133.1 🎓 醫孞生版

133.1.0.1 📌 䞀頁重點

  • Definition: 心內膜 (native or prosthetic valve, mural endocardium, indwelling devices) 感染 → vegetation 圢成
  • Modified Duke Criteria 是蚺斷暙準: 2 major OR 1 major + 3 minor OR 5 minor
  • 病原:
    • Native valve, community: Streptococcus viridans (subacute), S. aureus (acute, increasingly even native)
    • IVDU: S. aureus (right-sided, tricuspid)
    • Prosthetic valve early (< 60 d): S. epidermidis (CoNS), S. aureus
    • Prosthetic valve late (> 60 d): S. viridans, Enterococcus, CoNS
    • HACEK: Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella (slow-growing GN)
    • Culture-negative IE (~10%): Coxiella, Bartonella, Brucella, Tropheryma whipplei, fungi
  • Empirical: Vancomycin + Ceftriaxone (or Vanco + Gentamicin in fulminant or prosthetic)
  • Duration: 4-6 週 IV (specific 䟝 organism/valve)

133.1.0.2 1⃣ Modified Duke Criteria

133.1.0.2.1 Major
  1. Positive blood culture (typical organism × 2 separate cultures):
    • Strep viridans, Strep gallolyticus (S. bovis), HACEK, S. aureus, community-acquired Enterococcus (without 1° focus)
    • OR persistent positive (≥ 2 cultures > 12 hr apart, or 3/3, or 4/4)
    • OR single positive C. burnetii (Q fever) or anti-phase I IgG > 1:800
  2. Echocardiographic evidence:
    • Vegetation, abscess, valvular perforation, new prosthetic dehiscence
    • OR new valvular regurgitation (worsening murmur)
133.1.0.2.2 Minor
  1. Predisposition: pre-existing cardiac, IVDU
  2. Fever ≥ 38.0°C
  3. Vascular phenomena: arterial emboli, septic pulmonary infarcts, mycotic aneurysm, ICH, conjunctival hemorrhages, Janeway lesions (painless palms/soles)
  4. Immunologic phenomena: glomerulonephritis, Osler nodes (painful pulp), Roth spots (retinal), RF +
  5. Microbiology (not meeting major): single positive culture (uncommon org), serology consistent
133.1.0.2.3 Diagnosis
  • Definite IE: 2 major OR 1 major + 3 minor OR 5 minor
  • Possible: 1 major + 1 minor OR 3 minor

133.1.0.3 2⃣ 病原 + Empirical Treatment

133.1.0.3.1 Native Valve
情境 Empirical
Subacute (insidious) Vancomycin (cover MRSA) + Ceftriaxone (cover S. viridans + HACEK + Enterococcus)
Acute (fulminant) Vancomycin + Cefepime (or pip-tazo) — wider gram-negative
IVDU (right-sided) Vancomycin + Pip-tazo (cover MRSA + Pseudomonas)
133.1.0.3.2 Prosthetic Valve
Timing Empirical
Early (< 60 d) Vancomycin + Gentamicin + Cefepime (cover CoNS + S. aureus + Enterobacteriaceae)
Late (> 60 d) Vancomycin + Gentamicin + Ceftriaxone (similar to native + cover CoNS)
133.1.0.3.3 Specific Organism (after culture)
  • S. viridans (penicillin-sensitive, MIC ≀ 0.12): Penicillin G or Ceftriaxone × 4 wk; OR + Gentamicin × 2 wk (synergy, shortened to 2 wk overall)
  • S. aureus MSSA: Cefazolin or Nafcillin × 6 wk
  • MRSA: Vancomycin × 6 wk (or daptomycin alternative)
  • Enterococcus: Ampicillin + Ceftriaxone × 6 wk (or Amp + Gent if synergy)
  • HACEK: Ceftriaxone × 4 wk
133.1.0.3.4 Treatment Duration
  • Native valve, S. viridans: 4 weeks
  • Native valve, S. aureus: 6 weeks
  • Prosthetic valve: 6 weeks + Gentamicin × 2 wk + (if Staph) Rifampin × 6 wk

133.1.0.4 3⃣ 手術 Indications (絕對 + 盞對)

📖 䞭文抂念說明IE 的手術門檻比想像䞭䜎 — 因為 vegetation 䞀旊造成 mechanical 問題 (HF)、感染倱控 (abscess)、或反芆 embolism抗生玠再匷也無法逆蜉組織砎壞。最垞芋的手術指埵是 acute regurgitation 匕起的 HF (chordae rupture 或 leaflet perforation)最 emergent 的指埵是 aortic root abscess 出珟新的 conduction block (代衚 abscess 已䟵入 AV node 呚邊幟小時內可胜 complete heart block)fungal IE 與 prosthetic dehiscence 是 definite surgery。Timing 原則HF 或 uncontrolled infection 䞍必等抗生玠完成1-2 週內 OR 即可手術埌仍芁完成完敎 IV 療皋。

Surgery indications (Class I-IIa in 2023 ESC/AHA): 1. Heart failure due to severe valvular dysfunction (acute regurgitation) 2. Uncontrolled infection: persistent fever > 7-10 d, abscess, perforation, fistula, large mobile vegetation 3. Prevent embolism: large vegetation > 10 mm + previous embolic event, > 15 mm even without 4. Prosthetic valve dehiscence or fungal endocarditis (definite surgery)

Timing: 倚圚癌䜜 1-2 週內;䞍必等 antibiotic 完成

133.1.0.5 4⃣ 䜵癌症

  • Heart failure: acute regurgitation (chordae rupture, leaflet perforation)
  • Embolism: stroke (mycotic aneurysm), splenic infarct, kidney infarct, pulmonary embolism (right-sided)
  • Abscess: aortic root abscess (high-grade conduction block — emergent surgery)
  • Mycotic aneurysm: ICH, peripheral
  • Glomerulonephritis (immune complex)
  • Septic shock