今日の臨床サポート

感染性心内膜炎(小児科)

著者: 豊田彰史 キッズクリニック鴨居

監修: 渡辺博 帝京大学老人保健センター

著者校正/監修レビュー済:2020/01/17
患者向け説明資料

概要・推奨   

  1. 感染性心内膜炎(IE)は、弁膜や心内膜、大血管内膜に細菌集簇を含む疣腫を形成し、菌血症、血管塞栓、心障害などの多彩な臨床症状を呈する全身性敗血症性疾患である。
  1. 小児のIEの発症リスクとして、①先天性心疾患、②先天性心疾患術後の血行動態異常および手術期に使用する人工弁やパッチなど人工物、③手術期などでのカテーテル留置、④免疫防御機構の低下、⑤Staphylococcus aureus易感染性などがある。
  1. 原因菌はStaphylococcus aureus、VGS、CNSの順に多い。特にStaphyrococcus aureusが多いことから重症化しやすい傾向がある。
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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:
豊田彰史 : 特に申告事項無し[2021年]
監修:渡辺博 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 感染性心内膜炎の予防と治療に関するガイドライン(2017年改訂版) に基づき、本項全般の改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 感染性心内膜炎(IE)は、弁膜や心内膜、大血管内膜に細菌集簇を含む疣腫(vegetation)を形成し、菌血症、血管塞栓、心障害などの多彩な臨床症状を呈する全身性敗血症性疾患である[1]
  1. 発症には、弁膜疾患や先天性心疾患に伴う異常血流や、人工弁置換術後などに異物の影響で生じる非細菌性血栓性心内膜炎(nonbacterial thrombogenic endocarditis、NBTE)が重要とされる[1]
  1. NBTEを有する例において、歯科処置、耳鼻咽喉科的処置、婦人科的処置、泌尿器科的処置などにより一過性の菌血症が生じると、NBTEの部位に菌が付着、増殖し、疣腫が形成されると考えられている[1]
  1. 一般小児におけるIEの発症率は、10万人・年あたり0.34から0.64で成人より低く、発症時期は、乳児期後半と思春期後半に多い[1][2][3][4][5][6][7][8]
  1. 小児におけるIEリスクの特徴としては、乳歯から永久歯に変わるため抜歯などの歯科治療の機会が成人に比べて多いことや、アトピー性皮膚炎に伴う皮膚の感染症が多いことがあげられる[9][10]
  1. 急性(6週未満)、亜急性に分類される。菌血症から症状の発現までは、80%以上の例では2週間以内である[11]
  1. 原因菌として、小児ではStaphylococcus aureus、VGS、CNSの順に多く、特にStaphyrococcus aureusが多いことから重症化しやすい傾向がある[1]
  1. 先天性心疾患が存在すると、IEのリスクが増大するといわれている[12][13]
  1. 先天性心疾患入院患者の0.71%がIEとの報告がある[14]
  1. 先天性心疾患を有する小児におけるIEの発症率は10万人・年あたり41で高く、小児のIE全体に占める先天性心疾患患者の割合は30~80%である[1][5][8][15][16]
  1. 小児のIEの発症リスクとして、①先天性心疾患の存在、②先天性心疾患術後の血行動態異常および手術期に使用する人工弁やパッチなど人工物の存在、③手術期などでのカテーテル留置、④免疫防御機構の低下、⑤Staphylococcus aureus易感染性などがあげられる[1][2][17][6][18][19]
  1. 感染経路が不明であることが少なくないが、歯科処置(全体の12%程度)、心臓外科手術(8%)に起因する[13]
  1. 小児期IEは、成人と比べ、左心系よりも右心系IEの頻度が高い(46% vs 51%)ため、心不全合併、塞栓症発生頻度は低い。また、真菌性IEの頻度も低い[13]
  1. 未手術の先天性心疾患では、ファロー四徴症などのチアノーゼ型先天性心疾患がもっとも高リスク(210~580例/10万人・年)であり、心室中隔欠損、大動脈弁狭窄/閉鎖不全、大血管転位、動脈管開存の順にリスクが高い[1][13][20][8][18][16][21][9]
  1. 無脾症候群などの内臓錯位症候群では、チアノーゼ型の複雑先天性心疾患の合併が多いことに加えて Streptococcus pneumoniae感染に対する抵抗力がないため、IEリスク、致死率とも高い[1]
  1. 右心流出路形成術、大動脈肺動脈吻合術、欠損孔閉鎖術などに用いる人工材料感染を起こすことが多く、急性期に心臓外科適応となることが少なくない。先天性心疾患IEの26%で外科適応となる[13]
  1. 先天性心疾患の外科手術後では、右室-肺動脈に人工血管などの導管を用いるRastelli手術や、人工血管による短絡術、人工弁置換術後などが高度リスクである[1][13][21]
  1. 小児のIEについては、予防処置のあり方や治療法などが成人と異なり、多施設二重盲検試験などのデータが不十分で、倫理的にも対象群をおいた試験を行えないため、専門家の意見を採用している部分が多い[1]
  1. IEのリスク患者については、成人と同様、小児でも感染予防の啓蒙と実践が重要である。 >詳細情報 
問診・診察のポイント  
  1. 小児期感染性心内膜炎(IE)で最も頻度の高い症状は発熱(56~100%)、次に食思不振・体重減少(8~83%)、倦怠感(40~79%)である。発熱を認めない場合もあるが、多くは中等度発熱である。

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文献 

著者: B L Strom, E Abrutyn, J A Berlin, J L Kinman, R S Feldman, P D Stolley, M E Levison, O M Korzeniowski, D Kaye
雑誌名: Ann Intern Med. 1998 Nov 15;129(10):761-9.
Abstract/Text BACKGROUND: Although antibiotic prophylaxis against infective endocarditis is recommended, the true risk factors for infective endocarditis are unclear.
OBJECTIVE: To quantitate the risk for endocarditis from dental treatment and cardiac abnormalities.
DESIGN: Population-based, case-control study.
SETTING: 54 hospitals in the Philadelphia area.
PATIENTS: Persons with community-acquired infective endocarditis not associated with intravenous drug use were compared with community residents, matched by age, sex, and neighborhood of residence.
MEASUREMENTS: Information on demographic characteristics, host risk factors, and dental treatment was obtained from structured telephone interviews, dental records, and medical records.
RESULTS: During the preceding 3 months, dental treatment was no more frequent among case-patients than controls (adjusted odds ratio, 0.8 [95% CI, 0.4 to 1.5]). Of 273 case-patients, 104 (38%) knew of previous cardiac lesions compared with 17 controls (6%) (adjusted odds ratio, 16.7 [CI, 7.4 to 37.4]). Case-patients more often had a history of mitral valve prolapse (adjusted odds ratio, 19.4 [CI, 6.4 to 58.4]), congenital heart disease (adjusted odds ratio, 6.7 [CI, 2.3 to 19.4]), cardiac valvular surgery (adjusted odds ratio, 74.6 [CI, 12.5 to 447]), rheumatic fever (adjusted odds ratio, 13.4 [CI, 4.5 to 39.5]), and heart murmur without other known cardiac abnormalities (adjusted odds ratio, 4.2 [CI, 2.0 to 8.9]). Among case-patients with known cardiac lesions--the target of prophylaxis--dental therapy was significantly (P = 0.03) less common than among controls (adjusted odds ratio, 0.2 [CI, 0.04 to 0.7] over 3 months). Few participants received prophylactic antibiotics.
CONCLUSIONS: Dental treatment does not seem to be a risk factor for infective endocarditis, even in patients with valvular abnormalities, but cardiac valvular abnormalities are strong risk factors. Few cases of infective endocarditis would be preventable with antibiotic prophylaxis, even with 100% effectiveness assumed. Current policies for prophylaxis should be reconsidered.

PMID 9841581  Ann Intern Med. 1998 Nov 15;129(10):761-9.
著者: E Mylonakis, S B Calderwood
雑誌名: N Engl J Med. 2001 Nov 1;345(18):1318-30. doi: 10.1056/NEJMra010082.
Abstract/Text
PMID 11794152  N Engl J Med. 2001 Nov 1;345(18):1318-30. doi: 10.1056/・・・
著者: Walter Knirsch, David Nadal
雑誌名: Eur J Pediatr. 2011 Sep;170(9):1111-27. doi: 10.1007/s00431-011-1520-8. Epub 2011 Jul 20.
Abstract/Text UNLABELLED: Congenital heart disease (CHD) has become the leading risk factor for pediatric infective endocarditis (IE) in developed countries after the decline of rheumatic heart disease. Advances in catheter- and surgery-based cardiac interventions have rendered almost all types of CHD amenable to complete correction or at least palliation. Patient survival has increased, and a new patient population, referred to as adult CHD (ACHD) patients, has emerged. Implanted prosthetic material paves the way for cardiovascular device-related infections, but studies on the management of CHD-associated IE in the era of cardiovascular devices are scarce. The types of heart malformation (unrepaired, repaired, palliated) substantially differ in their lifetime risks for IE. Streptococci and staphylococci are the predominant pathogens. Right-sided IE is more frequently seen in patients with CHD. Relevant comorbidity caused by cardiac and extracardiac episode-related complications is high. Transesophageal echocardiography is recommended for more precise visualization of vegetations, especially in complex type of CHD in ACHD patients. Antimicrobial therapy and surgical management of IE remain challenging, but outcome of CHD-associated IE from the neonate to the adult is better than in other forms of IE.
CONCLUSION: Primary prevention of IE is vital and includes good dental health and skin hygiene; antibiotic prophylaxis is indicated only in high-risk patients undergoing oral mucosal procedures.

PMID 21773669  Eur J Pediatr. 2011 Sep;170(9):1111-27. doi: 10.1007/s0・・・
著者: Nana Toyoda, Joanna Chikwe, Shinobu Itagaki, Annetine C Gelijns, David H Adams, Natalia N Egorova
雑誌名: JAMA. 2017 Apr 25;317(16):1652-1660. doi: 10.1001/jama.2017.4287.
Abstract/Text Importance: Prophylaxis and treatment guidelines for infective endocarditis have changed substantially over the past decade. In the United States, few population-based studies have explored the contemporary epidemiology and outcomes of endocarditis.
Objective: To quantify trends in the incidence and etiologies of infective endocarditis in the United States.
Design, Setting, and Participants: Retrospective population epidemiology study of patients hospitalized with a first episode of endocarditis identified from mandatory state databases in California and New York State between January 1, 1998, and December 31, 2013.
Exposure: Infective endocarditis.
Main Outcomes and Measures: Outcomes were crude and standardized incidence of endocarditis and trends in patient characteristics and disease etiology. Trends in acquisition mode, organism, and mortality were analyzed.
Results: Among 75 829 patients with first episodes of endocarditis (mean [SD] age, 62.3 [18.9] years; 59.1% male), the standardized annual incidence was stable between 7.6 (95% CI, 7.4 to 7.9) and 7.8 (95% CI, 7.6 to 8.0) cases per 100 000 persons (annual percentage change [APC], -0.06%; 95% CI, -0.3% to 0.2%; P = .59). From 1998 through 2013, the proportion of patients with native-valve endocarditis decreased (from 74.5% to 68.4%; APC, -0.7%; 95% CI, -0.9% to -0.5%; P < .001). Prosthetic-valve endocarditis increased (from 12.0% to 13.8%; APC, 1.3%; 95% CI, 0.8% to 1.7%; P < .001), and cardiac device-related endocarditis increased (from 1.3% to 4.1%; APC, 8.8%; 95% CI, 7.8% to 9.9%; P < .001). The proportion of patients with health care-associated nosocomial endocarditis decreased (from 17.7% to 15.3%; APC, -1.0%; 95% CI, -1.4% to -0.7%; P < .001). The proportion of patients with health care-associated nonnosocomial endocarditis increased (from 32.1% to 35.9%; APC, 0.8%; 95% CI, 0.5% to 1.1%; P < .001). The incidence of oral streptococcal endocarditis did not increase (unadjusted: APC, -0.1%; 95% CI, -0.8% to 0.6%; P = .77; adjusted: APC, -1.3%; 95% CI, -1.8% to -0.7%; P < .001). Crude 90-day mortality was unchanged (from 23.9% to 24.2%; APC, -0.3%; 95% CI, -1.0% to 0.4%; P = .44); adjusted risk of 90-day mortality decreased (adjusted hazard ratio per year, 0.982; 95% CI, 0.978 to 0.986; P < .001).
Conclusions and Relevance: In California and New York State, the overall standardized incidence of infective endocarditis was stable from 1998 through 2013, with changes in patient characteristics and etiology over this time.

PMID 28444279  JAMA. 2017 Apr 25;317(16):1652-1660. doi: 10.1001/jama.・・・
著者: Keith Coward, Nancy Tucker, Toni Darville
雑誌名: Pediatr Infect Dis J. 2003 Dec;22(12):1048-52. doi: 10.1097/01.inf.0000101186.88472.b5.
Abstract/Text BACKGROUND: Recent medical and surgical advances have increased the potential risk of endocarditis. Epidemiology, pathogens, morbidity and/or mortality may have evolved in the past decade in pediatric patients diagnosed with endocarditis.
METHODS: Retrospective reviews of medical records from Arkansas Children's Hospital were done to identify patients with infective endocarditis from January 1990 through December 2002. Basic demographic and clinical data were gathered and reviewed.
RESULTS: Of 76 patients identified, 57 were included based on diagnostic criteria. Congenital heart disease with (56%) and without (25%) correction were the most common risk factors. Echocardiograms revealed vegetations in 67%. Echocardiograms remain relatively deficient in patients with complex cyanotic heart disease (50% positive) vs. those with normal anatomy (83% positive). Streptococci (30%) and Staphylococcus aureus (21%) were the most common organisms identified overall; however, we observed a predominance of enterococci in infants <2 years of age (41%). Our study revealed a reduced rate of complications, especially of the central nervous system (7% vs. 25 and 33% in prior studies); however, our rate of S. aureus was lower (21% vs. 32 and 39%), and this pathogen continues to be associated with a higher incidence of complications.
CONCLUSIONS: Infective endocarditis continues to present a difficult challenge in pediatrics; its associated pathogens and outcomes have changed little in the past decade.

PMID 14688563  Pediatr Infect Dis J. 2003 Dec;22(12):1048-52. doi: 10.・・・
著者: J Schollin, B Bjarke, G Wesström
雑誌名: Acta Paediatr Scand. 1986 Nov;75(6):993-8. doi: 10.1111/j.1651-2227.1986.tb10329.x.
Abstract/Text A retrospective study of Swedish children with infective endocarditis (IE) during the period 1971-80 was made. Sixty-six instances were identified in 64 children (0.39 cases per 100,000 children per year). Fifty (78%) had a previously known heart disease. Most commonly this was a ventricular septal defect and tetralogy of Fallot. Seventy-one percent had positive blood cultures. Streptococcus viridans and Staphylococcus aureus were most commonly isolated. Twenty-two percent of the children had undergone previous cardiac surgery. One case closely followed cardiac surgery and in only nine children could a definite port of entry of infection be demonstrated.

