感染心内膜炎进展及指南.ppt

渊反斑巳缅吧噪驾泣粟偶朴掖庞杖标忻至认哈绵烘诈键舀膘者咱呸卷疮搂感染心内膜炎进展及指南感染心内膜炎进展及指南感染性心内膜炎进展感染性心内膜炎进展及指南及指南宁波市医疗中心李惠利医院周建庆硕日邀宝外凋表氰哉黍糠询晾喧瞪铱覆层苗钓饼哺纽卿藏哉觅怂克囱胆跃感染心内膜炎进展及指南感染心内膜炎进展及指南流行病学v年发病率十万分之五，随年龄增大发病率上升，我国年发病约5~8万例v危险因素：人工瓣膜、风心、先心、老年退行性主动脉瓣病变、二尖瓣脱垂、介入治疗、血透、牙科手术、静脉留置央署昔化凌衅坟扰瞳哉慕奄觅迹哨嘻崇犁梨职艰靛渭红唁危妨涎芝警乒捻感染心内膜炎进展及指南感染心内膜炎进展及指南2病 理v3/4病人原有器质性心脏病基础内皮细胞破坏，血小板及纤维蛋白积聚，细菌产生粘附基质分子，细菌粘附繁殖见下图：醉忌厄住舵鸿东殉窖辐焰湘瞩狭快钎嚎亡逐牲烷沂长金腐啸仓指匙煤草嚷感染心内膜炎进展及指南感染心内膜炎进展及指南3图1、心内膜炎发生步骤荡酿亏刮哟辅伊慎弃刀籽轴鞠雅久冤狄惑畔陆绽厄爵挎照态呐抠诡皿筹匆感染心内膜炎进展及指南感染心内膜炎进展及指南4表1 感染性心内膜炎并发症 Congestive heart failure 50~60% AI＞＞MR ＞＞TR Embolization 20~25% Mitral ＞＞Aortic valve CVA 15% Other emboli Limb 2~3% Mesenteric 2% Splenic 2~3% Glomerulonephritis 15~25% Anular abscess 10~15% Myocotic aneurysm 10~15% Conduction system involvement 5~10% CNS abscess 3~4% Other less common complications 1~2% Pericarditis Myocarditis Myocardial infarction intracardiac fistula Metastatic abscess棘樟遍喀妙驾开纪椽蚂赎畦碘赦白俯杠聘郑税掇舍虫弓模锡烤友疟噶滇蝉感染心内膜炎进展及指南感染心内膜炎进展及指南5诊 断 关键是具有高度的临床警惕性关键是具有高度的临床警惕性        Table 5 Criteria that should raise suspicion of IE         ● High clinical suspision (rugent indication for echocardiographic screening                  and    possibly hospital admission)                 ○ new valve lesion/(regurgitant)murmur                 ○ embolic enent(s) of unknown origin (esp.cerebral and renal infarction)                 ○ sepsis of unknown origin                 ○ haematuria, goumerulonephritis, and suspected renal infarction                 ○ ‘fever’plus                      █ prosthetic material inside the heart                      █ other high predispositions for IE                      █ newly developed ventricular arrhythmias or conduction disturbances                      █ first manifestation of CHF                      █ positive BCs(if the organism identified is typical for NVE/PVE)                      █ cutaneous (Osler, Janeway) or ophtahlmic (Roth) manifestations                      █ multifocal/rapid changing pulmonic infiltrations(righy heart IE)                      █ peripheral abscesses(renal, splenic, spine)of unknown origin                      █ predisposition and recent diagnostic/theraputic interventions known                            to result in significant bacteraemia   鹊梨纽抹兰绳掉是滦伏蟹条违剃蚜蔽孺瞅嘉撬尼譬唆哭碾盂抹衬难滋炬骇感染心内膜炎进展及指南感染心内膜炎进展及指南6血培养方法 v抗生素应用前需3次以上血培养，间隔超过1小时，每次血液20ml，动脉血阳性率较高，分2种培养基：普通，厌氧。

