MEASURES: Incidence of IE, proportion of patients with underlying heart disease, and causative microorganisms and clinical characteristics.
RESULTS: Age- and sex-adjusted incidence of IE ranged from 5.0 to 7.0 cases per 100,000 person-years during the study period and did not change significantly over time (P = .42 for trend). Infective endocarditis caused by viridans group streptococci was the most common organism-specific subgroup, with an annual adjusted incidence of 1.7 to 3.5 cases per 100,000; in comparison, IE due to Staphylococcus aureus had an annual adjusted incidence of 1.0 to 2.2 cases per 100,000. No time trend was detected for either pathogen group (P = .63 and P = .66, respectively). An increasing temporal trend was observed in the proportions of prosthetic valve IE cases (P = .09). Among people with underlying heart disease, there was an increasing temporal trend in mitral valve prolapse (P = .04) and a decreasing trend in rheumatic heart disease (P = .08). However, the absolute numbers were small. There was no time trend in rates of valve surgery or 6-month mortality during the study period (P = .97 and P = .59, respectively).
CONCLUSIONS: In this community-based temporal trend study, we found no substantial change in the incidence of IE over the past 3 decades. Viridans group streptococci continue to outnumber S aureus as the most common causative organisms of IE in this population.

PMID 15972564  JAMA. 2005 Jun 22;293(24):3022-8. doi: 10.1001/jama.293・・・
著者: M P Tornos, G Permanyer-Miralda, M Olona, M Gil, E Galve, B Almirante, J Soler-Soler
雑誌名: Ann Intern Med. 1992 Oct 1;117(7):567-72.
Abstract/Text OBJECTIVE: To describe the incidence and clinical manifestations of long-term cardiac complications of endocarditis.
DESIGN: Cohort study.
SETTING: University-affiliated tertiary medical center.
PATIENTS: One hundred twelve consecutive patients, survivors from a series of 140 non-addicted patients with a first episode of infective endocarditis on native valves hospitalized from 1975 to 1990. Thirty-two patients had had valve replacement during the active phase of the infection, and the remaining 80 patients received medical treatment alone.
MEASUREMENTS: Relapse, recurrence, need for late cardiac surgery, and cardiac mortality.
RESULTS: Relapses occurred in three patients (2.7%) and recurrences in five patients (4.5%, incidence density at 15 years, 0.0030 per patient-year). Late cardiac surgery was needed by 47% of the patients treated medically during the active phase, and most had surgery in the first 2 years of follow-up (incidence density, 0.25 per patient-year at 2 years). Aortic valve involvement (relative risk, 2.66; 95% CI, 1.15 to 6.17) and end-diastolic diameter greater than 60 mm (relative risk, 1.04; 95% CI, 1.03 to 2.43) were associated with the need for late surgery in univariate analysis. Multiple logistic regression analysis showed aortic valve involvement to be an independent predictor of the need for late surgery (relative risk, 3.04; CI, 1.23 to 7.54). Only 2 of the 32 patients who had surgery during the active infection needed a second operation during follow-up. At the end of follow-up, the number of patients who had surgery after the onset of the infection was 86 (60% of the whole series). Cardiac death occurred in 16 patients; most deaths were sudden or postoperative and occurred in the first 2 years of follow-up (incidence density, 0.047 per patient-year at 2 years). Independent predictors of death were not found. Survival was 90% at 2 years, 88% at 5 years, 81% at 10 years, and 61% at 15 years.
CONCLUSIONS: Survival after infective endocarditis is fair (81% probability of survival at 10 years), and the most common types of cardiac death are sudden and postoperative. Aortic valve involvement is an independent predictor of the need for late cardiac surgery. The rate of recurrences is not negligible (incidence density at 15 years, 0.0030 per patient-year).