PMID 3564983  Acta Paediatr Scand. 1986 Nov;75(6):993-8. doi: 10.1111・・・
著者: Dinela Rushani, Jay S Kaufman, Raluca Ionescu-Ittu, Andrew S Mackie, Louise Pilote, Judith Therrien, Ariane J Marelli
雑誌名: Circulation. 2013 Sep 24;128(13):1412-9. doi: 10.1161/CIRCULATIONAHA.113.001827.
Abstract/Text BACKGROUND: The American Heart Association guidelines for prevention of infective endocarditis (IE) in 2007 reduced the groups of congenital heart disease (CHD) patients for whom antibiotic prophylaxis was indicated. The evidence base in CHD patients is limited. We sought to determine the risk of IE in children with CHD.
METHODS AND RESULTS: We performed a population-based analysis to determine the cumulative incidence and predictors of IE in children (0-18 years) with CHD by the use of the Quebec CHD Database from 1988 to 2010. In 47 518 children with CHD followed for 458 109 patient-years, 185 cases of IE were observed. Cumulative incidence of IE was estimated in the subset of 34 279 children with CHD followed since birth, in whom the risk of IE up to 18 years of age was 6.1/1000 children (95% confidence interval, 5.0-7.5). In a nested case-control analysis, the following CHD lesions were at highest risk of IE in comparison with atrial septal defects (adjusted rate ratio, 95% confidence interval): cyanotic CHD (6.44, 3.95-10.50), endocardial cushion defects (5.47, 2.89-10.36), and left-sided lesions (1.88, 1.01-3.49). Cardiac surgery within 6 months (5.34, 2.49-11.43) and an age of <3 years (3.53, 2.51-4.96; reference, ages 6-18) also conferred an elevated risk of IE.
CONCLUSIONS: In a large population-based cohort of children with CHD, we documented the cumulative incidence of IE and associated factors. These findings help identify groups of patients who are at the highest risk of developing IE.

PMID 24060942  Circulation. 2013 Sep 24;128(13):1412-9. doi: 10.1161/C・・・
著者: S Di Filippo, F Delahaye, B Semiond, M Celard, R Henaine, J Ninet, F Sassolas, A Bozio
雑誌名: Heart. 2006 Oct;92(10):1490-5. doi: 10.1136/hrt.2005.085332. Epub 2006 Jul 3.
Abstract/Text OBJECTIVE: To assess the changing profile of infective endocarditis in patients with congenital heart disease.
METHODS: All cases diagnosed from 1966 to 2001 (revised Duke criteria) were retrospectively reviewed and categorised in periods I (< 1990) and II (>or= 1990).
RESULTS: 153 episodes occurred, 81 in period I and 72 in period II. Mean age of affected patients was higher in period II. Non-operated ventricular septal defect, Rastelli correction and palliated cyanotic heart disease increased. Infective endocarditis in corrective surgery changed to patients with prosthetic material. Post-surgical cases decreased. Dental problems were the leading cause (period I 20% v II 33% of cases) with a large variety of pathological organisms (multiple species of Streptococcus). Cutaneous causative infections increased (5% to 17%) with different species of Staphylococcus. Negative blood cultures lessened (20% to 7%, p = 0.03). Streptococci were the most common causative organisms in both periods. Severe heart failure and cardiac complications lessened (20% to 4% and 31% to 18% during periods I and II, respectively). Early surgery was more frequent in period II (32% v 18.5%, p = 0.02). One- and 10-year survival was 91% v 97% in period I and 89% v 97% in period II, respectively (NS).
CONCLUSION: Current targets include complex cyanotic disease, congenital heart disease corrected with prosthetic material and small ventricular septal defect. Postoperative cases lessened; dental and cutaneous causes increased. Survival was unchanged. Prophylactic measures targeted at dental and cutaneous sources should be emphasised.

PMID 16818488  Heart. 2006 Oct;92(10):1490-5. doi: 10.1136/hrt.2005.08・・・
著者: Lauren B Rosenthal, Kristina N Feja, Stéphanie M Levasseur, Luis R Alba, Welton Gersony, Lisa Saiman
雑誌名: Pediatr Cardiol. 2010 Aug;31(6):813-20. doi: 10.1007/s00246-010-9709-6. Epub 2010 Apr 23.
Abstract/Text This study sought to determine whether improvements in the care of children with congenital heart disease (CHD) have changed the epidemiology of infective endocarditis (IE). A retrospective study of patients 18 years of age and younger treated for IE from 1992 to 2004 (era 3) was conducted at the authors' children's hospital in New York City. This study was compared with two previous studies conducted at the same hospital from 1930 to 1959 (era 1) and from 1977 to 1992 (era 2). During the three eras, IE was diagnosed for 205 children with a median age of 8 years during eras 1 and 2, which decreased to 1.5 years during era 3, partly because of IE after cardiac surgery for young infants. In era 3, nonstreptococcal and nonstaphylococcal pathogens associated with hospital-acquired IE increased. Complications from IE declined during era 3, but after the widespread availability of antibiotics in 1944, crude mortality rates were similar in eras 1 (32%), 2 (21%), and 3 (24%). However, in era 3, mortality occurred only among subjects with hospital-acquired IE. The epidemiology of pediatric IE has changed in the modern era. Currently, IE is most likely to occur among young children with complex congenital heart disease. Pediatric IE remains associated with high crude mortality rates when it is acquired in the hospital.

PMID 20414646  Pediatr Cardiol. 2010 Aug;31(6):813-20. doi: 10.1007/s0・・・
著者: M Starkebaum, D Durack, P Beeson
雑誌名: Yale J Biol Med. 1977 Jan-Feb;50(1):49-58.
Abstract/Text In an attempt to gain information about the "incubation period" of subacute bacterial endocarditis, the literature was searched for case reports stating a specific interval between an event likely to cause bacteremia and the onset of symptoms. In 76 cases of streptococcal endocarditis for which this information was given, the median "incubation period" was one week. Symptoms began within two weeks in 64 of these cases (84%). Although there may be a bias toward reporting short incubation periods, it is concluded that the incubation period of subacute bacterial endocarditis is often shorter than is generally realized, and that procedures carried out more than two weeks before onset of symptoms are less likely to be causally related. In postcardiotomy cases, where timing of the bacteremia causing endocarditis is less easy to define, 27% of 122 cases of staphylococcal endocarditis developed within two weeks of surgery. This information is relevant to the planning and evaluation of prophylactic chemotherapy against bacterial endocarditis.

PMID 848048  Yale J Biol Med. 1977 Jan-Feb;50(1):49-58.
著者: J H Moller, R C Anderson
雑誌名: Am J Cardiol. 1992 Sep 1;70(6):661-7.
Abstract/Text The current status of 997 of 1,000 consecutive children with a cardiac malformation initially evaluated between 1952 and 1963 was determined. Of the 1000, 285 have died and the survivors have been followed up for periods of 26 to 37 years. Six hundred thirty-two are in excellent or good clinical condition, being asymptomatic and without planned need for further treatment. The other 80 have significant abnormalities, although 63 of these have few symptoms. Infective endocarditis occurred in 12 of 10,000 susceptible patient-years, with a lower rate in the past decade. Only 22 of the survivors are currently receiving cardiac medication. These data are derived from a group of patients initially seen during a period of time that cardiac surgery was being developed for congenital heart disease. Thus, the outlook should be even better for children who are currently undergoing treatment.

PMID 1510017  Am J Cardiol. 1992 Sep 1;70(6):661-7.
著者: K Niwa, M Nakazawa, S Tateno, M Yoshinaga, M Terai
雑誌名: Heart. 2005 Jun;91(6):795-800. doi: 10.1136/hrt.2004.043323.
Abstract/Text OBJECTIVE: To provide pure cohorts of paediatric and adult patients with congenital heart disease (CHD) and infective endocarditis (IE) for making future guidelines.
DESIGN: Japanese nationwide survey.
SETTING: 66 Japanese institutions.
PATIENTS: 170 children, mean (SD) age 7.4 (5.7) years (range 14 days to 17 years), and 69 adults, age 32.5 (14.1) years (range 18-69) who developed IE between 1997 and 2001 (one in 240 admissions with CHD).
MAIN OUTCOME MEASURES: Clinical presentation of IE.
RESULTS: 119 patients including 88 with cyanotic CHD had previous cardiac surgery. Procedures preceding IE were dental (12%) followed by cardiovascular surgery (8%). Sites of infection were left sided in 46% and right sided in 51%. Vegetation with diameter of 11 mm was documented in 151 (63%). Frequent complications were embolic events (stroke 11%, other emboli 20%) and cardiac failure (23%). The most common microorganisms were streptococci (50%) and staphylococci (37%) with methicillin resistant Staphylococcus aureus in 7.5%. Empirical treatments were penicillins (alone or with other antibiotics 57%) followed by cephems (22%) and vancomycin (11%). Surgery during active IE was common (26%), with vegetation (45%) and heart failure (29%) as the most frequent indications. Mortality was 8.8%: 8.0% among patients who received medical treatment alone and 11.1% among those with active IE who underwent surgery. The causes of death (n = 21) were surgery (7), infection (7), cardiac failure (6), and renal failure (1).
CONCLUSIONS: Because of a recent increase in the incidence of IE and high mortality and complication rate, it is mandatory to establish well formulated recommendations for management of IE in paediatric and adult patients with CHD based on a large cohort. Results of this nationwide multicentre database should be helpful in establishing guidelines.

PMID 15894782  Heart. 2005 Jun;91(6):795-800. doi: 10.1136/hrt.2004.04・・・
著者: Koichiro Niwa, Makoto Nakazawa, Kunio Miyatake, Shigeru Tateno, Masao Yoshinaga, Japanese Circulation Society (JCS) Joint Working Groups for Guidelines for Management of Infective Endocarditis, Japanese Society of Pediatric Cardiology and Cardiac Surgery Joint Working Groups for Guidelines for Prophylaxix, Diagnosis and Management of Infective Endocarditis in Patients with Congenital Heart Disease
雑誌名: Circ J. 2003 Jul;67(7):585-91.
Abstract/Text Guidelines for the prevention and management of infective endocarditis (IE) in children with congenital heart disease (CHD) have not been established, so the aim of this study was to clarify the incidence, practical prevention and management of IE in patients with CHD in Japan through a nationwide survey. A written questionnaire was sent to members of the Japanese Society of Pediatric Cardiology and Cardiac Surgery and information was obtained from 236 cardiologists in 228 institutions. Four hundred and eight patients with IE were hospitalized during 1997 to 2001 (1/173 admissions with CHD including those hospitalized for cardiac catheterization or surgery). Prevention of IE for CHD was undertaken by 92% of cardiologists, usually oral penicillins (73%) and less frequently cephems (18%) were prescribed. The Duke criteria were used as clinical criteria by 38%. Blood culture was performed once only by 40%. Penicillins and aminoglycosides (38%) were frequently administered for management of culture-negative IE. There were variations in the dose and duration of antibiotics for prevention and management of IE. It appears that the prevalence of IE in CHD is rising and the nationwide survey revealed more variations in practical prevention and management of IE in patients with CHD than expected. The results should be helpful in making future guidelines for management of IE in CHD.

PMID 12845180  Circ J. 2003 Jul;67(7):585-91.
著者: Jennifer A Johnson, Thomas G Boyce, Frank Cetta, James M Steckelberg, Jonathan N Johnson
雑誌名: Mayo Clin Proc. 2012 Jul;87(7):629-35. doi: 10.1016/j.mayocp.2012.02.023.
Abstract/Text OBJECTIVE: To determine the epidemiology of infective endocarditis (IE) presenting in pediatric patients during a 60-year period at our institution.
PATIENTS AND METHODS: In this retrospective medical record review, we extracted demographic characteristics, diagnostic variables, and outcomes for patients less than 20 years of age diagnosed with IE from January 1, 1980, to June 30, 2011. We compared this cohort with a previously reported cohort of pediatric patients with IE from our institution diagnosed from 1950 to 1979.
RESULTS: We identified 47 patients (24 males; mean ± SD age at diagnosis, 12.3±5.5 years [range, 1 day to 18.9 years]) who had 53 episodes of IE. The most common isolated organisms were viridans streptococci (17 of 53 episodes [32%]) and Staphylococcus aureus (12 of 53 episodes [23%]). Of the 47 patients, 36 (77%) had congenital heart disease, 24 of whom had cardiac surgery before their first episode of IE (mean ± SD time to IE diagnosis after surgery, 4.2±3.2 years [range, 64 days to 11.3 years]). Fourteen patients (30%) required valve replacement because of valvular IE, and 16 (34%) had complications, including mycotic aneurysm, myocardial abscess, or emboli. Vegetations were identified using echocardiography in 37 of the 53 unique episodes of IE (70%). Endocarditis-related mortality occurred in 1 patient. Compared with the historical (1950-1979) cohort, there were no differences in patient demographic characteristics, history of congenital heart disease, or infecting organisms. One-year mortality was significantly lower in the modern cohort (4%) compared with the historical cohort (38%) (P<.001).
CONCLUSION: Most pediatric episodes of IE occur in patients with congenital heart disease. Mortality due to endocarditis has decreased in the modern era.

Copyright © 2012 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
PMID 22766082  Mayo Clin Proc. 2012 Jul;87(7):629-35. doi: 10.1016/j.m・・・
著者: Michael D Day, Kimberlee Gauvreau, Stanford Shulman, Jane W Newburger
雑誌名: Circulation. 2009 Feb 17;119(6):865-70. doi: 10.1161/CIRCULATIONAHA.108.798751. Epub 2009 Feb 2.
Abstract/Text BACKGROUND: Infective endocarditis in children is rare, and most reports describe the experience in referral centers. The purpose of our study was to assess the characteristics of children with infective endocarditis in a large national sample.
METHODS AND RESULTS: We analyzed hospital discharge records with International Classification of Diseases, ninth revision, codes indicating infective endocarditis among admissions of patients <21 years of age in the Kids' Inpatient Databases 2000 and 2003; analyses for the 2 years were combined. In 1588 hospitalizations, the age distribution was bimodal, with peaks in infancy and late adolescence. The organism was coded in 632 admissions; Staphylococcus aureus was most common (57%), followed by the viridans group of streptococci (20%). Preexisting heart disease was present in 662 patients admitted (42%), among whom 81% had congenital heart disease, 8% had prosthetic valve endocarditis, and 5% had rheumatic heart disease. In-hospital mortality occurred in 84 patients (5%), 38 with preexisting heart disease. Death occurred in 12 of 25 patients (48%) with tetralogy of Fallot and pulmonary atresia, and 4 of 54 (8%) with prosthetic valve endocarditis. Among 46 deaths without preexisting heart disease, S aureus was the causative organism in 13 of 14 patients (93%) beyond infancy; among 32 infants who died, 10 (31%) were premature.
CONCLUSIONS: In 2000 and 2003, we found a continuing shift in the epidemiology of pediatric infective endocarditis toward a higher proportion of children without preexisting heart disease. Risk factors for mortality included some forms of congenital heart disease and, among patients without preexisting heart disease, premature/neonatal age and S aureus as an etiologic agent.