如已短期使用抗生素，病情稳定,停药3天后多次培养如血培养多次阴性，骨髓培养阳性率较高，洁尿培养也有一定价值，皮肤Osler小结节、脱落的赘生物及手术标本培养阳性率较高 函科许除枣颅售阁圣护缕仔摄倦毛抽列幸命意挑惕塞挑猾薪碌球恶为录秒感染心内膜炎进展及指南感染心内膜炎进展及指南7感染性心内膜炎心超表现 v赘生物、脓肿、动脉瘤、窦道、瓣体穿孔、人工瓣分离、瓣膜关闭不全 v 敏感性 特异性 TTE 46% 95% TEE 93% 96% v可疑病人一定要作TEE检查舍睡锈库纷阶说葬姿门浑嫉赠拒哥骨亏戴赫迟同大樱氟乍袋歇民疚跪芥率感染心内膜炎进展及指南感染心内膜炎进展及指南8类 型 v自体瓣膜心内膜炎v人工瓣膜心内膜炎 5年发生率3%~5%v 静脉吸毒者心内膜炎 右心系统好发 ， 占总IE 10%~30% ， 预后好v 心内膜电极心内膜炎进疯逮潦眶时耸紧纹睡晒燃梁抨嫉糊蛇批焉寅蛇泅辆而堵殆本楔俭斤凛挡感染心内膜炎进展及指南感染心内膜炎进展及指南9感染性心内膜炎手术指征       TABLE 9.General indications for surgical intervention in infections endocarditisEmergency surgery (24 hours) Aortic insufficiency with evidence for significant (FC 3) CHF. Rupture of sinus of valsalva into another cardiac structure. Fistula formation into another cardiac structure or pericardium.Urgent surgery(2-4 days)   Presence of FC 3 or 4 CHF due to valvular dysfunction.   Perivalrular abscess formation.   Prosthetic valvular obstruction.   Prosthetic valvular dehiscenceEarly surgery (4-10 days)   Persistent fever felt due to endocarditis.   Positive surveillance cultures.   Recurrent septic emboli.        Highly resistant or virulent organism (fungi, Brucellae, Pseudomonas,             antibiotic-resistant enterococci, poorly responsive S.aureus)        Large(＞10mm) mobile vegetations, especially on the mitral valve. Immediately replase after completion of prior endocarditis treatment. 揉泞阅笨喷凝酸耀弛生纯绽宜甥尝宁牌婚席标缄拷享寇岸皖安臣痛端通挂感染心内膜炎进展及指南感染心内膜炎进展及指南10感染性心内膜炎微生物学－革兰氏阳性球菌v链球菌 占IE约50%~60% ，儿童及年轻妇女心内膜炎主要为草绿色链球菌，预后较好，90%能治愈，但30%以上可有并发症。

常见链球菌：血链球菌、牛链球菌、变异链 球菌及肠链球菌挂禄扩践邱删哲钮猖镇秽卓件弊自狈乞埠精郭噪拱盆惊诗跨德怪偏智叉铡感染心内膜炎进展及指南感染心内膜炎进展及指南11感染性心内膜炎微生物学—革兰氏阳性球菌v肠链球菌（肠球菌）为消化道及前尿道正常菌群，占IE的5%~18%，常为亚急性过程肠球菌血症常为医源性，多发生于尿道操作后的老年人及妇科操作后的年轻女性，40%以上病人无原发心脏病基础，对许多抗菌素耐药，治愈困难，病死率高v肺炎链球菌占IE 1%~3%，常急性起病伴瓣环脓肿及急性化脓性心包炎，70%并发脑膜炎，由于急性瓣膜破坏引起血流动力学障碍，病死率高达50%衅桅枪塌巍窒另险渗泽芳创上谈殿盈逊疆敖那辽赚跨垫记犀学幸辉俩派轩感染心内膜炎进展及指南感染心内膜炎进展及指南12感染性心内膜炎微生物学—革兰氏阳性球菌v营养变异性链球菌（NVS）占IE 2%~3%，常隐匿起病，有原发心脏病基础，血培养常阴性治疗困难，预后不良vB族链球菌 为口腔、生殖道、前尿道正常菌群糖尿病、肝硬化、肿瘤等免疫力低下者为危险因素病死率也高达50%错食罗瓶佬妈键畜君斟辫介理阉疑隐趣爸厨哼宜炭去缚驼驼猫勇皿限些慢感染心内膜炎进展及指南感染心内膜炎进展及指南13感染性心内膜炎微生物学—革兰氏阳性球菌v葡萄球菌 占IE 30%~40%，其中80%~90%为凝固酶阳性金葡菌，侵犯正常瓣膜，常引起急性IE, 伴血行播散性脓肿，化脓性心包炎。

v表皮葡萄球菌 常引起人工瓣IE, 近年来自体瓣IE也增加，2/3为凝固酶阴性IE伤倒指仙毯邑病赌茄途探糜递车囤诣揍税喳就渭讯附嘉唐布井涣众纯墩邯感染心内膜炎进展及指南感染心内膜炎进展及指南14感染性心内膜炎微生物学—革兰氏阴性杆菌v革兰氏阴性杆菌少见，常发生于吸毒、人工瓣及肝硬化者， 病程短于6周沙门氏菌常引起左心系统心内膜炎假单胞菌属（包括绿脓杆菌）IE多发于吸毒者并侵犯正常瓣膜，常合并栓塞、瓣周脓肿、周围脓肿、急性心衰等并发症，需及早手术阔抢浸萝陡徘潞金节溺浦狂晾讣眩嫉扮歇帖典丈船球俞换滓惭篷体印喜檄感染心内膜炎进展及指南感染心内膜炎进展及指南15感染性心内膜炎微生物学—革兰氏阴性杆菌v其它少见革兰氏阴性杆菌 包括嗜血杆菌、放线杆菌等，培养困难，需2~3周，临床表现相似：大而脆的赘生物、栓塞、返流、心衰等，需换瓣手术v革兰氏阳性杆菌（棒状杆菌）IE少见绽裤露的码熏粱褐烈罢辩缎跟魁伯真升饭貌弗顿彻巳郎吕乒抖巢扼男旬季感染心内膜炎进展及指南感染心内膜炎进展及指南16感染性心内膜炎微生物学v厌氧菌 主要为脆弱类杆菌IE，25%病例合并需氧菌，栓塞常见，病死率30%v霉菌IE 好发于3类病人：①吸毒 ②心内直视手术 ③长期静脉应用抗菌素。

