Brief introduction of acute infective endocarditis

Directory 1 Pinyin 2 English Reference 3 Overview 4 Disease Names 5 English Names 6 Alias Acute Infectious Endocarditis 7 Classification 8 ICD No.9 Epidemiology 10 Etiology of Acute Infectious Endocarditis 165438+ 0 Pathogenesis 12 Clinical Manifestations of Acute Infectious Endocarditis12./KLOC Common manifestations of acute infective endocarditis/KOOC-0/2.2 Special types of acute infective endocarditis/KOOC-0/2 help/KOOC-0/6 diagnosis of acute infective endocarditis/KOOC-0/7 differential diagnosis/KOOC-0/8 treatment of acute infective endocarditis/KOOC-0/8. 9 prognosis 20 prevention of acute infective endocarditis 20. 1 elimination of inducement and treatment reasons 20.2 health education 20.3 preventive drugs 2 1 related drugs accessories: 1 treatment of acute infective endocarditis acupoints 1 pinyin jí xing g m n r m n x x x n m× n x xing x and né i m ó y.

2 English reference acute infective endocarditis

Acute inclusion encephalitis

Acute infective endocarditis (AIE) is a part of serious systemic infection, and the pathogenic microorganisms are very toxic, such as Staphylococcus aureus (the most common, accounting for more than 50%), hemolytic streptococcus, meningococcus and Escherichia coli. Usually, pathogenic bacteria first cause suppurative inflammation in a certain part of the body (such as suppurative osteomyelitis, carbuncle, puerperal fever, etc.). ), and when the body's resistance drops (such as tumor, heart surgery, immunosuppression, etc.). ), pathogenic bacteria invade the blood stream, causing sepsis and invading the endocardium. This type of endocarditis mainly occurs on the normal endocardium and mainly invades the single aortic valve or mitral valve. Clinically, it is less common than subacute infective endocarditis, and most patients have no history of heart disease. Because the symptoms of systemic infection are serious, it can cover up the clinical manifestations of acute infective endocarditis. The prognosis of this disease depends on the treatment time, the ability of antibiotics to control primary bacteria, the degree of heart valve damage and the resistance of patients, Staphylococcus aureus, hemolytic streptococcus, pneumococcus, gram-negative bacilli and so on. Because of the virulence of bacteria, the infected valve leaves will be damaged quickly. In the process of antibiotic treatment, if heart failure or primary heart failure worsens, new murmurs or murmur changes appear, and embolism occurs, these are all signs that the infection is out of control, so it is necessary to consider replacing antibiotics. After strengthening supportive treatment and improving the general condition, strive for early surgery. If the delay is too long, the condition may deteriorate gradually, and the opportunity for surgery is often lost.

4 Name of disease Acute infective endocarditis

5 English name acute infective endocarditis

6 acute infective endocarditis alias infective endocarditis

7 Classification Cardiovascular Medicine > Endocardial Diseases

8 ICD number I33.0

Epidemiological acute infective endocarditis can occur in patients without heart disease or after artificial valve replacement. In recent years, with the extensive development of various trauma diagnosis and treatment techniques and the increasing number of intravenous drug users, the number of patients with infective endocarditis without heart disease has also increased. The incidence of the disease is inconsistent at home and abroad, and there is still a lack of accurate and reliable data. Domestic report 1.7/65438+ million ~ 4.2/65438+ million, foreign report 1.6/65438+ million ~ 6.0/65438+ million. The incidence of this disease has the characteristics of age, and the incidence rate of infants and young children is low, with an annual incidence rate of 0.34/65438+ 10,000, accounting for 1/4500 of the number of hospitalized children in pediatrics. After the age of 30, it gradually increases, reaching15/10000 ~ 30/65438+10,000 at the age of 60 ~ 80.

10 etiology of acute infective endocarditis Almost all bacteria can cause acute infective endocarditis. Acute infective endocarditis is mostly caused by virulent bacteria invading the endocardium, such as Staphylococcus aureus, Pneumococcus, Meningococcus, Streptococcus pyogenes, Influenza Bacillus, Proteus, Escherichia coli, etc. These bacteria have strong virulence, acute onset and serious illness, and are often secondary to infections in other parts, which are part of systemic infections, such as meningitis, pneumonia and thrombophlebitis. Sometimes accompanied by metastatic purulent lesions of other organs. Usually occurs in a normal heart.