PMID 19188508  Circulation. 2009 Feb 17;119(6):865-70. doi: 10.1161/CI・・・
著者: L Saiman, A Prince, W M Gersony
雑誌名: J Pediatr. 1993 Jun;122(6):847-53.
Abstract/Text Sixty-two cases of endocarditis occurring in children between January 1977 and February 1992 were reviewed and compared with series from the 1970s and early 1980s. Changes in risk factors, pathogens, diagnostic modalities, and outcome were determined. Complex congenital heart disease (22 cases) and unrepaired ventricular septal defect (9 cases) were the most common underlying lesions. A total of 19 children with normal anatomy had endocarditis; 6 had community-acquired infection and 13 had hospital-acquired endocarditis (11 of these 13 children had central venous catheters in place, including 7 premature infants). Echocardiograms revealed vegetations in 25 of 49 patients; 24 of these patients had positive echocardiographic findings on the first study. Echocardiographic findings were most often negative in children with complex cyanotic heart disease. Staphylococcus aureus (39%) was the most common pathogen isolated and was associated with a higher incidence of central nervous system complications (p < 0.0015) and a greater need for surgical intervention (p = 0.01) than were other pathogens. Methicillin-resistant S. aureus (eight cases) and coagulase-negative staphylococci (three cases) emerged as important pathogens but were not associated with increased morbidity or mortality rates. Fungal endocarditis (six cases) had a 67% mortality rate. Overall the mortality rate was 11%. Endocarditis remained undiagnosed in seven seriously ill patients until postmortem examination. This study indicates that, during the past decade, important changes in risk factors, pathogens, and the susceptible population have altered the presentation and management of endocarditis in children.

PMID 8501558  J Pediatr. 1993 Jun;122(6):847-53.
著者: Carianne L Verheugt, Cuno S P M Uiterwaal, Enno T van der Velde, Folkert J Meijboom, Petronella G Pieper, Gerrit Veen, Jan L M Stappers, Diederick E Grobbee, Barbara J M Mulder
雑誌名: Eur Heart J. 2011 Aug;32(15):1926-34. doi: 10.1093/eurheartj/ehq485. Epub 2011 Jan 8.
Abstract/Text AIMS: The risk of infective endocarditis (IE) in adults with congenital heart disease is known to be increased, yet empirical risk estimates are lacking. We sought to predict the occurrence of IE in patients with congenital heart disease at the transition from childhood into adulthood.
METHODS AND RESULTS: We identified patients from the CONCOR national registry for adults with congenital heart disease. Potential predictors included patient characteristics, and complications and interventions in childhood. The outcome measure was the occurrence of IE up to the age of 40 and 60. A prediction model was derived using the Cox proportional hazards model and bootstrapping techniques. The model was transformed into a clinically applicable risk score. Of 10 210 patients, 233 (2.3%) developed adult-onset IE during 220 688 patient-years. Predictors of IE were gender, main congenital heart defect, multiple heart defects, and three types of complications in childhood. Up to the age of 40, patients with a low predicted risk (<3%) had an observed incidence of less than 1%; those with a high predicted risk (≥3%) had an observed incidence of 6%. The model also yielded accurate predictions up to the age of 60.
CONCLUSION: Among young adult patients with congenital heart disease, the use of six simple clinical parameters can accurately predict patients at relatively low or high risk of IE. After confirmation in other cohorts, application of the prediction model may lead to individually tailored medical surveillance and educational counselling, thus averting IE or enabling timely detection in adult patients with congenital heart disease.

PMID 21217144  Eur Heart J. 2011 Aug;32(15):1926-34. doi: 10.1093/eurh・・・
著者: M Angeles García-Teresa, Juan Casado-Flores, M Angel Delgado Domínguez, Jorge Roqueta-Mas, Francisco Cambra-Lasaosa, Andrés Concha-Torre, Cristina Fernández-Pérez, Spanish Central Venous Catheter Pediatric Study Group
雑誌名: Intensive Care Med. 2007 Mar;33(3):466-76. doi: 10.1007/s00134-006-0508-8. Epub 2007 Jan 19.
Abstract/Text OBJECTIVE: Analysis of infectious complications and risk factors in percutaneous central venous catheters.
DESIGN: One-year observational, prospective, multicenter study (1998-1999).
SETTING: Twenty Spanish pediatric intensive care units.
PATIENTS: Eight hundred thirty-two children aged 0-14 years.
INTERVENTION: None.
MEASUREMENTS AND MAIN RESULTS: One thousand ninety-two catheters were analyzed. Seventy-four (6.81%) catheter-related bloodstream infections (CRBSI) were found. The CRBSI rate was 6.4 per 1,000 CVC days (95% CI 5.0-8.0). Risk factors for CRBSI were weight under 8 kg (p < 0.001), cardiac failure (RR 2.69; 95% CI 1.95-4.38; p < 0.001), cancer (RR 1.66; 95% CI 0.97-2.78; p=0.05), silicone catheters (RR 2.82; 95% CI 1.49-5.35; p = 0.006), guidewire exchange catheterization (p=0.002), obstructed catheters (RR 2.67; 95% CI 1.63-4.39; p<0.001), and more than 12 days' indwelling time (RR 5.9; 95% CI 3.63-9.41; p<0.001). Multivariate Cox regression identified lower patient weight (HR 2.4; 95% CI 1.11-5.19; p=0.002), guidewire exchange catheterization (HR 2.2; 95% CI 1.07-4.54; p=0.049) and more than 12 days' indwelling time (HR 1.97; 95% CI 0.89-4.36; p=0.089) as significant independent predictors of CRBSI. Factors which protected against infection were the use of povidone-iodine on hubs (HR 0.42; 95% CI 0.19-0.96; p=0.025) and porous versus impermeable dressing (HR 0.41; 95% CI 0.23-0.74; p=0.004). Two children (0.24%) died from endocarditis following catheter-related sepsis due to Stenotrophomonas maltophilia in one case and P. aeruginosa in the other.
CONCLUSIONS: Catheter-related sepsis is associated with lower patient weight and more than 12 days' indwelling time, but not with the insertion site. Cleaning hubs with povidone-iodine protects from infection.

PMID 17235512  Intensive Care Med. 2007 Mar;33(3):466-76. doi: 10.1007・・・
著者: P L Michel, J Acar
雑誌名: Eur Heart J. 1995 Apr;16 Suppl B:2-6.
Abstract/Text Although no epidemiological studies are available to evaluate the exact risk of infective endocarditis complicating native cardiac disease, analysis of data in the literature shows that cardiac disease can be classified into three groups of decreasing risk: (1) high risk disease includes cyanotic congenital heart lesions, previous bacterial endocarditis, aortic valve disease, mitral regurgitation and uncorrected left-to-right shunt, but not atrial septal defect; (2) cardiac conditions of moderate risk include mitral valve prolapse with valvar regurgitation or leaflet thickening, isolated mitral stenosis, tricuspid valve disease, pulmonary stenosis and hypertrophic cardiomyopathy; (3) conditions of low or no risk include isolated atrial septal defect, ischaemic heart disease and/or previous coronary artery bypass graft surgery, surgically corrected left-to-right shunt with no residual shunt, mitral valve prolapse with thin leaflets in the absence of regurgitation, and calcification of the mitral annulus.

PMID 7671919  Eur Heart J. 1995 Apr;16 Suppl B:2-6.
著者: C D Morris, M D Reller, V D Menashe
雑誌名: JAMA. 1998 Feb 25;279(8):599-603. doi: 10.1001/jama.279.8.599.
Abstract/Text CONTEXT: The incidence of infective endocarditis after surgical repair of congenital heart defects is unknown.
OBJECTIVE: To determine the long-term incidence of endocarditis after repair of any of 12 congenital heart defects in childhood.
DESIGN: Population-based registry started in 1982.
SETTING: State of Oregon.
PARTICIPANTS: All Oregon residents who underwent surgical repair for 1 of 12 major congenital defects at the age of 18 years or younger from 1958 to the present.
MAIN OUTCOME MEASURE: Diagnosis of infective endocarditis confirmed by hospital or autopsy records.
RESULTS: Follow-up data were obtained from 88% of this cohort of 3860 individuals through 1993. At 25 years after surgery, the cumulative incidence of infective endocarditis was 1.3% for tetralogy of Fallot, 2.7% for isolated ventricular septal defect, 3.5% for coarctation of the aorta, 13.3% for valvular aortic stenosis, and 2.8% for primum atrial septal defect. In the cohorts with shorter follow-up, at 20 years after surgery the cumulative incidence was 4.0% for dextrotransposition of the great arteries; at 10 years, the cumulative incidence was 1.1% for complete atrioventricular septal defect, 5.3% for pulmonary atresia with an intact ventricular septum, and 6.4% for pulmonary atresia with ventricular septal defect. No children with secundum atrial septal defect, patent ductus arteriosus, or pulmonic stenosis have had infective endocarditis after surgery.
CONCLUSION: The continuing incidence of endocarditis after surgery for congenital heart defect, particularly valvular aortic stenosis, merits education about endocarditis prophylaxis for children and adults with repaired congenital heart defects.

PMID 9486754  JAMA. 1998 Feb 25;279(8):599-603. doi: 10.1001/jama.279・・・
著者: G A McGuinness, R M Schieken, G F Maguire
雑誌名: Am J Dis Child. 1980 Jun;134(6):577-80.
Abstract/Text Three cases of endocarditis confirmed at autopsy were identified in an intensive care nursery during an eight-month period. Echocardiography demonstrated abnormal echoes in the region of the mitral valve in one infant and the tricuspid valve in the other two infants. Both the diverse clinical manifestations of bacterial and nonbacterial endocarditis and the value of echocardiography in the establishment of an antemortem diagnosis are discussed. This previously unusual entity seems to be occurring with greater frequency in neonatal intensive care units that provide vigorous efforts to support severely ill infants.

PMID 7386431  Am J Dis Child. 1980 Jun;134(6):577-80.
著者: V M Dato, A S Dajani
雑誌名: Pediatr Infect Dis J. 1990 May;9(5):309-14.
Abstract/Text We reviewed retrospectively 31 cases of candidemia in children with central venous catheters. Infection rate was significantly higher in 1- to 4-year-old children with central venous catheters. Infection rate was significantly higher in 1- to 4-year-old children than in other age groups (8.4% vs. 2.2%; P less than 0.05). Serious sequelae occurred in 11 (35%) cases and included fatal outcome (5 instances), Candida endocarditis (2), renal abscesses, meningitis, arthritis and osteomyelitis (1 each). Complications were significantly more common in infants than in older children (P less than 0.05) and appeared 3 to 52 days after the first positive blood culture (mean, 16 days). In fatal cases catheters were left in place a significantly greater number of days than in nonfatal cases (P less than 0.05). A literature review identified 43 additional cases of catheter-related candidemia described in 11 series. The rate of Candida infection in the group as a whole was 2.7%. Patients treated with catheter removal plus amphotericin B had a significantly higher cure rate then patients treated with catheter retention plus amphotericin B (P = 0.009). Prompt catheter removal remains crucial in the treatment of catheter-related candidemia.

PMID 2352815  Pediatr Infect Dis J. 1990 May;9(5):309-14.
著者: J M Steckelberg, W R Wilson
雑誌名: Infect Dis Clin North Am. 1993 Mar;7(1):9-19.
Abstract/Text The incidence of endocarditis is increased in patients with cardiac lesions causing turbulent flow. A 400-fold increase is observed in patients with prosthetic valves and a prior history of endocarditis. Other high risk lesions include rheumatic valvular disease, cyanotic congenital heart disease, and degenerative valve lesions. The smaller increased incidence in patients with mitral valve prolapse is important because of the high prevalence of mitral valve prolapse in the population. In addition, intravenous drug use and nosocomial bacteremia have emerged as important factors among patients with endocarditis.

PMID 8463656  Infect Dis Clin North Am. 1993 Mar;7(1):9-19.
著者: Walter Wilson, Kathryn A Taubert, Michael Gewitz, Peter B Lockhart, Larry M Baddour, Matthew Levison, Ann Bolger, Christopher H Cabell, Masato Takahashi, Robert S Baltimore, Jane W Newburger, Brian L Strom, Lloyd Y Tani, Michael Gerber, Robert O Bonow, Thomas Pallasch, Stanford T Shulman, Anne H Rowley, Jane C Burns, Patricia Ferrieri, Timothy Gardner, David Goff, David T Durack, American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, American Heart Association Council on Cardiovascular Disease in the Young, American Heart Association Council on Clinical Cardiology, American Heart Association Council on Cardiovascular Surgery and Anesthesia, Quality of Care and Outcomes Research Interdisciplinary Working Group
雑誌名: Circulation. 2007 Oct 9;116(15):1736-54. doi: 10.1161/CIRCULATIONAHA.106.183095. Epub 2007 Apr 19.
Abstract/Text BACKGROUND: The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997.
METHODS AND RESULTS: A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.
CONCLUSIONS: The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

PMID 17446442  Circulation. 2007 Oct 9;116(15):1736-54. doi: 10.1161/C・・・
著者: P Shah, W S Singh, V Rose, J D Keith
雑誌名: Circulation. 1966 Jul;34(1):127-31.
Abstract/Text
PMID 5940236  Circulation. 1966 Jul;34(1):127-31.
著者: W M Gersony, C J Hayes, D J Driscoll, J F Keane, L Kidd, W M O'Fallon, D R Pieroni, R R Wolfe, W H Weidman
雑誌名: Circulation. 1993 Feb;87(2 Suppl):I121-6.
Abstract/Text BACKGROUND: All of the 2,401 patients with aortic stenosis (AS), pulmonary stenosis (PS), or ventricular septal defect (VSD) admitted to the First Natural History Study of Congenital Heart Defects between 1958 and 1965 were eligible for the Second Natural History Study. Most patients with severe defects were managed surgically, and most with mild defects were managed medically. Final examination in the first study was carried out 8 years after admission.
METHODS AND RESULTS: For AS, the incidence rate of bacterial endocarditis (BE) was 27.1 per 10,000 person-years. The incidence rate was 15.7 per 10,000 person-years for those managed medically and 40.9 per 10,000 person-years for those managed surgically. Most patients managed surgically had severe AS, and severity was more important to the risk of BE than the method of management. For PS, only one of the 592 patients with PS experienced BE. For VSD, the incidence rate of BE was 14.5 per 10,000 person-years. Size of the VSD was not associated with risk of BE. The risk of BE before closure of the VSD was more than twice that after surgery.
CONCLUSIONS: The incidence rate of BE was nearly 35-fold the population-based rate. The increased incidence in patients with AS after valvotomy was a function of severity of the defect and not a function of surgery. Presence of aortic regurgitation in patients with AS did not increase the risk of developing BE. Surgical closure of VSD lowered the risk of BE.