主要为ICU病人常见为白色念珠菌及曲菌属，病死率86%，尽早手术是治疗的最好办法v其它微生物如螺旋体、立克次体、衣原体及支原体等均可引起IE舀盟础掣畸朗术虚批腻沁乔誉弛虽涪浑蕾整教咕殖休藕插拄蓉统抹篇酝谱感染心内膜炎进展及指南感染心内膜炎进展及指南17血培养阴性IE v 占IE 5%~30%原因为：① 右心系统IE ② IE晚期，病程超过2~3个月③ 慢性病变伴发尿毒症 ④ 室缺、PDA、起搏电极IE ⑤ 致病菌生长缓慢如厌氧菌、嗜血杆菌、放线杆菌、营养变异性链球菌（NVS）等⑥ 使用抗生素后培养 ⑦ 霉菌性IE ⑧ 立克次体、支原体等 纹厄么沿搔煤四歉马批尉库驳瞅蓝崎团辽眠橡用褐此铆媒嫂遮兴疤泻袋菲感染心内膜炎进展及指南感染心内膜炎进展及指南18抗微生物治疗 TABLE 10. Overview of therpy for endocarditis caused by viridans group or TABLE 10. Overview of therpy for endocarditis caused by viridans group or streptococcus bovis streptococcus bovisRegimen Regimen Dosage and route Duration(per type of valve)Dosage and route Duration(per type of valve) Highly penicillin-sensitive organismsHighly penicillin-sensitive organismsPenicillin G 12-18 million U/24 h either 4 weeks for native valve Penicillin G 12-18 million U/24 h either 4 weeks for native valve continuous or 4-6 doses 6 weeks for prosthetic continuous or 4-6 doses 6 weeks for prostheticORORCeftriaxone sodium 2 g/24 h IV/IM in 1 dose 4 weeks for native valveCeftriaxone sodium 2 g/24 h IV/IM in 1 dose 4 weeks for native valve 6 weeks for prosthetic 6 weeks for prostheticORORPenicillin G plusPenicillin G plus Gentamicin Gentamicin Penicillin G 12-18 million U/24 h either 2 weeks for native valve Penicillin G 12-18 million U/24 h either 2 weeks for native valve Continuous or 6 divided doses 6 weeks for prosthetic Continuous or 6 divided doses 6 weeks for prosthetic Gentamicin 3 mg/kg per 24h IV/IM in 1 dose 2 weeks for either Gentamicin 3 mg/kg per 24h IV/IM in 1 dose 2 weeks for either你沤寨戊扁才差勤帖惊翘循渠溃已网否才詹防棚捕迫坎也暖迁肖移往玩昭感染心内膜炎进展及指南感染心内膜炎进展及指南19抗微生物治疗Regimen Regimen Dosage and route Duration(per type of valve)Dosage and route Duration(per type of valve)ORORCeftriaxone sodiumCeftriaxone sodium plus gentamicin plus gentamicin Ceftriaxone 2 g/24 h IV/IM in 1 dose 2 weeks for native valve Ceftriaxone 2 g/24 h IV/IM in 1 dose 2 weeks for native valve 6 weeks for prosthetic 6 weeks for prosthetic Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 weeks for either Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 weeks for eitherORORVancomycin 30mg/kg per 24 h in 2 equal doses 4 weeks for native valveVancomycin 30mg/kg per 24 h in 2 equal doses 4 weeks for native valve to maximum of 2 g/24 hrs 6 weeks for prosthetic to maximum of 2 g/24 hrs 6 weeks for prosthetic Relatively penicillin-resistant organismsRelatively penicillin-resistant organisms(Penicillin or ceftriaxone) plus gentamicin(Penicillin or ceftriaxone) plus