1 1 The pathogenesis of acute infective endocarditis is different from that of subacute infective endocarditis, with 50.0% ~ 60.0% occurring on normal heart valves. Pathogenic microorganisms generally come from active lesions of skin, muscles, bones or lungs, and are highly toxic and corrosive (such as Staphylococcus aureus, Group A streptococcus, Streptococcus pneumoniae, Haemophilus influenzae, etc.). ) and adhesive, and can directly invade the valve and cause infection.

In the early stage, the edge of valve atresia may be covered with dirty yellow purulent exudate, and the valve may be destroyed. After the necrotic tissue falls off, it forms an ulcer, and there are many thrombi at the bottom. Thrombosis, necrotic tissue and a large number of bacterial colonies mixed together to form warts (figure 1). This kind of wart is generally large, soft in texture, grayish yellow or light green, easy to fall off and form embolus with bacteria, which can cause infarction of some organs in the great circulation and multiple embolic small abscesses (septicemia). In severe cases, valve rupture or perforation and/or chordae tendineae rupture may occur, leading to acute heart valve insufficiency and sudden death. Microscopically, the tissue at the bottom of the valve ulcer was necrotic, a large number of neutrophils infiltrated and granulation tissue was formed. Thrombosis is mainly composed of platelets and cellulose, mixed with necrotic tissue and a large number of bacteria.

Fig. 1 acute bacterial endocarditis

Warts on the ventricular surface of aortic valve (↑)

In the past, the course of this type of endocarditis was very short, and patients could die within weeks to months. In recent years, due to the wide application of antibiotics, the mortality rate has been greatly reduced.

Clinical manifestations of acute infective endocarditis 12 Acute infective endocarditis often has the following characteristics:

12. 1 The common manifestations of acute infective endocarditis (1) often include acute purulent infection, recent surgery, trauma, puerperal fever or instrumental examination.

(2) Sudden onset: the main manifestations are signs of sepsis, such as chills, high fever, hyperhidrosis, weakness, skin and mucous membrane bleeding, shock, vascular embolism and wandering abscess, and the original infection focus can be found.

(3) Heart: murmurs can appear in a short time, which are changeable and rough in nature. Because the valve injury is generally serious, it will produce signs of acute valve insufficiency. Clinically, mitral valve and/or aortic valve are most easily involved, and pulmonary valve and/or tricuspid valve may be involved in a few cases, resulting in corresponding valve insufficiency. In addition, it often causes acute cardiac insufficiency. If the lesion mainly invades the mitral valve or aortic valve, it will show acute left ventricular dysfunction and pulmonary edema. If the lesion involves tricuspid valve and pulmonary valve, signs of right heart failure may appear; If both left and right heart valves are involved, there may be signs of heart failure.

(4) If vegetation falls off, embolus carrying bacteria can cause multiple embolism and metastatic abscess, and cause corresponding clinical manifestations.

12.2 special acute infective endocarditis 12.2. 1 prosthetic valve infective endocarditis (PVIE) is one of the serious complications after heart valve replacement. The incidence rate was 1.4% ~ 3. 1%. The incidence of prosthetic valve infective endocarditis after double valve replacement is higher than that after single valve replacement. Aortic valve is more likely to occur than mitral valve, and patients with infective endocarditis before operation are more likely to get sick. The incidence of mechanical valve is similar to that of biological valve, but the risk of mechanical valve infection is higher within 12 months after operation.

According to the occurrence time of prosthetic valve infective endocarditis, it can be divided into early and late prosthetic valve infective endocarditis. Early stage refers to those who have symptoms within 60 days after operation. Pathogenic microorganisms are mainly Staphylococcus, including Staphylococcus epidermidis and Staphylococcus aureus. Diphtheria, other gram-negative bacilli and fungi are also common. Advanced stage refers to patients who develop endocarditis after 60 days after operation, and the pathogenic microorganisms are similar to those of natural valve infective endocarditis The purpose of staging is to distinguish surgical complications (early stage) from social infections (late stage). However, in fact, many patients who developed the disease from 60 days after operation to 1 year were probably acquired during hospitalization, but the onset time was delayed. After operation 1 year or more, the infection may mainly come from the operation of oral cavity, gastrointestinal tract and urinary tract, skin injury and infection.