PMID 8425318  Circulation. 1993 Feb;87(2 Suppl):I121-6.
著者: W Li, J Somerville
雑誌名: Eur Heart J. 1998 Jan;19(1):166-73.
Abstract/Text AIMS: Infective endocarditis accounts for 4% of admissions to a specialized unit for grown-up congenital heart patients. This study defines lesions susceptible to infection, antecedent events, organisms, outcome and surgical treatment in a group of such patients.
METHODS AND RESULTS: The grown-up congenital heart disease database was searched for all patients aged 13 years and above with adequate documentation of infective endocarditis retrospectively between 1983-1993 and thereafter between 1993-1996. There were 185 patients (214 episodes) divided into Group I: 128 patients unoperated or palliated and Group II: 57 patients after definitive repair and/or valve repair/replacement. In Group I, the commonest affected sites were ventricular septal defect in 31 (24%), left ventricular outflow tract in 22 (17%) and mitral valve in 17 (13%) and in Group II, left ventricular outflow tract in 20 (35%), repaired Fallot in 11 (19%), and atrioventricular defects in eight (14%). Infective endocarditis was not seen in secundum atrial septal defects before or after closure; in closed ventricular septal defects and ducts without left-sided valve abnormality; in isolated pulmonary stenosis; in unrepaired Ebstein: or after Fontan-type or Mustard operations. Surgery was performed in 39 patients: as an emergency in 17, and for failed medical therapy in 22. Only 87 (41%) of patients had a predisposing event: dental procedure or sepsis were the commonest events in Group I (33%) and cardiac surgery in Group II (50%). Streptococci species were found in 54% of Group I patients and in 45% of Group II. Staphylococci aureus was commoner in Group II (25%) compared to Group I (14%). Mean time from the onset of symptoms to diagnosis was 60 and 29 days in Groups I and II, respectively. Eight (4%) patients died as a result of septicaemia related to emergency or repeated surgery and Staphylococcus aureus infection. Recurrent attacks occurred in 21 (11%) patients.
CONCLUSION: Reparative surgery does not prevent endocarditis except for closure of a ventricular septal defect and duct. Delay in diagnosis is serious since it contributes to mortality, although the overall mortality % is not high. Specific lesions are not affected so prophylaxis is probably unnecessary in those anomalies.

PMID 9503191  Eur Heart J. 1998 Jan;19(1):166-73.
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: D T Durack, A S Lukes, D K Bright
雑誌名: Am J Med. 1994 Mar;96(3):200-9.
Abstract/Text PURPOSE: This study was designed to develop improved criteria for the diagnosis of infective endocarditis and to compare these criteria with currently accepted criteria in a large series of cases.
PATIENTS AND METHODS: A total of 405 consecutive cases of suspected infective endocarditis in 353 patients evaluated in a tertiary care hospital from 1985 to 1992 were analyzed using new diagnostic criteria for endocarditis. We defined two "major criteria" (typical blood culture and positive echocardiogram) and six "minor criteria" (predisposition, fever, vascular phenomena, immunologic phenomena, suggestive echocardiogram, and suggestive microbiologic findings). We also defined three diagnostic categories: (1) "definite" by pathologic or clinical criteria, (2) "possible," and (3) "rejected." Each suspected case of endocarditis was classified using both old and new criteria. Sixty-nine pathologically proven cases were reclassified after exclusion of the surgical or autopsy findings, enabling comparison of clinical diagnostic criteria in proven cases.
RESULTS: Fifty-five (80%) of the 69 pathologically confirmed cases were classified as clinically definite endocarditis. The older criteria classified only 35 (51%) of the 69 pathologically confirmed cases into the analogous probable category (p < 0.0001). Twelve (17%) pathologically confirmed cases were rejected by older clinical criteria, but none were rejected by the new criteria. Seventy-one (21%) of the remaining 336 cases that were not proven pathologically were probable by older criteria, whereas the new criteria almost doubled the number of definite cases, to 135 (40%, p < 0.01). Of the 150 cases rejected by older criteria, 11 were definite, 87 were possible, and 52 were rejected by the new criteria.
CONCLUSION: Application of the proposed new criteria increases the number of definite diagnoses. This should be useful for more accurate diagnosis and classification of patients with suspected endocarditis and provide better entry criteria for epidemiologic studies and clinical trials.

PMID 8154507  Am J Med. 1994 Mar;96(3):200-9.
著者: G Habib, G Derumeaux, J F Avierinos, J P Casalta, F Jamal, F Volot, M Garcia, J Lefevre, F Biou, A Maximovitch-Rodaminoff, P E Fournier, P Ambrosi, J G Velut, A Cribier, J R Harle, P J Weiller, D Raoult, R Luccioni
雑誌名: J Am Coll Cardiol. 1999 Jun;33(7):2023-9. doi: 10.1016/s0735-1097(99)00116-3.
Abstract/Text OBJECTIVES: The purpose of this study was to assess the value and limitations of Duke criteria for the diagnosis of infective endocarditis (IE).
BACKGROUND: Duke criteria have been shown to be more sensitive in diagnosing IE than the von Reyn criteria, but the diagnosis of IE remains difficult in some patients.
METHODS: Both classifications were applied in 93 consecutive patients with pathologically proven IE. Blood cultures, and transthoracic and transesophageal echocardiography were performed in all patients.
RESULTS: Sensitivities for the diagnosis of IE were 56% and 76% for von Reyn and Duke criteria, respectively. Fifty-two patients were correctly classified as "probable IE" by von Reyn and "definite IE" by Duke criteria (group 1). However, discrepancies were observed in 41 patients. Eleven patients (group 2) were misclassified as "rejected" by von Reyn, but were "definite IE" by Duke criteria; this difference could be explained by negative blood cultures and positive echocardiogram in all patients. In eight patients (group 3), the diagnosis of IE was "possible" by von Reyn but "definite" by Duke criteria. This difference was essentially explained by the failure of the von Reyn classification to consider echocardiographic abnormalities as major criteria. Twenty-two patients (group 4) were misclassified as possible IE using Duke criteria, being false negative of this classification. Echocardiographic major criteria were present in 19 patients, but blood cultures were negative in 21 patients. The cause of negative blood cultures was prior antibiotic therapy in 11 patients and Q-fever endocarditis diagnosed by positive serology in three cases.
CONCLUSIONS: Twenty-four percent of patients with proved IE remain misclassified as "possible IE" despite the use of Duke criteria, especially in cases of culture-negative and Q-fever IE. Increasing the diagnostic value of echographic criteria in patients with prior antibiotic therapy and typical echocardiographic findings and considering the serologic diagnosis of Q fever as a major criterion would further improve the clinical diagnosis of IE.

PMID 10362209  J Am Coll Cardiol. 1999 Jun;33(7):2023-9. doi: 10.1016/・・・
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: R E Kavey, D M Frank, C J Byrum, M S Blackman, H M Sondheimer, E L Bove
雑誌名: Am J Dis Child. 1983 Sep;137(9):851-6.
Abstract/Text We examined 11 children with infective endocarditis initially and serially by two-dimensional echocardiography. Nine (82%) of the 11 patients had echocardiographic findings at initial examination compatible with infective endocarditis. These results provided strong evidence in support of the diagnosis before bacteriologic confirmation was available. Congestive heart failure, major emboli, and/or the need for surgical intervention occurred in seven of the nine patients with positive two-dimensional echocardiograms. Echocardiographic evidence of vegetations persisted during antibiotic therapy and resolved slowly during many months. Serial echocardiograms were useful in cases in which obvious valve destruction or marked increase in vegetation size imaged echocardiographically could be combined with clinical evidence of progressive heart failure to support a decision for early surgical intervention. Two-dimensional echocardiography can make important contributions to the diagnosis and management of children with infective endocarditis.

PMID 6613950  Am J Dis Child. 1983 Sep;137(9):851-6.
著者: W G Daniel, A Mügge, R P Martin, O Lindert, D Hausmann, B Nonnast-Daniel, J Laas, P R Lichtlen
雑誌名: N Engl J Med. 1991 Mar 21;324(12):795-800. doi: 10.1056/NEJM199103213241203.
Abstract/Text BACKGROUND: Echocardiography is recognized as the method of choice for the noninvasive detection of valvular vegetations in patients with infective endocarditis, with transesophageal echocardiography being more accurate than transthoracic echocardiography. The diagnosis of associated abscesses by transthoracic echocardiography is difficult or even impossible in many cases, however, and it is not known whether transesophageal echocardiography is any better.
METHODS: To determine the value of transesophageal echocardiography in the detection of abscesses associated with endocarditis, we studied prospectively by two-dimensional transthoracic and transesophageal echocardiography 118 consecutive patients with infective endocarditis of 137 native or prosthetic valves that was documented during surgery or at autopsy.
RESULTS: During surgery or at autopsy, 44 patients (37.3 percent) had a total of 46 definite regions of abscess. Abscesses were more frequent in aortic-valve endocarditis than in infections of other valves, and the infecting organism was more often staphylococcus (52.3 percent of cases) in patients with abscesses than in those without abscesses (16.2 percent). The hospital mortality rate was 22.7 percent in patients with abscesses, as compared with 13.5 percent in patients without abscesses. Whereas transthoracic echocardiography identified only 13 of the 46 areas of abscess, the transesophageal approach allowed the detection of 40 regions (P less than 0.001). Sensitivity and specificity for the detection of abscesses associated with endocarditis were 28.3 and 98.6 percent, respectively, for transthoracic echocardiography and 87.0 and 94.6 percent for transesophageal echocardiography; positive and negative predictive values were 92.9 and 68.9 percent, respectively, for the transthoracic approach and 90.9 and 92.1 percent for the transesophageal approach. Variation between observers was 3.4 percent for transthoracic and 4.2 percent for transesophageal echocardiography.
CONCLUSIONS: The data indicate that transesophageal echocardiography leads to a significant improvement in the diagnosis of abscesses associated with endocarditis. The technique facilitates the identification of patients with endocarditis who have an increased risk of death and permits earlier treatment.

PMID 1997851  N Engl J Med. 1991 Mar 21;324(12):795-800. doi: 10.1056・・・
著者: S I Barbour, E K Louie, J P O'Keefe
雑誌名: Am Heart J. 1996 Dec;132(6):1287-9. doi: 10.1016/s0002-8703(96)90479-2.
Abstract/Text
PMID 8969587  Am Heart J. 1996 Dec;132(6):1287-9. doi: 10.1016/s0002-・・・
著者: Thierry V Scohy, Diederik Gommers, A Derk Jan ten Harkel, Yvon Deryck, Jackie McGhie, Ad J J C Bogers
雑誌名: Eur J Echocardiogr. 2007 Aug;8(4):241-6. doi: 10.1016/j.euje.2007.02.011. Epub 2007 May 7.
Abstract/Text INTRODUCTION: In the last years, transesophageal transducers for multiplane Doppler echocardiography have demonstrated their superior imaging performance in pediatric patients undergoing cardiac surgery. To date, the size of these probes has limited their use in neonates and small children. New technologies allowing performing TEE in smaller patients are therefore promising.
METHODS: We report our clinical experience with the Oldelft micromultiplane TEE probe (8.2-7mm diameter tip with a 5.2mm diameter shaft) specifically meant for use in neonates.
RESULTS: Forty-two patients were examined intra-operatively using the micromulti TEE harmonic transducer. Patients examined ranged in age from 4days to 6years and ranged in weight from 2.5 to 23.8kg. In two patients we had to adapt ventilatory settings because of increased airway resistance after probe insertion. In 3 patients surgical re-intervention was performed due to TEE assessment immediately after weaning from bypass. In two patients significant obstruction of the right ventricular outflow tract was still present after Fallot correction, and one patient had an additional muscular ventricular septal defect still present after VSD closure.
CONCLUSIONS: The micromulti TEE harmonic transducer provided excellent diagnostic intra-operative TEE in neonates and small children without major complications, special attention should be taken for ventilatory parameters in neonates less than 3kg.

PMID 17482518  Eur J Echocardiogr. 2007 Aug;8(4):241-6. doi: 10.1016/j・・・
著者: Robert S Baltimore, Michael Gewitz, Larry M Baddour, Lee B Beerman, Mary Anne Jackson, Peter B Lockhart, Elfriede Pahl, Gordon E Schutze, Stanford T Shulman, Rodney Willoughby, American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular and Stroke Nursing
雑誌名: Circulation. 2015 Oct 13;132(15):1487-515. doi: 10.1161/CIR.0000000000000298. Epub 2015 Sep 15.
Abstract/Text
PMID 26373317  Circulation. 2015 Oct 13;132(15):1487-515. doi: 10.1161・・・
著者: Jayanthi N Koneru, Kenneth A Ellenbogen
雑誌名: J Am Coll Cardiol. 2013 Apr 2;61(13):1406-8. doi: 10.1016/j.jacc.2013.01.016. Epub 2013 Feb 20.
Abstract/Text
PMID 23433559  J Am Coll Cardiol. 2013 Apr 2;61(13):1406-8. doi: 10.10・・・
著者: Maria Lucia Narducci, Gemma Pelargonio, Eleonora Russo, Leonardo Marinaccio, Antonio Di Monaco, Francesco Perna, Gianluigi Bencardino, Michela Casella, Luigi Di Biase, Pasquale Santangeli, Rosalinda Palmieri, Christian Lauria, Ghaliah Al Mohani, Francesca Di Clemente, Claudio Tondo, Faustino Pennestri, Carolina Ierardi, Antonio G Rebuzzi, Filippo Crea, Fulvio Bellocci, Andrea Natale, Antonio Dello Russo
雑誌名: J Am Coll Cardiol. 2013 Apr 2;61(13):1398-405. doi: 10.1016/j.jacc.2012.12.041.
Abstract/Text OBJECTIVES: The goal of this study was to compare transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) for the diagnosis of cardiac device-related endocarditis (CDI).
BACKGROUND: The diagnosis of infective endocarditis (IE) was established by using the modified Duke criteria based mainly on echocardiography and blood culture results. No previous studies have compared ICE with TEE for the diagnosis of IE.
METHODS: We prospectively enrolled 162 patients (age 72 ± 11 years; 125 male) who underwent transvenous lead extraction: 152 with CDI and 10 with lead malfunction (control group). Using the modified Duke criteria, we divided the patients with infection into 3 groups: 44 with a "definite" diagnosis of IE (group 1), 52 with a "possible" diagnosis of IE (group 2), and 56 with a "rejected" diagnosis of IE (group 3). TEE and ICE were performed before the procedure.
RESULTS: In group 1, ICE identified intracardiac masses (ICM) in all 44 patients; TEE identified ICM in 32 patients (73%). In group 2, 6 patients (11%) had ICE and TEE both positive for ICM, 8 patients (15%) had a negative TEE but a positive ICE, and 38 patients (73%) had ICE and TEE both negative. In group 3, 2 patients (3%) had ICM both at ICE and TEE, 1 patient (2%) had an ICM at ICE and a negative TEE, and 53 patients (95%) had no ICM at ICE and TEE. ICE and TEE were both negative in the control group.
CONCLUSIONS: ICE represents a useful technique for the diagnosis of ICM, thus providing improved imaging of right-sided leads and increasing the diagnostic yield compared with TEE.

Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
PMID 23500279  J Am Coll Cardiol. 2013 Apr 2;61(13):1398-405. doi: 10.・・・
著者: Patricia Ferrieri, Michael H Gewitz, Michael A Gerber, Jane W Newburger, Adnan S Dajani, Stanford T Shulman, Walter Wilson, Ann F Bolger, Arnold Bayer, Matthew E Levison, Thomas J Pallasch, Tommy W Gage, Kathryn A Taubert, Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the American Heart Association Council on Cardiovascular Disease in the Young
雑誌名: Circulation. 2002 Apr 30;105(17):2115-26.
Abstract/Text
PMID 11980694  Circulation. 2002 Apr 30;105(17):2115-26.
著者: Masao Yoshinaga, Koichiro Niwa, Atsuko Niwa, Naruhiko Ishiwada, Hideto Takahashi, Shigeyuki Echigo, Makoto Nakazawa, Japanese Society of Pediatric Cardiology and Cardiac Surgery
雑誌名: Am J Cardiol. 2008 Jan 1;101(1):114-8. doi: 10.1016/j.amjcard.2007.07.054.
Abstract/Text Despite developments in preventative and medical therapy, infective endocarditis (IE) carries a high rate of mortality. Risk factors for mortality are unknown in pediatric and adult patients with congenital heart disease (CHD). We determined the risk factors for in-hospital mortality in pediatric and adult patients with CHD. A retrospective observational cohort study was conducted from January 1997 to December 2001 in Japan. Of the 239 patients for whom complete data were available, 216 patients with CHD were identified. Outcomes were alive or deceased. The proposed modified Duke's criteria identified 137 patients, aged 1 month to 62 years with a median of 12 years, with IE. In-hospital mortality was 10%. Four risk factors were independently associated with mortality by stepwise logistic regression analysis: (1) vegetation size > or =20 mm (odds ratio 40.6, 95% confidence interval 2.42 to 681); (2) age <1 year (odds ratio 19.5, 95% confidence interval 1.74 to 219); (3) presence of heart failure (odds ratio 7.16, 95% confidence ratio 1.34 to 38.4); and (4) Staphylococcus aureus as a causative organism (odds ratio 5.68, 95% confidence interval 1.16 to 27.9). Surgical intervention emerged as a predictive factor for lower in-hospital mortality (odds ratio 0.045, 95% confidence interval 0.003 to 0.70) by stepwise logistic regression analysis. In conclusion, surgical intervention, which decreases the risk of in-hospital mortality, should always be considered.

PMID 18157976  Am J Cardiol. 2008 Jan 1;101(1):114-8. doi: 10.1016/j.a・・・
著者: E L Kaplan, H Rich, W Gersony, J Manning
雑誌名: Circulation. 1979 Feb;59(2):327-35.
Abstract/Text Twenty-six major cardiovascular centers participated in a cooperative study of all cases of infective endocarditis occurring during a single calendar year to obtain an overview of infective endocarditis. The study was designed to learn which patients appear to be at highest risk to develop this infection after palliative or reparative cardiovascular surgery. Of 278 patients developing infective endocarditis during the year at these medical centers, 63 (23%) had had previous cardiovascular surgery and 215 had not. Seventy percent of the 278 patients had recognized congenital or acquired heart disease before developing the infection. Rheumatic heart disease accounted for over half of the patients with underlying structural heart disease. A majority (55%) of the 63 patients who had been operated on before developing endocarditis had prosthetic valves inserted. Of those who did not require prosthetic valves, the majority had congenital heart disease with systemic artery-to-pulmonary artery shunts. Although these data were obtained from a selected group of patients, they confirm a significant risk of endocarditis in patients with prosthetic valves and suggest that in postoperative patients with non-valvular congenital heart disease, the highest risk appears to be in cyanotic patients with palliative pulmonary artery-to-systemic artery shunts.

PMID 759000  Circulation. 1979 Feb;59(2):327-35.
著者: J A Kellogg, J P Manzella, D A Bankert
雑誌名: J Clin Microbiol. 2000 Jun;38(6):2181-5.
Abstract/Text A single blood culture inoculated with a small volume of blood is still frequently being used for the diagnosis of bacteremia in children because of the continued belief by many that bacteria are usually found in high concentrations in the blood of pediatric patients with sepsis. To determine the importance of both blood volume cultured and the number of culture devices required for the reliable detection of pathogens in our pediatric population, blood from children from birth to 15 years of age and with suspected bacteremia at York Hospital (a 500-bed community hospital) was inoculated into at least a Pediatric Isolator (Wampole Laboratories; 1.5 ml of blood) or a standard Isolator (10 ml of blood) and a bottle of ESP anaerobic broth (Trek Diagnostic Systems; 0.5 to 10 ml of blood). The use of a second Isolator and additional aerobic and anaerobic bottles and the total blood volume recommended for cultures (2 to 60 ml) depended on the weight and total blood volume of each patient. One hundred forty-seven pathogens were recovered from the blood of 137 (3.6%) of 3,829 children for whom culturing was done. Of 121 septic episodes for which the concentration of pathogens in the blood could be determined using Isolators, 73 (60. 3%) represented low-level bacteremia (
PMID 10834973  J Clin Microbiol. 2000 Jun;38(6):2181-5.
著者: B K Shively, F T Gurule, C A Roldan, J H Leggett, N B Schiller
雑誌名: J Am Coll Cardiol. 1991 Aug;18(2):391-7.
Abstract/Text To compare the diagnostic value of transesophageal and transthoracic echocardiography in infective endocarditis, paired transesophageal and transthoracic echocardiograms were obtained prospectively for 66 episodes of suspected endocarditis in 62 patients. Echocardiographic results were compared with the presence or absence of endocarditis determined by pathologic or nonechocardiographic data from the subsequent clinical course. All echocardiograms were interpreted by an observer told only that the studies were from patients in whom the diagnosis of endocarditis was suspected. The diagnosis of endocarditis was eventually made in 16 of the 66 episodes of suspected endocarditis (14 by pathologic and 2 by clinical criteria). In 7 of 16 transthoracic and 15 of 16 transesophageal echocardiograms, endocarditis was diagnosed at a probability level of "almost certain," giving a sensitivity of 44% and 94%, respectively (p less than 0.01). For the remaining episodes, 49 of 50 transthoracic and all transesophageal studies yielded normal results, giving a specificity of 98% and 100%, respectively. This study suggests that transesophageal echocardiography is highly sensitive and specific for the diagnosis of infective endocarditis and significantly more sensitive than transthoracic echocardiography. Although echocardiography cannot rule out endocarditis, the high diagnostic sensitivity of transesophageal echocardiography results in a low probability of the disease when the study yields negative results in a patient with an intermediate likelihood of the disease.

PMID 1856406  J Am Coll Cardiol. 1991 Aug;18(2):391-7.
著者: A S Bayer
雑誌名: Clin Infect Dis. 1993 Sep;17(3):313-20; quiz 321-2.
Abstract/Text As compared to the characterization of IE in the 1970s and early 1980s, it appears that IE in the 1990s is more likely to present acutely and in association with fewer classic stigmata and is more likely to be caused by S. aureus. Whether this represents a true clinical and microbiological shift in disease spectrum or is the result of reporting bias is unclear at this time. The ability to clinically designate a case definitely as IE has been improved with utilization of new diagnostic criteria that incorporate findings from two-dimensional echocardiography in the classification schema. These new criteria have been validated in selected patient populations but remain to be validated in other patient groups at risk for IE (e.g., prosthetic-valve recipients). Two-dimensional echocardiography is the noninvasive technique of choice for defining vegetative IE. TEE is significantly more sensitive in identifying valvular vegetations than is TTE, and TEE also is the method of choice for delineating periannular complications of IE. The role of Doppler flow assessment of valvular regurgitation in IE remains to be clarified. Short-course (2-week) regimens of beta-lactam agents plus aminoglycosides appear to be highly effective for the treatment of right-sided IE due to S. aureus. The use of vancomycin for treatment of S. aureus IE remains problematic because of reports of slow response and suboptimal treatment outcomes.

PMID 8218670  Clin Infect Dis. 1993 Sep;17(3):313-20; quiz 321-2.
著者: A S Ali, V Trivedi, M Lesch
雑誌名: Prog Cardiovasc Dis. 1994 Nov-Dec;37(3):149-60.
Abstract/Text
PMID 7972850  Prog Cardiovasc Dis. 1994 Nov-Dec;37(3):149-60.
著者: L Olaison, H Hogevik, K Alestig
雑誌名: Arch Intern Med. 1997 Apr 28;157(8):885-92.
Abstract/Text BACKGROUND: Fever and sustained elevations of levels of C-reactive protein, erythrocyte sedimentation rate, and other inflammatory markers are common problems during treatment of infective endocarditis. We studied the value of these measurements during an 8-year period in all episodes of infective endocarditis treated in 1 university-affiliated institution.
METHODS: A total of 193 consecutive episodes that fulfilled the criteria for infective endocarditis were prospectively enrolled during 2 periods, 1984 through 1988 and 1993 through 1995. Fever and results of serial measurements of C-reactive protein, erythrocyte sedimentation rate, white blood cell counts, and platelet counts were related to the clinical course of infective endocarditis.
RESULTS: Fever persisted or recurred in 108 episodes (57%) despite appropriate antibiotic treatment. The causes of persistent fever and recurrent fever were different. Persistent fever that lasted 7 days or longer was caused by a complicating cardiac infection in 56% of these episodes. Recurrent fever, noted in 31% of all episodes and the major cause of fever during the third and fourth treatment weeks, was caused most often by hypersensitivity reactions to beta-lactams. Elevations in C-reactive protein levels were significantly prolonged in the episodes with complicated courses compared with the episodes with uncomplicated courses, while mean erythrocyte sedimentation rate remained unchanged during treatment, not differentiating between complicated and uncomplicated episodes.
CONCLUSIONS: Fever during treatment must be analyzed in terms of persistence and recurrence to provide a basis for clinical decisions. Serial measurements of C-reactive protein are useful to monitor the response to antimicrobial therapy and to detect complications, while serial determinations of erythrocyte sedimentation rate are of no value.

PMID 9129548  Arch Intern Med. 1997 Apr 28;157(8):885-92.
著者: M R Moon, E B Stinson, D C Miller
雑誌名: Prog Cardiovasc Dis. 1997 Nov-Dec;40(3):239-64.
Abstract/Text Since early investigators first suggested that the treatment of endocarditis should include valve replacement for infections not readily controlled with medical therapy alone, the role of surgery has become expanded, yet refined, to improve the outcome of patients with this potentially fatal disease. Innovative surgical techniques have also been developed in an effort to improve the results of surgical treatment for complex sequelae of invasive infections. This article examines the current indications for surgical intervention, compares the various surgical options, and assesses the expected short-and long-term outcome after valve replacement for patients with native valve or prosthetic valve endocarditis.

PMID 9406678  Prog Cardiovasc Dis. 1997 Nov-Dec;40(3):239-64.
著者: B Omari, S Shapiro, L Ginzton, J M Robertson, J Ward, R J Nelson, A S Bayer
雑誌名: Chest. 1989 Dec;96(6):1273-9.
Abstract/Text The study objective is to identify clinical, microbiologic, and/or echocardiographic risk factors present early in the course of native valve endocarditis that predict subsequent development of periannular extension of infection. A multivariate computer-generated analysis of 21 clinical-microbiologic parameters and 11 two-dimensional echocardiographic parameters in patients with native valve endocarditis was designed. These parameters were statistically compared in operated-on patients with native valve endocarditis with and without periannular extension of infection. The study took place in a 600-bed acute-care, nonreferral, municipal hospital primarily servicing an indigent patient population. Seventy-three documented episodes of native valve endocarditis occurred between the years of 1973 and 1987, including 29 operated-on patients with surgically confirmed periannular extension of infection and 44 operated-on patients without periannular extension of infection. Multivariate logistic-regression analyses of multiple clinical, microbiologic, and echocardiographic parameters which are potentially predictive of eventual periannular extension of native valve endocarditis were carried out. The only two independent parameters that significantly predicted periannular infection among patients with native valve endocarditis were (1) aortic valve involvement and (2) abuse of intravenous (IV) drugs (p less than 0.01; p less than 0.01, respectively, multivariate analysis). The relative risk of developing periannular extension of endocarditis among patients with aortic valve involvement and/or IV drug abuse was increased by approximately 2.5-fold compared with patients without these characteristics. Factors not significantly associated with increased risk of periannular extension of native valve endocarditis included the following: prolonged febrile morbidity; Staphylococcus aureus etiology; or two-dimensional echocardiographic demonstration of vegetations, large vegetations (greater than or equal to 1 cm), multiple vegetations, or enlargement of aortic root or annulus. These data suggest that patients with native aortic valve endocarditis, particularly in the setting of IV drug abuse, should be considered for routine, serial noninvasive evaluation for the early detection of periannular extension of their infection.

PMID 2582833  Chest. 1989 Dec;96(6):1273-9.
著者: J Mills, J Utley, J Abbott
雑誌名: Chest. 1974 Aug;66(2):151-7.
Abstract/Text
PMID 4852232  Chest. 1974 Aug;66(2):151-7.
著者: Catherine Graupner, Isidre Vilacosta, JoséAlberto SanRomán, Ricardo Ronderos, Cristina Sarriá, Cristina Fernández, Ricardo Mújica, Olga Sanz, Juan Victor Sanmartín, Angel González Pinto
雑誌名: J Am Coll Cardiol. 2002 Apr 3;39(7):1204-11. doi: 10.1016/s0735-1097(02)01747-3.
Abstract/Text OBJECTIVES: This prospective study was designed to assess the current clinical course, risk factors, microbiologic profile and echocardiographic findings of patients with left-sided endocarditis and perivalvular complications.
BACKGROUND: Periannular complications worsen the prognosis of patients with endocarditis. The relation between these complications and the clinical and microbiologic data has not been clearly defined.
METHODS: In this clinical cohort study, 211 patients with left-sided endocarditis, according to the Duke criteria, were prospectively recruited. All patients underwent conventional and transesophageal echocardiography. The mean follow-up interval was 151 days.
RESULTS: Perivalvular complications were detected in 78 patients (37%). The incidence of periannular extension of infection in native and prosthetic valves was 29% and 55%, respectively. The presence of prosthesis (relative risk [RR] 1.88, 95% confidence interval [CI] 1.35 to 2.64) and previous endocarditis (RR 1.78, 95% CI 1.16 to 2.7) were the only pre-existing heart conditions associated with perivalvular complications. Aortic infection (RR 1.8, 95% CI 1.23 to 2.66) and the development of atrioventricular (AV) block (RR 2.55, 95% CI 1.91 to 3.41) were related with the existence of these complications. Coagulase-negative staphylococci were very common in patients with perivalvular complications (RR 1.77, 95% CI 1.21 to 2.59), and small vegetations were more frequent in these patients (RR l.45, 95% CI 0.95 to 2.22). An operation was more frequently performed in patients with perivalvular complications, but mortality was similar in patients with and without these complications.
CONCLUSIONS: Aortic infection, prosthetic endocarditis, new AV block and coagulase-negative staphylococci were independent risk factors of periannular complications. The period between symptom onset and diagnosis, the incidence of pericardial effusion and persistent signs of infection were similar between patients with and without perivalvular complications. Patients with perivalvular complications did not demonstrate a difference in the presence or size of vegetations or the frequency of embolism. An operation was more frequently performed in these patients, but mortality was similar in both groups.