gentamicin Penicillin G 24million U/24 h either continuously 4 weeks for native valve Penicillin G 24million U/24 h either continuously 4 weeks for native valve Or 4-6 equally divided dose 6 weeks for prosthetic Or 4-6 equally divided dose 6 weeks for prosthetic秤窝乘修柑谬咖靳阐仇货濒覆芭抨赶叔抚柏懈怯情蹈茫初陇觅鲁尿货辽词感染心内膜炎进展及指南感染心内膜炎进展及指南20抗微生物治疗Regimen Regimen Dosage and route Duration(per type of valve)Dosage and route Duration(per type of valve)OROR Ceftriaxone 2 g/24 h IV/IM in 1 dose 4 weeks for native valve Ceftriaxone 2 g/24 h IV/IM in 1 dose 4 weeks for native valve 6 weeks for prosthetic 6 weeks for prosthetic PLUS PLUS Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 weeks for native valve Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 weeks for native valve 6 weeks for prosthetic 6 weeks for prostheticORORVancomycin 30 mg/kg per 24 h in 2 equal doses 4 weeks for native valveVancomycin 30 mg/kg per 24 h in 2 equal doses 4 weeks for native valve to maximum of 2 g/24 h 6 weeks for prosthetic to maximum of 2 g/24 h 6 weeks for prosthetic 埂嫁押晕额鸿脊嘻烃价急拽氦漂祸邪拉默疹缝座舆戒曳纯飞迪胆胺宽涕犯感染心内膜炎进展及指南感染心内膜炎进展及指南21抗微生物治疗v营养变异性链球菌（NVS）及青霉素高度耐药者：万古6周+庆大6周v肺炎链球菌：青霉素4周或头孢曲松4周v耐青霉素者：头孢噻肟4周或万古4周或头孢曲松+万古4周汁赋未擞韦畦累漂榷多肿姜保乓赂庆佑荷覆吝蘑空钮筛炎窖枪婆些舵税承感染心内膜炎进展及指南感染心内膜炎进展及指南22肠球菌治疗方案（一）vRegimen Dosage and route  Duration v v Susceptible to penicillin,gentamicin,and vancomycinvAmpicillin sodium                   12g/24 h IV in 6 doses                                                 4~6 weeksvORvPenicillin G                 18-30million U/24h either continuously or 6 doses               4~6 weeksv   PLUSv  Gentamicin                   3 mg/kg per 24h IV/IM in 3 equal doses                              4~6 weeksvOR  vVancomycin               30 mg/kg per 24h IV in 2 equally divided doses                        6 weeksv  PLUSv  Gentamicin                     3mg/kg per 24h IV/IM in 3 equal doses                                 6 weeksv Susceptible to penicillin, streptomycin, vancomycin, but resistant to gentamicinvAmipicillin sodium               12 g/24h IV in 6 doses                                                      4~6 weeksvORvPenicillin G                 18-30 million U/24h either continuously or 6 doses                4~6 weeks  v  PLUSv  Streptomycin sulfate       15mg/kg per 24h IV/IM in 2 equal doses                            4~6 weeksvORvVancomycin                     30mg/kg per 24h IV in 2 equally divided doses                    6 weeksv  PLUSv  Streptomycin sulfate        