血培养阴性的感染性心内膜炎研究进展  

Progress in Infective Endocarditis with Negative Blood Cultures

作　　者：邓万俊[1] 

机构地区：[1]南华大学附属南华医院心内科,衡阳421002

出　　处：《国外医药（抗生素分册）》2011年第2期53-59,71,共8页World Notes on Antibiotics

摘　　要：血培养阴性的心内膜炎(BCNE)常见于:(1)血培养前已应用抗生素;(2)生长缓慢的苛养菌如厌氧菌、HACEK族、布氏杆菌属感染;(3)专性细胞内致病微生物如立克次体、衣原体、Tropheryma whippelii或病毒感染;(4)霉菌感染;(5)IE病程中3个月以上方采血进行血培养;(6)亚急性右心IE;(7)IE慢性病程中并发尿毒症;(8)室间隔缺损、心肌梗死后血栓形成或起搏器相关性感染导致的心室壁IE;(9)其他疾患被误诊为IE。其中最常见的原因为血培养前接受抗生素治疗,其次为来源于动物传染病的致病微生物或霉菌感染。当血培养阴性时,目前普遍采用的改良Duke标准不能得出诊断性结论。血清学检查、瓣膜组织学检查及分子生物学新技术有助于BCNE的诊断。手术切除的心脏瓣膜组织16S rDNA及23S rDNA实时PCR扩增可明显改善BCNE的诊断,并可指导抗生素治疗。BCNE治疗前应了解既往抗生素用药史、近期与动物接触史、有创操作或牙科手术史、天然瓣抑或人工瓣、瓣膜手术状况、酗酒或静脉吸毒史等,以便指导经验式抗生素治疗。应选用对致病微生物敏感的抗生素治疗。此外,BCNE患者常需瓣膜置换手术。Blood-culture-negative endocarditis （BCNE） can be found under the following circumstances： （1） prior administration of antibiotics; （2） slow growth of fastidious organisms such as anaerobes, HACEK spp., nutritionally variant streptococci, or Brucella spp.; （3） IE caused by obligate intracellular organisms such as Rickettsia spp., Chlamydia spp., Tropheryma whippelii, or viruses; （4） fungal IE; （5） cultures taken toward the end of a chronic course （〉3 months）; （6） subacute right-sided IE; （7） uremia supervening in a chronic course; （8） mural IE such as might result in patients with a ventricular septal defect, post-myocardial infarction thrombi, or infection related to pacemaker wires; （9） an incorrectdiagnosis or non-infective endocarditis. Of these, the most common causes include previous administration of antibiotics and the presence of fastidious organisms （eg., zoonotic agents and fung. The diagnosis of IE is based on the most accepted Modified Duke＇s criteria which can be inconclusive when blood cultures are negative. Serology, valve histology and new molecular methods may assist in the diagnosis of BCNE. 16S rDNA and 23S rDNA real-time PCR of surgically removed heart valves especially improves the diagnosis and allow the optimization of the antimicrobial therapy of BCNE. In cases of BCNE, history of antibiotic use, clues from recent exposures （animals, invasive and dental procedures）, and underlying medical conditions （native versus prosthetic valve, interval since valvular surgery, alcoholism, injection drug use） can be used to guide empirical antibiotic coverage. Antibiotic therapy in BCNE is targeted against the isolated organisms on the basis of susceptibility patterns.Valve replacement is done more often among patients with BCNE.

关 键 词：心内膜炎 血培养 抗生素 瓣膜置换 

分 类 号：R378[医药卫生—病原生物学]