PMID 1306055  Ann Intern Med. 1992 Oct 1;117(7):567-72.
著者: José M Miró, Ana del Río, Carlos A Mestres
雑誌名: Infect Dis Clin North Am. 2002 Jun;16(2):273-95, vii-viii.
Abstract/Text Infective endocarditis (IE) is one of the most severe complications of parenteral drug abuse. The incidence of IE in intravenous drug abusers (IVDAs) is 2% to 5% per year, being responsible for 5% to 20% of hospital admissions and 5% to 10% of the overall death rate. IVDAs often develop recurrent IE. The prevalence of HIV infection among IVDAs with IE ranges between 30% and 70% in urban areas in developed countries. The incidence of IE in IVDAs is currently decreasing in some geographical areas, probably due to changes in drug administration habits undertaken by addicts in order to avoid HIV transmission. Overall, Staphylococcus aureus is the most common etiological agent, being in most geographical areas sensitive to methicillin (MSSA). The remainder of cases is caused by streptocococci, enterococci, GNR, Candida spp, and other less common organisms. Polymicrobial infection occurs in 2% to 5% of cases. The tricuspid valve is the most frequently affected (60% to 70%), followed by the mitral and aortic valves (20% to 30%); pulmonic valve infection is rare (< 1%). More than one valve is infected in 5% to 10% of cases. HIV-positive IVDAs have a higher ratio of right-sided IE and S. aureus IE than HIV-negative IVDAs. Response to antibiotic therapy is similar among HIV-infected or non-HIV-infected IVDAs. Drug addicts with non-complicated MSSA right-sided IE can be treated successfully with an i.v. short-course regimen of nafcillin or cloxacillin for 2 weeks, with or without addition of an aminoglycoside during the first 3 to 7 days. Surgery in HIV-infected IVDAs with IE does not worsen the prognosis. The prognosis of right-sided endocarditis is generally good; overall mortality is less than 5%, and with surgery less than 2%. In contrast, the prognosis of left-sided IE is less favorable; mortality is 20% to 30%, and even with surgery is 15% to 25%. IE caused by GNB or fungi has the worst prognosis. Mortality between HIV-infected or non-HIV-infected IVDAs with IE is similar. However, among HIV-infected IVDAs, mortality is significantly higher in those who are most severely immunosuppressed, with CD4+ cell count < 200/microL or with AIDS criteria. Finally, IE in HIV-infected patients who are not drug abusers is rare.

PMID 12092473  Infect Dis Clin North Am. 2002 Jun;16(2):273-95, vii-vi・・・
著者: Vivian H Chu, Christopher H Cabell, Daniel K Benjamin, Erin F Kuniholm, Vance G Fowler, John Engemann, Daniel J Sexton, G Ralph Corey, Andrew Wang
雑誌名: Circulation. 2004 Apr 13;109(14):1745-9. doi: 10.1161/01.CIR.0000124719.61827.7F. Epub 2004 Mar 22.
Abstract/Text BACKGROUND: Data on early determinants of outcome in infective endocarditis (IE) are limited. We evaluated the prognostic significance of early clinical characteristics in a large, prospective cohort of patients with IE.
METHODS AND RESULTS: Two hundred sixty-seven consecutive patients with definite or possible IE by modified Duke criteria and echocardiography performed within 7 days of presentation were evaluated. Acute physiology was assessed by the Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) score at the time of presentation, and early heart failure was diagnosed by Framingham criteria. In-hospital mortality rate in the cohort was 19% and similar for patients with definite or possible IE (20% versus 16%, respectively; P=0.464). Independent predictors of death determined by logistic regression modeling were diabetes mellitus (OR 2.48; 95% CI, 1.24 to 4.96), Staphylococcus aureus as causative organism (OR, 2.06; 95% CI, 1.01 to 4.20), APACHE II score (OR, 1.07; 95% CI, 1.01 to 1.12), and embolic event (OR, 2.79; 95% CI, 1.15 to 6.80). Early echocardiographic findings of the Duke criteria were not predictive of death.
CONCLUSIONS: Early in the course of IE, readily available clinical characteristics that reflect the host-pathogen interaction are predictive of in-hospital death. These factors may identify those patients with IE for more aggressive treatment.