The pathological damage of prosthetic valve infective endocarditis is different from that of autologous valve infective endocarditis, which is mostly confined to valve leaflets. The infection of mechanical valve is often the injury at the junction of valve annulus, which easily spreads to the tissues around the valve annulus, causing myocardial abscess, fistula, artificial valve rupture and perivalvular fistula, leading to serious hemodynamic abnormalities. Infective endocarditis of biological valve is mainly the destruction and perforation of valve leaflet, followed by the damage of tissue around the valve annulus similar to mechanical valve.

The clinical manifestations of prosthetic valve infective endocarditis are similar to those of autologous valve infective endocarditis, but the early symptoms and signs of prosthetic valve infective endocarditis are easily concealed by surgery or other complications in the short term after valve replacement.

12.2.2 Right infective endocarditis (RHIE) Right infective endocarditis is mainly found in intravenous drug users, and other rare causes include right cardiac catheterization, cardiac pacing and congenital heart disease. With the increase of intravenous drug users, the incidence of infective endocarditis caused by prosthetic valves has an obvious upward trend. According to statistics, the risk of infective endocarditis among intravenous drug users is 2% ~ 5% every year, which is significantly higher than that of patients with rheumatic heart valve disease or artificial valve replacement. The incidence of right heart infective endocarditis is significantly lower than that of left heart infective endocarditis, which may be related to the following factors: ① rheumatic heart disease and congenital heart disease rarely affect the right heart valve; ② The pressure of the right heart is lower than that of the left heart, and the valve endothelium is not easy to be damaged; ③ Low oxygen content in right heart blood is not conducive to bacterial growth. Most intravenous drug users do not have heart disease, which may be related to drug pollution and non-compliance with aseptic operation. Staphylococcus aureus is the main pathogenic microorganism of prosthetic valve infective endocarditis, followed by streptococcus, fungi and gram-negative bacilli. Vegetation is mostly located in tricuspid valve, right ventricular wall or pulmonary valve. Most cases had a history of intravenous drug abuse before onset, and a few cases had a history of right heart catheterization or congenital heart disease before onset. Patients may have fever, cough, expectoration, hemoptysis, chest pain and shortness of breath. Reflux murmur of tricuspid valve and/or pulmonary valve can be heard, and enlargement of heart or right heart failure is not common. Some cases may be complicated with clinical manifestations of left heart infective endocarditis and systemic arterial embolism.

12.2.3 mycotic endocarditis (ME) has been on the rise in recent years. At present, many kinds of fungi are known to cause fungal endocarditis, among which Candida (especially Candida albicans), Histoplasma, Cryptococcus and Aspergillus are common in clinic. Fungi, like bacterial endocarditis, mostly occur on the basis of organic heart disease. The clinical manifestations of bacterial endocarditis can be seen in fungal endocarditis, but fungal endocarditis can have the following characteristics: ① It mostly occurs in the elderly and infirm who use antibiotics, immunosuppressive drugs or hormones for a long time, and those who insert venous catheter or catheterization for a long time after valve repair or replacement; ② The antibiotic treatment was ineffective or even aggravated, and the blood culture was negative for many times: ③ The course of disease was long, which could reach half a year or 1 year, and arterial embolism was common, especially in lower limbs; ④ It may be accompanied by uveitis or endophthalmitis; ⑤ Evidence of systemic fungal infection. For patients with fungal endocarditis, besides the relevant examination according to SIE, blood fungal culture must also be carried out. Serological tests, such as immunoprecipitation or agglutination tests, can be used to culture negative fungal endocarditis. In addition, the detection of candida in urine without indwelling catheter also has certain diagnostic value.

Complications of acute infective endocarditis 13 Acute infective endocarditis often has complications such as heart failure, embolism, metastatic abscess and infectious aneurysm.

13. 1 Patients with acute infective endocarditis due to heart failure are most prone to mitral and aortic valve diseases, and the valves are seriously damaged, leading to acute valve insufficiency, which may lead to acute left ventricular insufficiency and pulmonary edema. If the lesion involves tricuspid valve and pulmonary valve, right heart failure may occur. If both left and right heart valves are involved, there may be signs of heart failure.

13.2 embolism If vegetation falls off, embolus carrying bacteria can cause multiple embolism. The most common parts of brain, kidney, spleen and coronary artery can produce corresponding clinical manifestations.

