重视儿童感染性心内膜炎的诊治

doi:10.12372/jcp.2024.24e0887

Abstract

Abstract:

Infective endocarditis (IE) is an infection originating from the endocardium and/or heart valves. Although the overall incidence of IE in children is relatively low, it carries a high mortality once happened. Timely identification and prompt treatment are crucial to avert adverse clinical outcomes. In recent issue, Prof. Cao et al. reported a case of IE caused by methicillin-resistant Staphylococcus aureus after congenital heart disease operation (J Clin Pediatr Vol.42 No.8 Aug. 2024), which underscored the complexities and challenges involved in diagnosing and managing IE in pediatric patients. Herein, we will further discuss the clinical features, antibiotic options, and optimal timing of surgical intervention for pediatric IE, aiming to enhance clinicians' understanding of this condition.

Key words: infective endocarditis, diagnosis, treatment, child

CHENG Zhenli, ZHANG Zhenzhen. Diagnosis and treatment of infectious endocarditis in children[J].Journal of Clinical Pediatrics, 2024, 42(10): 902-906.

Figures/Tables 2

病理学标准	临床标准
病理学标准	主要标准	次要标准
对患者赘生物、心脏组织、取出的人工瓣膜或缝合环、升主动脉移植物（兼有瓣膜受累证据）、心内植入式电子装置、栓子）样本进行检测，出现以下情况： ①具备IE的临床表现，同时检测出病原： ②病理学检查显示活动性急性、亚急性或慢性心内膜炎	1.微生物学标准（符合以下1项） ①血培养阳性：－从至少2套来自不同部位的血培养标本中分离出典型IE病原体－从至少3套来自不同部位的血培养标本中分离出少见或罕见IE病原体 ②实验室检查阳性－血液PCR或其他血液核酸检测发现贝纳柯克斯体、巴通体或惠普尔养障体－单次血培养分离出贝纳柯克斯体，或贝纳柯克斯体的IgG抗体滴度>1∶800 －间接免疫荧光分析法检出汉赛巴通体或五日热巴通体的IgM和IgG抗体，IgG滴度≥1∶800 2.影像学标准（符合以下任意1项）： ①超声心动图和/或心脏CT：－查见赘生物、瓣膜/瓣叶穿孔、瓣膜/瓣叶瘤、脓肿、假性动脉瘤或心内瘘－与先前影像相比，超声心动图发现明显的新发瓣膜反流；既存瓣膜反流加重或改变不算－与先前影像相比，新出现人工瓣膜部分开裂 ② PET/CT －以下部位代谢活动异常：自体瓣膜或人工瓣膜（植入后至少3个月）、升主动脉移植物（兼有瓣膜受累证据）、心内装置导线或其他人工材料 3.外科主要指标在既没有主要影像学标准，也没有随后的组织学或微生物学确认的前提下，心脏手术中直接探查证实的IE。	1.易感因素：既往IE 病史、人工瓣膜、瓣膜修复病史、先天性心脏病、中度及以上瓣膜反流或狭窄、血管内心内植入式电子装置、肥厚梗阻性心肌病、注射毒品 2.发热：体温高于38 ℃ 3.血管症状：动脉栓子、脓毒性肺梗死、脑或脾脓肿、感染性动脉瘤、颅内出血、结膜出血、Janeway 病变、化脓性紫癜的临床或影像学证据。 4.免疫相关症状：类风湿因子阳性、Olser结节、Roth斑、肾小球肾炎 5.不符合主要指标的微生物证据：血培养阳性且微生物符合IE，但未达到主要指标的要求；从心脏组织、心脏假体或栓子以外的无菌部位培养出符合IE的微生物、PCR或其他核酸检测阳性结果；仅PCR发现瓣膜或导线标本存在皮肤细菌，无其他临床或微生物学支持证据 6.影像学指标：PET/CT检查在植入人工瓣膜、升主动脉移植物（伴有瓣膜受累证据）、心内装置导线或其他假体材料的3个月内检测到异常代谢活动 7.查体（超声心动图不可用）：听诊发现新的瓣膜反流，原有杂音变化或加重不算。
确诊	符合2项主要临床标准；符合1项主要临床标准+3项次要临床标准符合5项次要临床标准
疑似诊断	符合1项主要临床标准+1项次要临床标准；符合3项次要临床标准
排除诊断	有其他明确的诊断能够解释体征和症状；抗生素治疗<4日但未复发抗生素治疗≤4日之后，手术或尸检未发现IE的病理学证据；不满足疑诊或确诊IE的临床标准

类型	病原体	AHA	ESC
自体瓣膜感染	草绿色链球菌、牛链球菌（青霉素敏感）	青霉素/氨苄西林/头孢曲松；万古霉素；总疗程4周	青霉素/阿莫西林/头孢曲松；万古霉素；总疗程4周
	草绿色链球菌、牛链球菌（青霉素耐药）	青霉素/氨苄西林/头孢曲松+庆大霉素（前2周）；万古霉素；总疗程4周	青霉素/阿莫西林/头孢曲松+庆大霉素（前2周）；万古霉素+庆大霉素（前2周）；总疗程4周
	MSSA	萘夫西林/苯唑西林/头孢唑林；总疗程4~6周	苯唑西林/氯唑西林/氟氯西林/头孢唑林/头孢噻肟；达托霉素+头孢洛林/磷霉素；总疗程4~6周
	MRSA	万古霉素，总疗程6周	万古霉素；达托霉素+头孢洛林/磷霉素/氯唑西林，总疗程4~6周
	HACEK微生物	头孢曲松/头孢噻肟；氨苄西林+庆大霉素；总疗程4周	头孢曲松；氨苄西林+环丙沙星（成人）；总疗程4周
	肠球菌	头孢曲松+氨苄西林，总疗程6周；青霉素G/氨苄西林+庆大霉素，总疗程4~6周	头孢曲松+氨苄西林/阿莫西林；青霉素G/氨苄西林+庆大霉素（前2周），总疗程6周
植入物感染	草绿色链球菌、牛链球菌（青霉素敏感）	青霉素/氨苄西林/头孢曲松+庆大霉素（前2周）；万古霉素；总疗程6周	青霉素/氨苄西林/头孢曲松；万古霉素；总疗程6周
	草绿色链球菌、牛链球菌（青霉素耐药）	青霉素/氨苄西林/头孢曲松+庆大霉素；万古霉素；总疗程6周	青霉素/阿莫西林/头孢曲松+庆大霉素（至少2周）；万古霉素+庆大霉素（前2周）；总疗程4周
	MSSA	萘夫西林/苯唑西林/头孢唑林+利福平+庆大霉素（前2周）；总疗程≥6周	苯唑西林/氯唑西林/氟氯西林/头孢唑林+利福平+庆大霉素（前2周）；达托霉素+利福平+庆大霉素（前2周）；总疗程≥6周
	MRSA	万古霉素+利福平+庆大霉素（前2周）；总疗程≥6周	万古霉素/达托霉素+利福平+庆大霉素（前2周）；总疗程≥6周

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Diagnosis and treatment of infectious endocarditis in children

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