PMID 15037538  Circulation. 2004 Apr 13;109(14):1745-9. doi: 10.1161/0・・・
著者: Gilbert Habib, Patrizio Lancellotti, Manuel J Antunes, Maria Grazia Bongiorni, Jean-Paul Casalta, Francesco Del Zotti, Raluca Dulgheru, Gebrine El Khoury, Paola Anna Erba, Bernard Iung, Jose M Miro, Barbara J Mulder, Edyta Plonska-Gosciniak, Susanna Price, Jolien Roos-Hesselink, Ulrika Snygg-Martin, Franck Thuny, Pilar Tornos Mas, Isidre Vilacosta, Jose Luis Zamorano, Document Reviewers, Çetin Erol, Petros Nihoyannopoulos, Victor Aboyans, Stefan Agewall, George Athanassopoulos, Saide Aytekin, Werner Benzer, Héctor Bueno, Lidewij Broekhuizen, Scipione Carerj, Bernard Cosyns, Julie De Backer, Michele De Bonis, Konstantinos Dimopoulos, Erwan Donal, Heinz Drexel, Frank Arnold Flachskampf, Roger Hall, Sigrun Halvorsen, Bruno Hoen, Paulus Kirchhof, Mitja Lainscak, Adelino F Leite-Moreira, Gregory Y H Lip, Carlos A Mestres, Massimo F Piepoli, Prakash P Punjabi, Claudio Rapezzi, Raphael Rosenhek, Kaat Siebens, Juan Tamargo, David M Walker
雑誌名: Eur Heart J. 2015 Nov 21;36(44):3075-128. doi: 10.1093/eurheartj/ehv319. Epub 2015 Aug 29.
Abstract/Text
PMID 26320109  Eur Heart J. 2015 Nov 21;36(44):3075-128. doi: 10.1093/・・・
著者: D T Durack, P B Beeson
雑誌名: Br J Exp Pathol. 1972 Feb;53(1):50-3.
Abstract/Text
PMID 4111329  Br J Exp Pathol. 1972 Feb;53(1):50-3.
著者: Eleonora Widmer, Yok-Ai Que, José M Entenza, Philippe Moreillon
雑誌名: Curr Infect Dis Rep. 2006 Jun;8(4):271-9.
Abstract/Text Endocarditis pathogens colonize valves with pre-existing sterile vegetations or valves with minimal endothelial lesions. Inflamed endothelia produce cytokines, integrins, and tissue factor, which in turn attract fibronectin, monocytes, and platelets. Bacteria attaching to such structures further activate the cascade, becoming embedded and protected from host defenses. Staphylococcus aureus also actively invade the endothelium, causing apoptosis and endothelial damage. Knowledge of this interplay identifies host factors as potential therapeutic targets. Blocking infection by modulating host factors might be opportune because host factors are conserved. In contrast, interfering with bacterial virulence factors might be more complicated because they vary among different bacteria.