13.3 the vegetation of acute infective endocarditis with metastatic abscess is easy to fall off, and these embolus with bacteria can cause abscess formation with blood reaching all parts of the body.

13.4 infectious aneurysms are mostly caused by severe infection, and pathogenic microorganisms erode the elastic tissue of the arterial wall, resulting in local dilatation of the artery. Aneurysms that occur in smaller arteries have a better prognosis, while those that occur in larger arteries have a worse prognosis once they rupture.

Laboratory examination 14 1. The white blood cells increased obviously, and the neutrophil nucleus moved to the left, which may be toxic particles. In addition, progressive anemia may occur.

2. Blood culture is easy to obtain positive pathogenic bacteria, and most of them are purulent bacteria.

15 Echocardiography showed valve damage caused by endocardial vegetation and its hemodynamic disorder.

16 acute infective endocarditis can be diagnosed according to clinical manifestations, echocardiography and blood culture results. Acute infective endocarditis is mainly the clinical manifestation of septicemia. Especially when there is no murmur in the heart, the disease is often covered up by primary infection and easily missed diagnosis. For fever over a week, we should pay attention to the auscultation changes of the heart, bleeding spots on the skin, embolism and so on. It is often differentiated from influenza, acute arthritis, acute purulent meningitis and acute pyelonephritis. In recent years, due to the progress of cardiac surgery and the wide application of antibiotics, atypical or special types of infective endocarditis are increasing, such as artificial valve replacement, hemodialysis or congenital heart disease correction, which increases the chance of endocarditis infection. Be vigilant for patients with fever after operation.

17 differential diagnosis of acute infective endocarditis should be differentiated from active rheumatic heart disease and septicemia caused by gram-negative bacilli of Staphylococcus aureus. When the complication embolism is prominent, it should be differentiated from cerebrovascular accident, acute glomerulonephritis, vasculitis, coronary heart disease or angina pectoris.

18 treatment of acute infective endocarditis 18.6438+0 antibiotic treatment Early use of sufficient and effective antibiotics is the key to successful treatment. The principle of treatment is early, large dose and long course intravenous injection of bactericidal drugs. The so-called early treatment means giving antibiotics immediately after etiological examination (such as continuous blood culture for 2-3 times), high dose means that the blood concentration must reach 6-8 times of the effective bactericidal concentration of serum, and long course of treatment means taking drugs for at least 4-6 weeks. Before the blood culture results come out, it is necessary to check and speculate the most likely pathogenic bacteria to use antibiotics according to clinical signs. Generally, two antibiotics should be used in combination. In view of the fact that more than 50% of acute infective endocarditis is caused by Staphylococcus aureus, penicillin G 2000 million ~ 40 million U/d is still the first choice in general (unless nosocomial infection), intravenous drip or intravenous injection by stages; Streptomycin 1 ~ 1.5g/d intramuscular injection, the above scheme is effective not only for common staphylococci, but also for AIE caused by pneumococcus, hemolytic streptococcus and meningococcus. If the symptoms improve after the above treatment, continue to use. If the symptoms do not improve after 3 days of treatment, it should be considered as drug-resistant strain infection, and semi-synthetic penicillin can be used instead, such as oxacillin, oxacillin, ampicillin, piperacillin, etc. The general dose is 6 ~ 12g/d, intravenous drip, or slow intravenous injection in 4 ~ 6 times. For patients with severe illness, the following antibiotics can be added, such as lincomycin 1.8 ~ 2.4g/d, Qingke. Rifamycin SV (rifamycin) 0.5 ~ 1.0g/d, wanmycin 2.0g/d, amikacin 0.4g/d, and cephalosporins such as cephalosporins I, II, III, V, VI and VII. Cefoxitin), cefamandole, cefotaxime, cefoperazone (cefobid) and ceftriaxone (rocephin), etc. , the general dosage is 4 ~ 6.0g/d, and there are blood culture results.

For gram-negative bacilli and enterococci endocarditis, aminoglycosides can be used in combination with β -lactams (penicillin or cephalosporins). The former includes gentamicin 654.38+0.8 million ~ 240,000 U/d, tobramycin 240 mg/d and kanamycin 654.38+0 ~ 654.48. Amikacin (amikacin 400mg/d, netilmicin 200 ~ 400 mg/d, Libomycin 1 ~ 2g/d, etc. The latter includes ampicillin 4 ~ 8g/d, carbenicillin) 10~20g/d ~ 20g/d, sulbenicillin) 8~ 12g/d+02g/d, and furbenicillin (furbenicillin).