PMID 11923047  J Am Coll Cardiol. 2002 Apr 3;39(7):1204-11. doi: 10.10・・・
著者: Danijela Trifunovic, Bosiljka Vujisic-Tesic, Biljana Obrenovic-Kircanski, Branislava Ivanovic, Dimitra Kalimanovska-Ostric, Milan Petrovic, Marija Boricic-Kostic, Snezana Matic, Goran Stevanovic, Jelena Marinkovic, Olga Petrovic, Gordana Draganic, Mirjana Tomic-Dragovic, Svetozar Putnik, Dejan Markovic, Vladimir Tutus, Ivana Jovanovic, Maja Markovic, Ivana M Petrovic, Jelena M Petrovic, Jelena Stepanovic
雑誌名: J Cardiol. 2018 Mar;71(3):291-298. doi: 10.1016/j.jjcc.2017.08.010. Epub 2017 Oct 18.
Abstract/Text BACKGROUND: The etiology of infective endocarditis (IE) is changing. More aggressive forms with multiple IE cardiac lesions have become more frequent. This study sought to explore the relationship between contemporary causative microorganisms and IE cardiac lesions and to analyze the impact of multiple lesions on treatment choice.
METHODS: In 246 patients hospitalized for IE between 2008 and 2015, cardiac lesions caused by IE were analyzed by echocardiography, classified according to the 2015 European Society of Cardiology guidelines and correlated with microbiological data. We defined a new parameter, the Echo IE Sum, to summarize all IE cardiac lesions in a single patient, enabling comprehensive comparisons between different etiologies and treatment strategies.
RESULTS: Staphylococcus aureus was associated with the development of large vegetation (OR 2.442; 95% CI 1.220-4.889; p=0.012), non-HACEK bacteria with large vegetation (OR 13.662; 95% CI 2.801-66.639; p=0.001), perivalvular abscess or perivalvular pseudoaneurysm (OR 5.283; 95% CI 1.069-26.096; p=0.041), and coagulase-negative staphylococci (CoNS) with leaflet abscess or aneurysm (OR 3.451; 95% CI 1.285-9.266, p=0.014), and perivalvular abscess or perivalvular pseudoaneurysm (OR 4.290; 95% CI 1.583-11.627; p=0.004). The Echo IE Sum significantly differed between different etiologies (p<0.001), with the highest value in non-HACEK and the lowest in streptococcal endocarditis. Patients operated for IE had a significantly higher Echo IE Sum vs those who were medically treated (p<0.001).
CONCLUSION: None of the IE cardiac lesions is microorganism-specific. However, more severe lesions were caused by S. aureus, CoNS, and non-HACEK bacteria. The highest propensity to develop multiple lesions was shown by the non-HACEK group. Higher Echo IE Sum in patients sent to surgery emphasized the importance of multiple IE cardiac lesions on treatment choice and potential usage of Echo IE Sum in patient management.

Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
PMID 29055511  J Cardiol. 2018 Mar;71(3):291-298. doi: 10.1016/j.jjcc.・・・
著者: O Pachirat, V Klungboonkrong
雑誌名: J Med Assoc Thai. 2000 May;83(5):467-73.
Abstract/Text BACKGROUND: Perivalvular abscesses are major complications of infective endocarditis (IE). The prevalence and best approach to detection of this complication in Staphylococcus aureus (SA) in comparison to Streptococcus viridans (SV) IE is unclear.
METHOD: Among 243 consecutive episodes of IE diagnosed using the Duke criteria, who underwent either transthoracic (TTE) or transesophageal echocardiography (TEE) at the Mayo Clinic between 1988 and 1993, there were 64 cases of SV and 61 of SA IE. Comparison of TTE and TEE detection of abscesses were restricted to patients with either surgical or autopsy examination and both TTE and TEE were performed.
RESULTS: Prosthetic valve and valve repair were significantly higher in SA compared to SV IE (46 vs 23%, P = 0.008). The prevalence of abscesses was higher in SA compared to SV IE (42 vs 14%, P = 0.08). 1 (10%) of abscess detected by TTE in SA compared to 1 (50%) in SV IE and 6 (60%) by TEE in SA and 1 (50%) in SV IE. Incremental value of TEE vs TTE was higher in SA 5/24 (21%) than in SV IE 0/14 (0%) P = 0.067. Hospital mortality was significantly higher in SA than SV IE (13 vs 2%, P = 0.013).
CONCLUSION: Patients diagnosed with IE and those with SA 1) presented more often with prosthetic valve IE, 2) developed more perivalvular abscesses, and 3) had a higher in hospital mortality than those with SV. Incremental value of TEE was higher in SA than in SV IE, 4) therefore, had a stringent requirement for initial and repeated TEE to detect this ominous complication of IE.

PMID 10863891  J Med Assoc Thai. 2000 May;83(5):467-73.
著者: A J Sanfilippo, M H Picard, J B Newell, E Rosas, R Davidoff, J D Thomas, A E Weyman
雑誌名: J Am Coll Cardiol. 1991 Nov 1;18(5):1191-9.
Abstract/Text To enhance the echocardiographic identification of high risk lesions in patients with infectious endocarditis, the medical records and two-dimensional echocardiograms of 204 patients with this condition were analyzed. The occurrence of specific clinical complications was recorded and vegetations were assessed with respect to predetermined morphologic characteristics. The overall complication rates were roughly equivalent for patients with mitral (53%), aortic (62%), tricuspid (77%) and prosthetic valve (61%) vegetations, as well as for those with nonspecific valvular changes but no discrete vegetations (57%), although the distribution of specific complications varied considerably among these groups. There were significantly fewer complications in patients without discernible valvular abnormalities (27%). In native left-sided valve endocarditis, vegetation size, extent, mobility and consistency were all found to be significant univariate predictors of complications. In multivariate analysis, vegetation size, extent and mobility emerged as optimal predictors and an echocardiographic score based on these factors predicted the occurrence of complications with 70% sensitivity and 92% specificity in mitral valve endocarditis and with 76% sensitivity and 62% specificity in aortic valve endocarditis.

PMID 1918695  J Am Coll Cardiol. 1991 Nov 1;18(5):1191-9.
著者: Emilio García-Cabrera, Nuria Fernández-Hidalgo, Benito Almirante, Radka Ivanova-Georgieva, Mariam Noureddine, Antonio Plata, Jose M Lomas, Juan Gálvez-Acebal, Carmen Hidalgo-Tenorio, Josefa Ruíz-Morales, Francisco J Martínez-Marcos, Jose M Reguera, Javier de la Torre-Lima, Arístides de Alarcón González, Group for the Study of Cardiovascular Infections of the Andalusian Society of Infectious Diseases, Spanish Network for Research in Infectious Diseases
雑誌名: Circulation. 2013 Jun 11;127(23):2272-84. doi: 10.1161/CIRCULATIONAHA.112.000813. Epub 2013 May 6.
Abstract/Text BACKGROUND: The purpose of this study was to assess the incidence of neurological complications in patients with infective endocarditis, the risk factors for their development, their influence on the clinical outcome, and the impact of cardiac surgery.
METHODS AND RESULTS: This was a retrospective analysis of prospectively collected data on a multicenter cohort of 1345 consecutive episodes of left-sided infective endocarditis from 8 centers in Spain. Cox regression models were developed to analyze variables predictive of neurological complications and associated mortality. Three hundred forty patients (25%) experienced such complications: 192 patients (14%) had ischemic events, 86 (6%) had encephalopathy/meningitis, 60 (4%) had hemorrhages, and 2 (1%) had brain abscesses. Independent risk factors associated with all neurological complications were vegetation size ≥3 cm (hazard ratio [HR] 1.91), Staphylococcus aureus as a cause (HR 2.47), mitral valve involvement (HR 1.29), and anticoagulant therapy (HR 1.31). This last variable was particularly related to a greater incidence of hemorrhagic events (HR 2.71). Overall mortality was 30%, and neurological complications had a negative impact on outcome (45% of deaths versus 24% in patients without these complications; P<0.01), although only moderate to severe ischemic stroke (HR 1.63) and brain hemorrhage (HR 1.73) were significantly associated with a poorer prognosis. Antimicrobial treatment reduced (by 33% to 75%) the risk of neurological complications. In patients with hemorrhage, mortality was higher when surgery was performed within 4 weeks of the hemorrhagic event (75% versus 40% in later surgery).
CONCLUSIONS: Moderate to severe ischemic stroke and brain hemorrhage were found to have a significant negative impact on the outcome of infective endocarditis. Early appropriate antimicrobial treatment is critical, and transitory discontinuation of anticoagulant therapy should be considered.

PMID 23648777  Circulation. 2013 Jun 11;127(23):2272-84. doi: 10.1161/・・・
著者: Franck Thuny, Giovanni Di Salvo, Giovanni Disalvo, Olivier Belliard, Jean-François Avierinos, Valeria Pergola, Valerie Rosenberg, Jean-Paul Casalta, Joanny Gouvernet, Geneviève Derumeaux, Diana Iarussi, Pierre Ambrosi, Raffaele Calabró, Raffaello Calabro, Alberto Riberi, Frédéric Collart, Dominique Metras, Hubert Lepidi, Didier Raoult, Jean-Robert Harle, Pierre-Jean Weiller, Ariel Cohen, Gilbert Habib
雑誌名: Circulation. 2005 Jul 5;112(1):69-75. doi: 10.1161/CIRCULATIONAHA.104.493155. Epub 2005 Jun 27.
Abstract/Text BACKGROUND: The incidence of embolic events (EE) and death is still high in patients with infective endocarditis (IE), and data about predictors of these 2 major complications are conflicting. Moreover, the exact role of echocardiography in risk stratification is not well defined.
METHODS AND RESULTS: In a multicenter prospective European study, including 384 consecutive patients (aged 57+/-17 years) with definite IE according to Duke University criteria, we tested clinical, microbiological, and echocardiographic data as potential predictors of EE and 1-year mortality. Transesophageal echocardiography was performed in all patients. Embolism occurred before or after IE diagnosis (total-EE) in 131 patients (34.1%) and after initiation of antibiotic therapy (new-EE) in 28 patients (7.3%). Staphylococcus aureus and Streptococcus bovis were independently associated with total-EE, whereas vegetation length >10 mm and severe vegetation mobility were predictors of new-EE, even after adjustment for S aureus and S bovis. One-year mortality was 20.6%. In multivariable analysis, independently of the other predictors of death (age, female sex, creatinine serum >2 mg/L, moderate or severe congestive heart failure, and S aureus) and comorbidity, vegetation length >15 mm was a predictor of 1-year mortality (adjusted relative risk=1.8; 95% CI, 1.10 to 2.82; P=0.02).
CONCLUSIONS: In IE, vegetation length is a strong predictor of new-EE and mortality. In combination with clinical and microbiological findings, echocardiography may identify high-risk patients who will need a more aggressive therapeutic strategy.

PMID 15983252  Circulation. 2005 Jul 5;112(1):69-75. doi: 10.1161/CIRC・・・
著者: Isidre Vilacosta, Catherine Graupner, José Alberto San Román, Cristina Sarriá, Ricardo Ronderos, Cristina Fernández, Leonardo Mancini, Olga Sanz, Juan Victor Sanmartín, Walter Stoermann
雑誌名: J Am Coll Cardiol. 2002 May 1;39(9):1489-95. doi: 10.1016/s0735-1097(02)01790-4.
Abstract/Text OBJECTIVES: This study was designed to assess the risk of systemic embolization in patients with left-sided infective endocarditis, once adequate antibiotic treatment had been initiated, on the basis of prospective clinical follow-up.
BACKGROUND: As one of the complications of infective endocarditis, embolization has a great impact on prognosis. Prediction of an individual patient's risk of embolization is very difficult.
METHODS: We studied 217 episodes of left-sided endocarditis that were experienced among a cohort of 211 prospectively recruited patients. According to the Duke criteria, 91% of the episodes were definite infective endocarditis. Seventy-two episodes involved infections located on prosthetic valves. All patients were studied by transthoracic and transesophageal echocardiography. Clinical, echocardiographic and microbiologic data were entered in a data base. The mean follow-up interval was 151 days.
RESULTS: Twenty-eight episodes (12.9%; group I) of endocarditis had embolic events after the initiation of antibiotic therapy. The remaining 189 episodes did not embolize (group II). Most emboli (52%) affected the central nervous system, and 65% of the embolic events occurred during the first two weeks after initiation of antibiotic therapy. Previous embolism was associated with new embolism (relative risk [RR] 1.73, 95% confidence interval [CI] 1.02 to 2.93; p = 0.05). There was an increase in the risk of embolization with increasing vegetation size (RR 3.77, 95% CI 0.97 to 12.57; p = 0.07). Vegetation size had no impact on the risk of embolization in streptococcal endocarditis or aortic infection. By contrast, large (> or = 10 mm) vegetations had a higher incidence of embolism when the microorganism was staphylococcus (p = 0.04) and the mitral valve was infected (p = 0.03). The increase in vegetation size at follow-up showed a higher risk for embolization (RR 2.64, 95% CI 0.98 to 7.16; p = 0.02).
CONCLUSIONS: Embolism before antimicrobial therapy is a risk factor for new emboli. The risk of embolization seems to increase with increasing vegetation size, and this is particularly significant in mitral endocarditis and staphylococcal endocarditis. An increase in vegetation size, despite antimicrobial treatment, may predict later embolism.

PMID 11985912  J Am Coll Cardiol. 2002 May 1;39(9):1489-95. doi: 10.10・・・
著者: G Di Salvo, G Habib, V Pergola, J F Avierinos, E Philip, J P Casalta, J M Vailloud, G Derumeaux, J Gouvernet, P Ambrosi, M Lambert, A Ferracci, D Raoult, R Luccioni
雑誌名: J Am Coll Cardiol. 2001 Mar 15;37(4):1069-76. doi: 10.1016/s0735-1097(00)01206-7.
Abstract/Text OBJECTIVES: The aim of our study was to assess the value of transesophageal echocardiography (TEE) in predicting embolic events (EEs) in a large group of patients with definite endocarditis according to the Duke criteria, including silent embolism.
BACKGROUND: The value of echocardiography in predicting embolism in patients with endocarditis remains controversial. Some studies reported an increased risk of embolism in patients with large and mobile vegetations, whereas other studies failed to demonstrate such a relationship.
METHODS: Multiplane transesophageal echocardiograms of 178 consecutive patients with definite infective endocarditis (IE) were analyzed. The incidence of embolism was compared with the echocardiographic characteristics (localization, size and mobility) of the vegetations. To detect silent embolism, cerebral and thoraco-abdominal scans were performed in 95% of patients.
RESULTS: Among 178 patients, 66 (37%) had one or more EEs. There was no difference between patients with and without embolism in terms of age, gender and left valve involved. On univariate analysis, Staphylococcus infection, right-side valve endocarditis and vegetation length and mobility were significantly related to EEs. A significant higher incidence of embolism was present in patients with vegetation length >10 mm (60%, p < 0.001) and in patients with mobile vegetations (62%, p < 0.001). Embolism was particularly frequent among 30 patients with both severely mobile and large vegetations (> 15 mm) (83%, p < 0.001). On multivariate analysis, the only predictors of embolism were vegetation length (p = 0.03) and mobility (p = 0.01).
CONCLUSIONS: Our study shows that the presence of vegetations on TEE is predictive of embolism and that the morphologic characteristics of vegetations are helpful in predicting EEs in both mitral and aortic valve IE. It also suggests that early operation may be recommended in patients with vegetations > 15 mm and high mobility, irrespective of the degree of valve destruction, heart failure and response to antibiotic therapy.