PMID 16822370  Curr Infect Dis Rep. 2006 Jun;8(4):271-9.
著者: Kasper Iversen, Nikolaj Ihlemann, Sabine U Gill, Trine Madsen, Hanne Elming, Kaare T Jensen, Niels E Bruun, Dan E Høfsten, Kurt Fursted, Jens J Christensen, Martin Schultz, Christine F Klein, Emil L Fosbøll, Flemming Rosenvinge, Henrik C Schønheyder, Lars Køber, Christian Torp-Pedersen, Jannik Helweg-Larsen, Niels Tønder, Claus Moser, Henning Bundgaard
雑誌名: N Engl J Med. 2019 Jan 31;380(5):415-424. doi: 10.1056/NEJMoa1808312. Epub 2018 Aug 28.
Abstract/Text BACKGROUND: Patients with infective endocarditis on the left side of the heart are typically treated with intravenous antibiotic agents for up to 6 weeks. Whether a shift from intravenous to oral antibiotics once the patient is in stable condition would result in efficacy and safety similar to those with continued intravenous treatment is unknown.
METHODS: In a randomized, noninferiority, multicenter trial, we assigned 400 adults in stable condition who had endocarditis on the left side of the heart caused by streptococcus, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci and who were being treated with intravenous antibiotics to continue intravenous treatment (199 patients) or to switch to oral antibiotic treatment (201 patients). In all patients, antibiotic treatment was administered intravenously for at least 10 days. If feasible, patients in the orally treated group were discharged to outpatient treatment. The primary outcome was a composite of all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed.
RESULTS: After randomization, antibiotic treatment was completed after a median of 19 days (interquartile range, 14 to 25) in the intravenously treated group and 17 days (interquartile range, 14 to 25) in the orally treated group (P=0.48). The primary composite outcome occurred in 24 patients (12.1%) in the intravenously treated group and in 18 (9.0%) in the orally treated group (between-group difference, 3.1 percentage points; 95% confidence interval, -3.4 to 9.6; P=0.40), which met noninferiority criteria.
CONCLUSIONS: In patients with endocarditis on the left side of the heart who were in stable condition, changing to oral antibiotic treatment was noninferior to continued intravenous antibiotic treatment. (Funded by the Danish Heart Foundation and others; POET ClinicalTrials.gov number, NCT01375257 .).

PMID 30152252  N Engl J Med. 2019 Jan 31;380(5):415-424. doi: 10.1056/・・・
著者: M J DiNubile, S B Calderwood, D M Steinhaus, A W Karchmer
雑誌名: Am J Cardiol. 1986 Dec 1;58(13):1213-7.
Abstract/Text Two hundred eleven episodes of native valve active infective endocarditis treated at the Massachusetts General Hospital between 1975 and 1983 were reviewed. The aortic (36%) and mitral (33%) valves were most frequently involved, but in 21% of the cases the site of infection could not be localized. Streptococcal (50%) and staphylococcal (35%) species were the most frequently isolated pathogens. New or changing ("unstable") conduction abnormalities developed in 9% of the patients, while an additional 7% had conduction abnormalities of "indeterminate" age. Unstable conduction block was more likely to develop in patients with aortic valve infective endocarditis than in those with mitral infection. Surgery was performed in 23% of the patients. Unstable conduction abnormalities were significantly associated with valve replacement, but in a multivariate analysis, this effect could be explained by the site of valvular infection. The mortality rate was 20%. Patients with unstable conduction abnormalities had a significantly higher mortality rate, even after other significant predictors of death (age, type of causative organism) were taken into account. Patients whose conduction changes persisted had a worse prognosis than those with transient conduction abnormalities. Although more hemodynamically compromised, patients with unstable conduction block who underwent valve replacement did at least as well as those given medical therapy alone. Patients with native valve active infective endocarditis in whom persistent, unstable conduction abnormalities develop without other identifiable cause, especially in the presence of aortic valve infection, should be considered for valve replacement.

PMID 3788810  Am J Cardiol. 1986 Dec 1;58(13):1213-7.
著者: Stuart A Dickerman, Elias Abrutyn, Bruno Barsic, Emilio Bouza, Enrico Cecchi, Asuncion Moreno, Thanh Doco-Lecompte, Damon P Eisen, Claudio Q Fortes, Vance G Fowler, Stamatios Lerakis, Jose M Miro, Paul Pappas, Gail E Peterson, Ethan Rubinstein, Daniel J Sexton, Fredy Suter, Pilar Tornos, Dominique W Verhagen, Christopher H Cabell, ICE Investigators
雑誌名: Am Heart J. 2007 Dec;154(6):1086-94. doi: 10.1016/j.ahj.2007.07.023. Epub 2007 Sep 12.
Abstract/Text BACKGROUND: Embolic events to the central nervous system are a major cause of morbidity and mortality in patients with infective endocarditis (IE). The appropriate role of valvular surgery in reducing such embolic events is unclear. The purpose of this study was to determine the relationship between the initiation of antimicrobial therapy and the temporal incidence of stroke in patients with IE and to determine if this time course differs from that shown for embolic events in previous studies.
METHODS: Prospective incidence cohort study involving 61 tertiary referral centers in 28 countries. Case report forms were analyzed from 1437 consecutive patients with left-sided endocarditis admitted directly to participating centers.
RESULTS: The crude incidence of stroke in patients receiving appropriate antimicrobial therapy was 4.82/1000 patient days in the first week of therapy and fell to 1.71/1000 patient days in the second week. This rate continued to decline with further therapy. Stroke rates fell similarly regardless of the valve or organism involved. After 1 week of antimicrobial therapy, only 3.1% of the cohort experienced a stroke.
CONCLUSIONS: The risk of stroke in IE falls dramatically after the initiation of effective antimicrobial therapy. The falling risk of stroke in patients with IE as a whole precludes stroke prevention as the sole indication for valvular surgery after 1 week of therapy.