15mg/kg per 24h IV/IM in 2 equal doses                            6 weeks 羚因井涨形耳烽渠炕腆渊观最涩贬卓蒸搓烽俞渗泰迟福陌酒麓锹姆游撵揩感染心内膜炎进展及指南感染心内膜炎进展及指南23肠球菌治疗方案（二）v Regimen                                        Dosage and route                                                  Duration v Susceptible to aminoglycosides and vancomycin but resistant to penicillinvBeta-lactamase producing strainv  Ampicillin-sulbactam(舒巴坦舒巴坦)            12g/24h IV in 4 doses                                         6 weeksv     PLUSv     Gentamicin                       3mg/kg per  24h IV/IM in 3 equal doses                           6 weeksv     OR  v     Vancomycin                     30mg/kg per 24h IV in 2 equally divided doses               6 weeksv     PLUSv     Gentamicin                       3mg/kg per 24h IV/IM in 3 equal doses                            6 weeksvIntrinsic penicillin resistancev  Vancomycin                        30mg/kg per 24h IV in 2 equally divided doses                6 weeksv     PLUSv     Gentamicin                         3mg/kg per 24h IV/IM in 3 equal doses                           6 weeks v vResistant to penicillin, aminoglycosides, and vanvomycinvE.faecium (屎肠球菌）屎肠球菌）v  Linezolid(利钠唑胺利钠唑胺)              1200mg/24h IV/po in 2 equal doses                                ≥8weeksvE.faecalis (粪肠球菌）粪肠球菌）v  Ceftriaxone sodium               2g/24h IV/IM in 1 doses                                                 ≥8weeksv  PLUSv  Ampicillin sodium                   12g/24h IV in 6 doses                                                    ≥8weeks蔑奔孰雄竣更经排寿闰截愉昏葫忧娥瀑枪器垮炬笆棕酌滔绪沸析站磅膨忘感染心内膜炎进展及指南感染心内膜炎进展及指南24葡萄球菌IE抗菌素应用 TABLE 12. Oerview of therapy for endocarditis caused by staphylococcus      Regimen                        Dosage and route                                 Duration                                               Methicillin-susceptible organisms(native valves)Nafcillin(新青新青ⅢⅢ) or oxacillin     12g/24h IV in 4-6 doses             6 weeks  With option of gentamicin  Gentamicin            3mg/kg per 24h IV/IM in 2 or 3 doses         3-5 daysORCefazolin  With option of gentamicin     6g/24h in 3 divided doses            6 weeks  Gentamicin            3mg/kg per 24h IV/IM in 2 or 3 doses         3-5 days                                       Methicillin-resistant organisms(native valves)Vancomycin     30mg/kg per 24h in 2 equally divided doses      6 weeks 夷篱藕墟阁馁鞘瓦误古欠丧嗅脊酝肺哎琴傅沂栓叹装叫抢缔闪口兔震衷墟感染心内膜炎进展及指南感染心内膜炎进展及指南25葡萄球菌IE抗菌素应用TABLE 12. Oerview of therapy for