18.2 strengthening support for symptomatic treatment can lead to a small amount of blood transfusion, freeze-dried plasma or human albumin, and various amino acids. , thus improving the general condition and enhancing the body's resistance. Appropriate use of myocardial drugs, pay attention to water and electrolyte balance, and treat patients with acute cardiac insufficiency as heart failure.

18.3 surgical treatment of infective endocarditis complicated with acute aortic or mitral insufficiency leads to serious hemodynamic disorder, and medical treatment is ineffective. We should actively fight infection, seize the opportunity of operation and strive for valve replacement.

19 prognosis acute infective endocarditis is usually caused by virulent pathogens such as staphylococcus aureus, streptococcus pyogenes, streptococcus pneumoniae and diplococcus gonorrhoeae, which often invade normal heart valves. The disease is characterized by progressive septicemia, and if it is not diagnosed and treated early, it will die within a few days to six weeks. The postoperative survival rate of prosthetic valve infective endocarditis has reached 75.0% ~ 80.0%, and the survival rate of patients with this type of disease after surgical treatment for 4 ~ 6 years is 50.0% ~ 80.0%.

20. Prevention of acute infective endocarditis 20. 1 Eliminate the inducement, treat the cause, and actively prevent and treat various infectious diseases such as oral infection, skin infection, urinary tract infection and pneumonia, so as to reduce the incidence of this disease.

20.2 Health education should focus on prevention, publicize the dangers of diseases to the masses, and advise people to stay away from drugs. It is an important way to persuade intravenous drug users to give up drugs actively and reduce infective endocarditis.

20.3 Preventive medication should start from preventing bacteremia. Many scholars have found that temporary bacteremia often occurs after tooth extraction, especially periodontal disease or simultaneous extraction of multiple teeth. Many oral bacteria can enter the blood through wounds, but Streptococcus viridis is the most common. Trauma and infection of digestive tract and urogenital system often cause bacteremia of enterococci and gram-negative bacilli. Staphylococcal bacteremia was found in skin far from the heart and in infections. Therefore, it is necessary to actively use antibiotics to prevent the disease and avoid abuse.

2 1 Related drugs: oxygen, penicillin, streptomycin, oxacillin, cloxacillin, ampicillin, piperacillin, lincomycin, gentamicin, rifamycin, vancomycin, amikacin, kanamycin, cefoxitin, cefoperazone, ceftriaxone, tobramycin, netilmicin, ribomycin, etc.

Sixteen acupoints for treating acute infective endocarditis are used to treat acute diseases. Acupoints along the Yin meridian treat blood syndrome, while acupoints along the Yang meridian treat acute pain. Function of acupoints: Acupoints are often used to treat the parts where meridians pass. ...

In the mountains of Liang Qiu, it is named Liang Qiu. Indications: Stomach pain, epigastric pain, acute gastritis, stomach spasm, acute stomach pain, intestinal diarrhea and knee swelling. ...

The point of low back pain and the midpoint of metacarpophalangeal joint, two points on one side. Indications: lumbago and leg pain, sprain, acute lumbar sprain, redness and swelling of the back of the hand, fever and pain, acute and slow convulsion in children, headache and tinnitus. ...

Acupoints are used to treat acute diseases. Acupoints along the Yin meridian treat blood syndrome, while acupoints along the Yang meridian treat acute pain. For example, taking Liang Qiu for stomachache and taking acupoints for vomiting blood. Acupoints are often used for treatment. ...

Djinn is associated with abdominal distension, intestinal cutting pain, bowel sounds, diarrhea, umbilical abdominal pain, gastroenteritis, acute enteritis, acute simple appendicitis, dysentery, acute bacillary dysentery and drinking. ...

Treatment of acute infective endocarditis with multiple points

Body surface area calculator body mass index calculation and evaluation of female safety period calculator expected date calculator normal weight gain during pregnancy medication safety classification (FDA) five elements and eight characters adult blood pressure evaluation body temperature level evaluation diabetes diet suggestion clinical biochemical common units conversion basal metabolic rate calculation sodium supplement calculator iron supplement calculator prescription common Latin abbreviations quick check pharmacokinetics common symbols quick check effective plasma osmotic pressure calculator alcohol intake calculator.