PMID 11263610  J Am Coll Cardiol. 2001 Mar 15;37(4):1069-76. doi: 10.1・・・
著者: S De Castro, G Magni, S Beni, D Cartoni, M Fiorelli, M Venditti, S L Schwartz, F Fedele, N G Pandian
雑誌名: Am J Cardiol. 1997 Oct 15;80(8):1030-4. doi: 10.1016/s0002-9149(97)00598-5.
Abstract/Text Some studies describe an increased risk for emboli in infective endocarditis patients with large (>10 mm) and mobile vegetations. Other studies fail to demonstrate the above relation. Most studies have been performed using transthoracic echocardiography or with a monoplane transesophageal approach. The present study examines whether distinctive characteristics of vegetative lesions detected by transthoracic and multiplane transesophageal echocardiography are predictive of embolic risk. We reviewed both transthoracic and transesophageal echocardiograms of 57 patients with diagnosis of acute infective endocarditis and no documented or suspected previous embolic events. We evaluated site, length, width, mobility, and echodensity of vegetations. Twenty-five patients (44%) had embolic events. No statistical differences in age, sex distribution, location of endocarditis, or offending pathogens between embolic (n = 25) and nonembolic (n = 32) patients were found. There were no differences in any of the echo characteristics of vegetations detected by transthoracic and transesophageal approach in embolic and nonembolic groups. Thus, transthoracic and transesophageal characteristics of vegetations are not helpful in defining embolic risk in patients with infective endocarditis.

PMID 9352973  Am J Cardiol. 1997 Oct 15;80(8):1030-4. doi: 10.1016/s0・・・
著者: S Rohmann, R Erbel, G Görge, T Makowski, S Mohr-Kahaly, U Nixdorff, M Drexler, J Meyer
雑誌名: Eur Heart J. 1992 Apr;13(4):446-52. doi: 10.1093/oxfordjournals.eurheartj.a060195.
Abstract/Text Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction and congestive heart failure being more common in patients with echocardiographically discernible vegetations. The transoesophageal approach affords consistently high quality images with excellent structural resolution. Two-hundred and eighty-one patients with clinically suspected infective endocarditis were studied, to evaluate the prognostic value of ascertaining the site of vegetations. Among them were 118 patients with vegetations attached to the aortic or mitral valve. These patients were followed for a mean period of 14 months. Mitral valve vegetations were associated with a significantly higher incidence of embolic events than vegetations on aortic valves (25% vs 9.7%). The incidence of abscess formation was higher in aortic than in mitral valve endocarditis (6% vs 0%), as were the need for surgical intervention (11% vs 5.5%) and mortality (1.6% vs 0%) respectively). Bivalvular endocarditis was associated with an increased rate of complications: embolism (50%), abscess formation (15%), surgery (35%) and mortality (10%). By multivariate analysis, echocardiographically accessible risk factors for subsequent embolism were a vegetation size of more than 10 mm and mitral valve involvement. Risk factors associated with in-hospital fatality were embolism, a vegetation size of more than 10 mm, and Staphylococcus aureus infection. Our data suggest that the site influences both the rate and the type of complications. Precise echocardiographic visualization of vegetations helps to stratify patients into a high-risk sub-group, perhaps warranting early prophylactic surgical intervention. Transoesophageal echocardiography may play an important role in assessing the clinical outcome for these patients.

PMID 1600980  Eur Heart J. 1992 Apr;13(4):446-52. doi: 10.1093/oxford・・・
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: M D Tischler, P T Vaitkus
雑誌名: J Am Soc Echocardiogr. 1997 Jun;10(5):562-8.
Abstract/Text To clarify whether echocardiographic detection of a vegetation 10 mm or larger in size in patients with left-sided infective endocarditis poses an increased risk for complications, we performed a meta-analysis of English-language publications identified by a computerized search of the key words infective endocarditis and echocardiography. A pooled odds ratio was calculated by using the Robins, Greenland, and Breslow estimate of variance. The pooled odds ratio for increased risk of systemic embolization in the presence of a vegetation >10 mm (10 studies, 738 patients) was 2.80 (95% confidence interval [CI] 1.95 to 4.02; p < 0.01). The odds ratio of requiring valve-replacement surgery (seven studies, 549 patients) was 2.95 (95% CI 1.90 to 4.58; p < 0.01). The odds ratio of death (six studies, 476 patients) was 1.55 (95% CI 0.92 to 2.60; p = 0.10). Thus this analysis supports the hypothesis that echocardiographically detected left-sided vegetations >10 mm pose a significantly increased risk of (1) systemic embolization and (2) a need for valve-replacement surgery than cases where either no or smaller vegetations are detected.

PMID 9203497  J Am Soc Echocardiogr. 1997 Jun;10(5):562-8.
著者: Emanuele Durante Mangoni, Luigi E Adinolfi, Marie-Francoise Tripodi, Augusto Andreana, Michele Gambardella, Enrico Ragone, Davide F Precone, Riccardo Utili, Giuseppe Ruggiero
雑誌名: Am Heart J. 2003 Aug;146(2):311-6. doi: 10.1016/S0002-8703(02)94802-7.
Abstract/Text BACKGROUND: Infective endocarditis often is complicated by embolic events after hospital admission. Identifying patients at higher risk may improve the disease outcome. This study was aimed at identifying predictors of embolic risk among the clinical and laboratory data obtained on hospital admission in patients diagnosed as having definite infective endocarditis according to the Duke criteria.
METHODS: Ninety-four patients were enrolled in a prospective study. The results of hematologic, echocardiographic, and microbiological investigations were analyzed, using statistical methods as appropriate. Multivariate analysis was applied to variables significantly associated with embolism in univariate analysis.
RESULTS: Forty-six percent of patients had a major embolic complication after admission. No association was found between embolism and sex, site of infection, or microorganism involved. Patients with embolism were significantly younger, had larger vegetation, and showed a significantly higher level of serum C-reactive protein and lower albumin concentrations than those without embolism. Young age, larger vegetation size, and high levels of C-reactive protein were the independent variables associated with an increased incidence of embolic events in the multivariate logistic regression analysis.
CONCLUSIONS: Our data indicate that patients with infective endocarditis with young age and/or with large vegetation and/or with high serum levels of C-reactive protein are at increased risk of major embolic complications during the in-hospital course of the disease.

PMID 12891201  Am Heart J. 2003 Aug;146(2):311-6. doi: 10.1016/S0002-8・・・
著者: P Corr, M Wright, L C Handler
雑誌名: AJNR Am J Neuroradiol. 1995 Apr;16(4):745-8.
Abstract/Text PURPOSE: To document the response of mycotic aneurysms to antibiotic therapy and correlate these findings with patient outcome.
METHODS: Clinical findings, CT studies, and serial cerebral angiograms of patients with endocarditis related aneurysms seen over 10 years were retrospectively reviewed.
RESULTS: In 14 patients infective endocarditis was diagnosed. The patients presented with subarachnoid haemorrhage (4 patients), stroke (9 patients), and seizure (1 patient). CT findings were intracerebral hematoma (5 patients), infarcts (4 patients), subarachnoid hemorrhage (4 patients), and aneurysms (2 patients). On angiography, 10 (71%) patients had single aneurysms, and 4 (29%) patients had multiple aneurysms. Eighteen aneurysms were detected, of which 6 (33%) were centrally located, and 12 (66%) were located peripherally. The most common site was the peripheral middle cerebral artery (56%). Serial angiography during antibiotic treatment demonstrated complete resolution of 6 aneurysms (33%), with 12 aneurysms remaining after 6 weeks of treatment. Of the latter, there was no change in size in 6 aneurysms (33%), a decrease in size in 3 aneurysms (17%) and an increase in size in 3 aneurysms (17%). No new aneurysms appeared. Surgery was performed on 10 patients with residual aneurysms, 11 aneurysms being excised or clipped. After 6 weeks' treatment, there was complete recovery in 7 (50%) patients, permanent neurologic deficits in 6 patients, and death from aneurysm rebleed in 1 patient.
CONCLUSION: Follow-up angiography is recommended in all patients with mycotic aneurysms to assess response to antibiotic therapy, to detect new aneurysms, and to identify those aneurysms with no response or with enlargement.

PMID 7611032  AJNR Am J Neuroradiol. 1995 Apr;16(4):745-8.
著者: Sudheeran Kannoth, Rajesh Iyer, Sanjeev V Thomas, Sunil V Furtado, B J Rajesh, C Kesavadas, V V Radhakrishnan, P S Sarma
雑誌名: J Neurol Sci. 2007 May 15;256(1-2):3-9. doi: 10.1016/j.jns.2007.01.044. Epub 2007 Mar 23.
Abstract/Text BACKGROUND: Intracranial infectious aneurysms (IA) are infrequent, but can be fatal.
OBJECTIVES: To compare the clinical profile of IAs associated with intravascular/systemic infection like infective endocarditis with that associated with local infections like meningitis, orbital cellulitis and cavernous sinus thrombosis.
METHODS: We analysed all cases of IA, treated in this Institute from 1976 to 2003, in order to identify prognostic factors.
RESULTS: There were 25 persons (mean age 24.8+/-17.3 years, males 17) with 29 IA (carotid circulation 19, vertebrobasilar circulation 10). Headache (83%) and fever (67%) were the most common presenting symptoms. In contrast to noninfectious aneurysms, intracerebral haemorrhage (60%) and focal signs were more common than subarachnoid haemorrhage (7%) with IA. Sources of infection were cardiac (10), meningitis (12), orbital cellulitis (2) or uncertain (1). Infective agents included bacteria (18), fungi (4), and tubercle bacilli (3). Fifteen IA were distal and 14 were proximal. IAs associated with meningitis were proximal (75%) while those associated with cardiac diseases preferentially involved carotid territory and were distal (p=0.013). The overall mortality was 32%. Survivors were younger than those who expired (p=0.015). Of the sixteen patients treated medically, seven recovered (44%), others (56%) had treatment failure (three died and six required surgery later). Another five patients underwent early surgery (one died). Mortality of IA was significantly higher with meningitis, fungal aetiology and vertebrobasilar location.
CONCLUSIONS: IAs associated with local infections like meningitis had different clinical profile as compared to IAs associated with intravascular/systemic infections like infective endocarditis.

PMID 17360002  J Neurol Sci. 2007 May 15;256(1-2):3-9. doi: 10.1016/j.・・・
著者: D L Barrow, A R Prats
雑誌名: Neurosurgery. 1990 Oct;27(4):562-72; discussion 572-3.
Abstract/Text A series of 12 patients with infectious intracranial aneurysms is presented, and a number of unusual features of the disorder are emphasized. A comparison of characteristics of the aneurysms and clinical course is made between patients with and without infective endocarditis. Most of the unusual characteristics of infectious aneurysms, including rare locations, causative organisms, and predisposing medical conditions, occurred in the group without endocarditis. The relationship of atypical features of infectious aneurysms to the etiology of aneurysm formation is discussed, and an approach to treatment is presented.

PMID 2234359  Neurosurgery. 1990 Oct;27(4):562-72; discussion 572-3.
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: Georges Nadji, Dan Rusinaru, Jean-Paul Rémadi, Antoine Jeu, Claire Sorel, Christophe Tribouilloy
雑誌名: Eur J Heart Fail. 2009 Jul;11(7):668-75. doi: 10.1093/eurjhf/hfp077.
Abstract/Text AIMS: Although congestive heart failure (CHF) represents the most common cause of death in native valve infective endocarditis (IE), recent data on the outcome of IE complicated by CHF are lacking. We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by CHF and to evaluate the impact of early surgery on 1 year outcome.
METHODS AND RESULTS: Two hundred and fifty-nine consecutive patients with definite left-sided native valve IE according to the Duke criteria were included in this analysis. When compared with patients without CHF (n = 151), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in CHF patients (n = 108, 41.6%). Mitral valve IE, embolic events and neurological events were less frequent in CHF patients. Congestive heart failure was independently predictive of in-hospital [OR 3.8 (1.7-9.0); P = 0.0013] and 1 year mortality [HR 1.8 (1.1-3.0); P = 0.007]. Early surgery was performed in 46% of CHF patients with a peri-operative mortality of 10%. In the CHF group, comorbidity index, Staphylococcus aureus IE, uncontrolled infection, and major neurological events were univariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival [HR 0.45 (0.22-0.93); P = 0.03].
CONCLUSION: Left-sided native valve IE complicated by CHF is more frequent in aortic IE and is associated with severe regurgitation. Congestive heart failure is an independent predictor of in-hospital and 1 year mortality. In CHF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.

PMID 19553397  Eur J Heart Fail. 2009 Jul;11(7):668-75. doi: 10.1093/e・・・
著者: S Leone, V Ravasio, E Durante-Mangoni, M Crapis, G Carosi, P G Scotton, N Barzaghi, M Falcone, P Chinello, M B Pasticci, P Grossi, R Utili, P Viale, M Rizzi, F Suter
雑誌名: Infection. 2012 Oct;40(5):527-35. doi: 10.1007/s15010-012-0285-y. Epub 2012 Jun 19.
Abstract/Text BACKGROUND: The characteristics of patients with infective endocarditis (IE) vary significantly by region of the world. The aim of this study was to evaluate the contemporary epidemiology, characteristics, and outcome of IE in a large, nationwide cohort of Italian patients.
METHODS: We conducted a prospective, observational study at 24 medical centers in Italy, including all the consecutive patients with a definite or possible diagnosis of IE (modified Duke criteria) admitted from January 2004 through December 2009. A number of clinical variables were collected through an electronic case report form and analyzed to comprehensively delineate the features of IE. We report the data on patients with definite IE.
RESULTS: A total of 1,082 patients with definite IE were included. Of these, 753 (69.6%) patients had infection on a native valve, 277 (25.6%) on a prosthetic valve, and 52 (4.8%) on an implantable electronic device. Overall, community-acquired (69.2%) was more common than nosocomial (6.2%) or non-nosocomial (24.6%) health care-associated IE. Staphylococcus aureus was the most common pathogen (22.0%). In-hospital mortality was 15.1%. From the multivariate analysis, congestive heart failure (CHF), stroke, prosthetic valve infection, S. aureus, and health care-associated acquisition were independently associated with increased in-hospital mortality, while surgery was associated with decreased mortality.
CONCLUSIONS: The current mortality of IE remains high, and is mainly due to its complications, such as CHF and stroke.