endocarditis caused by staphylococcus TABLE 12. Oerview of therapy for endocarditis caused by staphylococcus Regimen Dosage and route DurationRegimen Dosage and route Duration Methicillin-susceptible organisms (prosthetic material)Methicillin-susceptible organisms (prosthetic material)Nafcillinor oxacillin 12g/24h IV in 4-6 doses ≥6 weeksNafcillinor oxacillin 12g/24h IV in 4-6 doses ≥6 weeks PLUS PLUSRifampin 900mg/24h IV/PO in 3 doses ≥6 weeksRifampin 900mg/24h IV/PO in 3 doses ≥6 weeks PLUS PLUSGentamicin 3mg/kg per 24h IV/IM in 2 or 3 equal doses 2 weeks Gentamicin 3mg/kg per 24h IV/IM in 2 or 3 equal doses 2 weeks Methicillin-resistant organisms (prosthetic material)Methicillin-resistant organisms (prosthetic material)Vancomycin 30mg/kg per 24h in 2 equal doses to ≥6 weeksVancomycin 30mg/kg per 24h in 2 equal doses to ≥6 weeks maximum of 2g/24h maximum of 2g/24h PLUS PLUSRifampin 900mg/24h IN/PO in 3 doses ≥6 weeksRifampin 900mg/24h IN/PO in 3 doses ≥6 weeks PLUS PLUSGentamicin 3mg/kg per 24h IV/IM 2 or 3 equal doses 2 weeksGentamicin 3mg/kg per 24h IV/IM 2 or 3 equal doses 2 weeks  砖讲哇棒行删豢逃犊秉膛宾笆淬滥炒熊使踞孟冀溶杨厢鸟逝偷炮采方木率感染心内膜炎进展及指南感染心内膜炎进展及指南26沙门氏菌IE抗菌素应用 三代头孢或氨苄青霉素 6周 v +庆大霉素 2周 v 或链霉素 4周 v绿脓杆菌 妥布霉素 8周v + v 替卡西林 8周v 或v 先锋必 8周v 煎夹好临疡唁爵滩末反串同鸭鸦椎曝潦爬进肆联僻栋诛也弗句幢撞它女荣感染心内膜炎进展及指南感染心内膜炎进展及指南27流感嗜血杆菌、放线杆菌IE抗菌素应用TABLE 13. Overview of therapy for either native or prosthetic endocardiiti            causedby HACEK organisems         Regimen                        Dosage and route                            DurationCeftriaxone sodium         2g/24h IV/IM in 1 dose                           4 weeks ORAmpicillin-sulbactam       12g per 24h IV in 4 equally                   4 weeks                                                 divided doses    ORCiprofloxacin         1000mg/24h PO or 800mg/24h           4 weeks for native valve                                            IV in  equal doses                    6 weeks for prosthetic舅酱吮痢诧渴阁院朱琵长丸漾滨愁胚翠日崖轴德笋草龙腆膛铡涌陶惧翟苑感染心内膜炎进展及指南感染心内膜炎进展及指南28霉菌性IE治疗方案 二性霉素B 1~2周 或 +手术 氟康唑（大扶康） 术后 氟康唑＋利福平6～8周耍怯椰略半搜爬厕卷俗接肄墅茵骸铆蝴甥齐商邑绅沈称患卯臃喇幅音观骸感染心内膜炎进展及指南感染心内膜炎进展及指南29血培养阴性IE抗菌疗法 TABLE 14. Overview of therapy for culture negative native or prosthetic endocarditis Regimen                          Dosage and Route                             Duration                                               Native        valveAmpicillin-sulbactam           12g/24h IV in 4 dose                          4-6 weeks  PLUS  Gentamicin sulfate           3mg/kg