PMID 18035080  Am Heart J. 2007 Dec;154(6):1086-94. doi: 10.1016/j.ahj・・・
著者: Jay R McDonald
雑誌名: Infect Dis Clin North Am. 2009 Sep;23(3):643-64. doi: 10.1016/j.idc.2009.04.013.
Abstract/Text Acute infective endocarditis is a complex disease with changing epidemiology and a rapidly evolving knowledge base. To consistently achieve optimal outcomes in the management of infective endocarditis, the clinical team must have an understanding of the epidemiology, microbiology, and natural history of infective endocarditis, as well as a grasp of guiding principles of diagnosis and medical and surgical management. The focus of this review is acute infective endocarditis, though many studies of diagnosis and treatment do not differentiate between acute and subacute disease, and indeed many principles of diagnosis and management of infective endocarditis for acute and subacute disease are identical.

PMID 19665088  Infect Dis Clin North Am. 2009 Sep;23(3):643-64. doi: 1・・・
著者: Hector Alonso-Valle, Concepcion Fariñas-Alvarez, Jose Daniel García-Palomo, Jose Manuel Bernal, Rafael Martín-Durán, Jose Francisco Gutiérrez Díez, Jose Manuel Revuelta, M Carmen Fariñas
雑誌名: J Thorac Cardiovasc Surg. 2010 Apr;139(4):887-93. doi: 10.1016/j.jtcvs.2009.05.042. Epub 2009 Jul 10.
Abstract/Text OBJECTIVE: To compare early and late outcome of patients with prosthetic valve endocarditis treated medically versus surgically and to determine predictors of in-hospital death. We retrospectively reviewed patient's clinical records, including laboratory findings, surgery, and pathologic files, in an acute-care, 1200-bed teaching hospital.
METHODS: One hundred thirty-three episodes of definite prosthetic valve endocarditis as defined by the Duke University diagnostic criteria occurred in 122 patients from January 1986 to December 2005. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long-term follow-up was made to assess late prognosis.
RESULTS: Bioprostheses were involved in 52% of cases and mechanical valves in 48%. The aortic valve was affected in 45% of patients. Staphylococcus epidermidis was isolated in 23% of cases, Streptococcus spp in 21%, S aureus in 13%, and Enterococcus in 8%. Cultures were negative in 18% of cases. Twenty-six patients were treated medically and 107 with combined antibiotics and valve replacement. The operative mortality was 6.5% and the in-hospital mortality, 29%. Presence of an abscess at echocardiography, urgent surgical treatment, heart failure, thrombocytopenia, and renal failure were significant predictors of in-hospital death. Kaplan-Meier survival at 12 months was 42% in patients treated medically and 71% in those treated surgically (P = .0007). Freedom from endocarditis was 91% at the end of follow-up.
CONCLUSIONS: Prosthetic valve endocarditis is a serious condition with high mortality. Patients with perivalvular abscess had a worse prognosis, and combined surgical and medical treatment could be the preferred approach to improve outcome.

Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
PMID 19660339  J Thorac Cardiovasc Surg. 2010 Apr;139(4):887-93. doi: ・・・

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