PMID 22711599  Infection. 2012 Oct;40(5):527-35. doi: 10.1007/s15010-0・・・
著者: Carmen Olmos, Isidre Vilacosta, Cristina Fernández, Javier López, Cristina Sarriá, Carlos Ferrera, Ana Revilla, Jacobo Silva, David Vivas, Isabel González, José Alberto San Román
雑誌名: Eur Heart J. 2013 Jul;34(26):1999-2006. doi: 10.1093/eurheartj/ehs336. Epub 2012 Oct 11.
Abstract/Text AIMS: The prognosis of patients with infective endocarditis (IE) remains poor despite the great advances in the last decades. One of the factors closely related to mortality is the development of septic shock (SS). The aim of our study was to describe the profile of patients with IE complicated with SS, and to identify prognostic factors of new-onset SS during hospitalization.
METHODS AND RESULTS: We conducted a prospective study including 894 episodes of IE diagnosed at three tertiary centres. A backward logistic regression analysis was undertaken to determine prognostic factors associated with SS development. Multivariable analysis identified the following as predictive of SS development: diabetes mellitus [odds ratio (OR) 2.06; confidence interval (CI) 1.16-3.68], Staphylococcus aureus infection (OR: 2.97; CI: 1.72-5.15), acute renal insufficiency (OR: 3.22; CI: 1.28-8.07), supraventricular tachycardia (OR: 3.29; CI: 1.14-9.44), vegetation size ≥15 mm (OR: 1.21; CI: 0.65-2.25), and signs of persistent infection (OR: 9.8; CI: 5.48-17.52). Risk of SS development could be stratified when combining the first five variables: one variable present: 3.8% (CI: 2-7%); two variables present: 6.3% (CI: 3.2-12.1%); three variables present: 14.6% (CI: 6.8-27.6%); four variables present: 29.1% (CI: 11.7-56.1%); and five variables present: 45.4% (95% CI: 17.5-76.6%). When adding signs of persistent infection, the risk dramatically increased, reaching 85.7% (95% CI: 61.2-95.9%) of risk.
CONCLUSIONS: In patients with IE, the presence of diabetes, acute renal insufficiency, Staphylococcus aureus infection, supraventricular tachycardia, vegetation size ≥15 mm, and signs of persistent infection are associated with the development of SS.

PMID 23060453  Eur Heart J. 2013 Jul;34(26):1999-2006. doi: 10.1093/eu・・・
著者: François Delahaye, François Alla, Isabelle Béguinot, Patrice Bruneval, Thanh Doco-Lecompte, Flore Lacassin, Christine Selton-Suty, François Vandenesch, Véronique Vernet, Bruno Hoen, AEPEI Group
雑誌名: Scand J Infect Dis. 2007;39(10):849-57. doi: 10.1080/00365540701393088.
Abstract/Text Infective endocarditis (IE) remains severe. Few predictors of prognosis have been identified. It is not known whether mortality of IE has decreased during recent decades. 559 definite cases of IE were collected in a prospective population-based survey in 1999 in France. In-hospital death rate was 17%. It was lower in operated patients (14.4% vs 19.3%), although not significantly so. In multivariate analysis, the following variables were independent and significant predictors of mortality: history of heart failure (odds ratio: 2.65), history of immunosuppression (OR: 3.34), insulin-requiring diabetes mellitus (OR: 7.82), left-sided IE (OR: 1.97), heart failure (OR: 2.19), septic shock (OR: 4.33), lower Glasgow coma scale score (OR: 4.09), cerebral haemorrhage (OR: 9.46), and higher C-reactive protein level (OR: 2.60). Adjusted mortality was significantly lower in 1999 than in 1991 (22%): OR: 0.64 (p = 0.03). Thus, in a large and unselected cohort of patients hospitalized for IE in 1999, in-hospital mortality rate was lower than in 1991. Multivariate analysis identified factors classically known as having an impact on mortality. However, other factors, such as age and responsibility of Staphylococcus aureus, were not retained in the model.

PMID 17852900  Scand J Infect Dis. 2007;39(10):849-57. doi: 10.1080/00・・・
著者: Kwan-Leung Chan, Jean G Dumesnil, Bibiana Cujec, Anthony J Sanfilippo, John Jue, Michele A Turek, Trevor I Robinson, David Moher, Investigators of the Multicenter Aspirin Study in Infective Endocarditis
雑誌名: J Am Coll Cardiol. 2003 Sep 3;42(5):775-80.
Abstract/Text OBJECTIVES: This study examined the effect of aspirin on the risk of embolic events in infective endocarditis (IE).
BACKGROUND: Embolism is a major complication of IE, and studies in animal models have shown that platelet inhibition with aspirin can lead to more rapid vegetation resolution and a lower rate of embolic events.
METHODS: We conducted a randomized, double-blinded, placebo-controlled trial of aspirin treatment (325 mg/day) for four weeks in patients with IE to test the hypothesis that the addition of aspirin would reduce the incidence of clinical systemic embolic events. Patients with perivalvular abscess were excluded. Serial cerebral computed tomograms and transesophageal echocardiograms were obtained in a subset of patients.
RESULTS: During the four-year study period, 115 patients were enrolled: 60 assigned to aspirin and 55 assigned to placebo. Embolic events occurred in 17 patients (28.3%) on aspirin and 11 patients (20.0%) on placebo, with an odds ratio (OR) of 1.62 (95% confidence interval [CI] 0.68 to 3.86, p = 0.29). There was a trend toward a higher incidence of bleeding in the patients taking aspirin versus placebo (OR 1.92, 95% CI 0.76 to 4.86, p = 0.075). Development of new intracranial lesions was similar in both groups. Aspirin had no effect on vegetation resolution and valvular dysfunction.
CONCLUSIONS: In endocarditis patients already receiving antibiotic treatment, the addition of aspirin does not appear to reduce the risk of embolic events and is likely associated with an increased risk of bleeding. Aspirin is not indicated in the early management of patients with IE.

PMID 12957419  J Am Coll Cardiol. 2003 Sep 3;42(5):775-80.
著者: B L Røder, D A Wandall, F Espersen, N Frimodt-Møller, P Skinhøj, V T Rosdahl
雑誌名: Am J Med. 1997 Apr;102(4):379-86.
Abstract/Text PURPOSE: To investigate the neurologic manifestations of infective endocarditis caused by Staphylococcus aureus in a population of nondrug addicts with special emphasis on the clinical presentation, epidemiology, and mortality.
PATIENTS AND METHODS: During the period from 1982 to 1991 a total of 8,514 cases of bacteremia with S aureus were reported to the Staphylococcus Laboratory, Copenhagen, Denmark. The medical records of cases of suspected infective endocarditis were retrospectively reviewed and classified according to the new diagnostic criteria for endocarditis proposed by Durack.
RESULTS: A total of 260 cases from 63 hospitals fulfilled the diagnostic criteria. Overall, 91 patients (35%) experienced neurologic manifestations. Sixty-one presented with neurologic symptoms, whereas 30 patients developed neurologic complications at various intervals (median: 10 days) after the debut of the disease. The most frequent neurologic manifestation was unilateral hemiparesis, which occurred in 41 patients (45%). Forty-two percent of the females had neurologic manifestations compared to only 30% of the males (P = 0.06). Cases with native mitral valve infection had a significantly higher frequency of neurologic manifestations compared with all other valvular involvement (44% versus 29%, P = 0.02) but the frequency of neurologic complications was only nonsignificantly higher in those patients with native mitral valve infection than in those patients with native aortic valve infection (44% versus 31%, P = 0.10). Only two of the patients with tricuspid valve infection and none of those with congenital heart disorder experienced neurologic manifestations. A neurologic manifestation occurred in 22 (35%) of the 63 episodes in which vegetations were detected on the echocardiograms, compared with 17 (26%) of the 65 episodes without vegetations (P = 0.38). The mortality was 74% in patients with major neurologic manifestations and 56% in patients without neurologic manifestations (P = 0.008). In patients with neurologic complications the mortality was significantly higher among those treated with antibiotics alone as compared with those treated surgically (65 of 81, 80% versus 2 of 10, 20%; P = 0.0003).
CONCLUSIONS: In a population of nondrug addicts with infective endocarditis caused by S aureus the following main conclusions can be drawn: neurologic manifestations occur with a higher frequency in patients with native mitral valve infection. The presence of vegetations on echocardiograms is not a risk factor for developing neurologic complications but this conclusion is based on the results of transthoracic echocardiograms performed in only one half of the patients. The majority of the neurologic manifestations occur on presentation or shortly thereafter and the risk of recurrent embolism is low. Mortality is increased in patients with neurologic manifestations. A neurologic event per se may constitute an indication for surgical treatment.

PMID 9217620  Am J Med. 1997 Apr;102(4):379-86.
著者: J M Martin, W H Neches, E R Wald
雑誌名: Clin Infect Dis. 1997 Apr;24(4):669-75. doi: 10.1093/clind/24.4.669.
Abstract/Text We review the predisposing conditions, the presenting signs and symptoms, as well as the risk factors and bacterial etiologies in children with infective endocarditis, focusing on hospital course and outcome. We conducted a retrospective analysis of 76 cases of endocarditis in 73 patients occurring at Children's Hospital of Pittsburgh from January 1958 through December 1992. The median age of the patients was 9 years (range, 1 month to 18 years). Predisposing conditions included congenital heart disease (62 patients) and rheumatic heart disease (four patients). Seventy-seven percent of the children with congenital heart disease had undergone cardiac surgery. After therapy with appropriate antibiotics was started, blood cultures for 67 patients (70 episodes of infective endocarditis) remained positive for a mean (+/-SD) of 0.7 +/- 1.41 days, and all patients who presented with fever (75 episodes in 72 patients) remained febrile for a mean (+/-SD) of 4.28 +/- 6.21 days. Secondary fever occurred in 39% of the children. Thirty (41%) of the 73 patients survived without any complications and 13 (18%) died. Fifteen children with complications required surgery. Children with endocarditis caused by Staphylococcus aureus were more likely than those with infection caused by viridans streptococci to have prolonged fever, secondary fever, and/or complications as well to require surgery.

PMID 9145742  Clin Infect Dis. 1997 Apr;24(4):669-75. doi: 10.1093/cl・・・
著者: Pirouz Shamszad, Muhammad S Khan, Joseph W Rossano, Charles D Fraser
雑誌名: J Thorac Cardiovasc Surg. 2013 Sep;146(3):506-11. doi: 10.1016/j.jtcvs.2012.12.001. Epub 2013 Jan 9.
Abstract/Text OBJECTIVES: Infective endocarditis is rare in children but potentially carries high mortality and morbidity. Few data exist regarding surgical therapy and the associated outcomes in children with infective endocarditis. The aim of the present study was to describe the characteristics and outcomes of children undergoing surgery for infective endocarditis.
METHODS: A retrospective review of all patients aged 21 years or younger diagnosed with definitive infective endocarditis at a single center from 1996 to 2010 was performed.
RESULTS: Of 76 identified patients with infective endocarditis (median age, 8.3 years; 73.9% boys), 46 patients (61%) required surgical intervention. Staphylococcus aureus was most commonly isolated (18 patients, 24%) followed by Streptococcus (17 patients, 22%). Common surgical indications included severe valvular insufficiency in 13 patients, septic embolization in 12, concomitant severe valvular insufficiency and ventricular dysfunction in 9, persistent vegetations in 9, and persistent bacteremia in 3. Although early surgery was performed within 7 days of diagnosis in 35 patients (76%), 25 (54%) underwent surgery within 3 days or less. The factors associated with surgery included the presence of ventricular dysfunction, left-sided vegetation, severe valvular insufficiency, septic embolization, and S aureus. Surgery within 3 days or less was associated with the presence of ventricular dysfunction and S aureus. Native valve repair was performed in 50% of patients with native-valve disease. Postoperatively, no septic embolization events occurred and recurrence was low (2%). The 1-, 5-, and 10-year survival was 98% ± 2%, 90% ± 8%, and 81% ± 11%, respectively.
CONCLUSIONS: Children with infective endocarditis can undergo successful early surgical therapy with a low risk of septic embolization, recurrence, and operative mortality.

Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
PMID 23312102  J Thorac Cardiovasc Surg. 2013 Sep;146(3):506-11. doi: ・・・
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: Franck Thuny, Sylvain Beurtheret, Julien Mancini, Vlad Gariboldi, Jean-Paul Casalta, Alberto Riberi, Roch Giorgi, Frédérique Gouriet, Laurence Tafanelli, Jean-François Avierinos, Sébastien Renard, Frédéric Collart, Didier Raoult, Gilbert Habib
雑誌名: Eur Heart J. 2011 Aug;32(16):2027-33. doi: 10.1093/eurheartj/ehp089. Epub 2009 Mar 26.
Abstract/Text AIMS: To determine whether the timing of surgery could influence mortality and morbidity in adults with complicated infective endocarditis (IE).
METHODS AND RESULTS: In 291 consecutive adults with definite IE who underwent surgery during the active phase, we compared those operated on within the first week of antimicrobial therapy (n=95) to those operated on later (n=191). The impact of the timing of surgery on 6-month mortality, relapses, and postoperative valvular dysfunctions (PVD) was analysed using propensity score (PS) analyses. After stratification of the cohort into quintiles based on the PS, ≤1st week surgery was associated with a trend of decrease in 6-month mortality in the quintile of patients with the most likelihood of undergoing this early surgical management [quintile 5: 11% vs. 33%, odds ratio (OR)=0.18, 95% CI (confidence interval) 0.04-0.83, P=0.03]. Patients of this subgroup were younger, were more likely to have Staphylococcus aureus infections, congestive heart failure, and larger vegetations. Besides, ≤1st week surgery was associated with an increased number of relapses or PVD (16% vs. 4%, adjusted OR=2.9, 95% CI 0.99-8.40, P=0.05).
CONCLUSION: Surgery performed very early may improve survival in patients with the most severe complicated IE. However, a greater risk of relapses and PVD should be expected when surgery is performed very early.

PMID 19329497  Eur Heart J. 2011 Aug;32(16):2027-33. doi: 10.1093/eurh・・・
著者: John Chambers, Jonathan Sandoe, Simon Ray, Bernard Prendergast, David Taggart, Stephen Westaby, Chris Arden, Lucy Grothier, Jo Wilson, Brian Campbell, Christa Gohlke-Bärwolf, Carlos A Mestres, Raphael Rosenhek, Philippe Pibarot, Catherine Otto
雑誌名: Heart. 2014 Apr;100(7):524-7. doi: 10.1136/heartjnl-2013-304354. Epub 2013 Aug 29.
Abstract/Text
PMID 23990639  Heart. 2014 Apr;100(7):524-7. doi: 10.1136/heartjnl-201・・・

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