per 24h IV/IM in 3 doses        4-6 weeksORVancomycin                       30mg/kg IV in 2 doses                         4-6 weeks  PLUS  Gentamicin sulfate           3mg/kg per 24h IV/IM in 3 doses        4-6 weeks  PLUS  Ciprofloxaxin（环丙沙星）（环丙沙星）    1000mg/24h po or 800mg              4-6 weeks                                                     IV in 2 equal doses                               Prosthetic valve(early, ＜＜1 year)Vancomycin                    30mg/kg per 24h IV/IM in 2 doses          6 weeks  PLUS  Gentamicin sulfate        3mg/kg per 24h IV/IM in 3 doses          2 weeks  PLUS  Cefepime                      6g/24h IV in 3 doses                                6 weeks    PLUS  Rifampin                       900mg/24h PO/IV in 3 doses                  6 weeks贾鹤酞持兜嚏印办油劈牧海莆宪砧父架浓刃顺各综妮贡乍伴辰名级岸妓善感染心内膜炎进展及指南感染心内膜炎进展及指南30血培养阴性IE抗菌疗法 Regimen                              Dosage and Route                     Duration                                   Prosthetic valve (late,＞＞1 year)Suspected bartonella.        culture negativeCeftriaxone sodium          2g/24h IV/IM in 1 dose                    6 weeks  PLUS  Gentamicin sulfate         3mg/ka per 24h in 3 doses             2 weeks  OPTINAL  Doxycycline                   200mg/24h IV/PO in 2 doses          6 weeksDocumented bartonella.         culture positive  Doxycycline                 200mg/24h IV/PO in 2 doses             6 weeks  PLUS  Gentamicin sulfate      3mg/kg per 24h IV/IM in 3 doses       2 weeks  OR  Rifampin                      600mg/24h IV/PO in 2 doses            2 weeks朗倪侍吠言嗜掀膊噬分蹄秘厂辐牟坐驯盖棘饱吮撇奴艳峻扫吊蹄嘱曝焊周感染心内膜炎进展及指南感染心内膜炎进展及指南31预防 v高危患者：人工瓣膜 、曾是IE患者、紫绀型先心病、主肺动脉分流术后v中危患者：其它先心、获得型瓣膜病、肥厚性心肌病、二尖瓣脱垂、主动脉瓣退行性变疤梁馒放狭钨矩啮冠蓑问盯地夏锰娱蛔师庚獭亿租鹏茹瞳走伍烧簧打俄岳感染心内膜炎进展及指南感染心内膜炎进展及指南32预 防vTABLE 15. Prophylactic regimens for dental, oral, respiratory tract, or esophageal procedures(follow-up dose no longer redcommended)vⅠⅠ Standard general prophylaxis for patients at risk:v     Amoxicillin:Adults, 2.0g (children, 50mg/kg) given orally 1 hour before peocedure.vⅡⅡ Unable to take oral medications:v     Ampicillin: Adults, 2.0 g  (children, 50mg/kg) given IM or IV within 30 minutes beforev      procedure.vⅢⅢ  Amoxicillin/ ampicillin/penicillin allergic patients:v     Clindamycin(克林霉素克林霉素): Adults, 600mg (children, 20mg/kg) given orally 1 hour before v       peocedure.v     -OR-v     Cephalexin* (头孢氨苄头孢氨苄) or Cefadroxil*（头孢羟氨苄）（头孢羟氨苄）: Adults, 2.0 g (children 50mg/kg) v     orally 1 hour before  peocedure. vⅣⅣ  Amoxicillin/ ampicillin/penicillin allergic patients unable to take oral medications：：v     Clindamycin(克林霉素克林霉素): Adults, 600mg (children, 20mg/kg) IV within 30 minutes before  v      peocedure.-OR-v     Cefazolin*：：Adults, 1.0 g (children 25 mg/kg) IM or IV within 30 minutes before procedure.v漫缄帐谈俞篆率鹿爪拭掳靶摘侮荫咬剔赫祁霞犁效闲答烛药对医阻扬树郡感染心内膜炎进展及指南感染心内膜炎进展及指南33预 防TABLE 16. Prophylactic regimens for genitourinary/gastrointestinal proceduresⅠⅠ.High-risk patients:    Ampicillin plus gentamicin: Ampicillin(adults,2.0g;chikdren 50mg/kg) plus    gentamicin 1.5mg/kg(for both adults and children, not to exceed 120 mg) IM or     IV  within 30 minutes before starting peocedure. 6 hours later, ampicillin(adults,    1.0g;children,25 mg/kg) IM or IV, or amoxilillin (adults,1.0g; children, 25mg/kg)     orally.ⅡⅡ.High-risk patients allergic to ampicillin/amoxicillin:    Vancomycin plus gentamixcin 1.5mg/kg(for both adults and children, not to     exceed 120 mg) IM or IV. Complete injection/infusion within 30 minutes before    starting  procedure.ⅢⅢ.Modetare-risk patients:    Amoxicillin: Adults, 2.0g(children 50mg/kg) orally 1 hour before procedure-OR-    Ampicillin: Aduuls, 2.0g(children 50mg/kg) IM or IV within 30 minutes before     starting  procedure.ⅣⅣ.Moderate-risk patients allergic to ampicillin/amoxicillin:    Vancomycin: adults, 1.0g (children 20mg/kg) IV over 1-2 hours. Complete     infusion  within 30 minutes of starting the procedure.痒另恩税幻帚均躺镑旋族辕消情佐任娟跪布摔枫嘘前栅橙焰辞钵盎贝谨妨感染心内膜炎进展及指南感染心内膜炎进展及指南34参考文献1.Baddour LM, Wilson WR, Bayer AS, et,al. AHA Scientific Statement: Infective endocarditis:diagnosis,antimicrobial therapy, and management of complications: a statement for health-care professionals from the committee on Rheumatic Fever, Endocarditis,and Kawasaki Disease, Council on Clinical Cardiology, Stroke, and Cardiovascular surgery and anesthesia, American Heart Association—ececutive summary : endorsed by the Infectious Diseases Society of America.1.Circulation 2005;111(23):3167-84. 2.The Task Force Members, Dieter Horstkotte, Ferenc Follath, Erno Gutschik, et,al. Guidelines on Prevention, Diagnosis and Treatment of Infective Endocarditis—Executive Summary. Europe Heart Journal2004;25(3):267-276.3.Thomas M. Bashore, Christopher Cabell, Vacne Fowler. Update on Infective Endocarditis. Current problems in Cardiology. 2006,31(4):265-352.漆琴忿矣喇釉到饼褂蒲捧淫卵虑剖仙给闰哦娩氮她氨妻易炬怂尺演掇诽做感染心内膜炎进展及指南感染心内膜炎进展及指南35 谢 谢 ！ 屯局恬俱龟泻脂欺霸苏大岿桶译和斯乃鲍心嫉铂镁汝呆糖缝管柜橙延爸灵感染心内膜炎进展及指南感染心内膜炎进展及指南36。