Blood culture-negative endocarditis: Improving the diagnostic yield using new diagnostic tools.
Blood culture-negative endocarditis: Improving the diagnostic yield using new diagnostic tools.
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DOI：
10.1097/md.0000000000008392
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发表时间：
2017-11
期刊：
影响因子：
1.6
通讯作者：
Raoult D
中科院分区：
文献类型：
--
作者：
Fournier PE;Gouriet F;Casalta JP;Lepidi H;Chaudet H;Thuny F;Collart F;Habib G;Raoult D
血培养阴性心内膜炎（BCNE）可能占所有心内膜炎病例的70%，具体取决于系列。从2001年到2009年，我们在实验室实施了BCNE的多模式诊断策略，包括系统化的血液检测，以及使用血清学、宽范围分子和组织病理学检测的瓣膜活检标本（如可用）。在62.7%的患者中鉴定出致病微生物。在2010年1月至2015年12月的这项研究中，为了增加确定的致病微生物数量，我们前瞻性地在诊断方案中增加了针对各种心内膜炎因子的特异性实时（RT）聚合酶链反应（PCR）检测，并将其应用于法国马赛4家公立医院收治的所有BCNE患者。共有283例BCNE患者入选本研究。其中，177例被归类为明确的心内膜炎。使用我们新的多模式诊断策略，我们确定了138例患者（78.0%的病例）的病因。其中，3例无感染性（2.2%），1例被诊断为牛分枝杆菌卡介苗心内膜炎。通过增加血液和瓣膜活检的特异性PCR检测，其灵敏度显著高于其他方法（P <10−2），在另外27例患者中鉴定出致病因子，主要是肠球菌、链球菌和人畜共患病微生物（14例仅来自瓣膜，11例仅来自血液，2例两者均来自）。 最后，在另外107例患者中，37例采用血清学检测病原体，8例采用瓣膜培养，19例和2例分别采用瓣膜活检和血液的广谱PCR，3例采用瓣膜的免疫组织化学，38例采用多种检测方法的组合。通过在BCNE患者的系统PCR检测中添加特异性RT-PCR检测，我们将诊断效率提高了24.3%，主要是通过检测其他诊断方法未检测到的肠球菌和链球菌，以及需要特异性管理的病原体，如人型支原体和惠氏滋养体。
Supplemental Digital Content is available in the text Blood culture-negative endocarditis (BCNE) may represent up to 70% of all endocarditis cases, depending on series. From 2001 to 2009, we implemented in our laboratory a multimodal diagnostic strategy for BCNE that included systematized testing of blood, and when available, valvular biopsy specimens using serological, broad range molecular, and histopathological assays. A causative microorganism was identified in 62.7% of patients. In this study from January 2010 to December 2015, in an effort to increase the number of identified causative microorganisms, we prospectively added to our diagnostic protocol specific real-time (RT) polymerase chain reaction (PCR) assays targeting various endocarditis agents, and applied them to all patients with BCNE admitted to the 4 public hospitals in Marseille, France. A total of 283 patients with BCNE were included in the study. Of these, 177 were classified as having definite endocarditis. Using our new multimodal diagnostic strategy, we identified an etiology in 138 patients (78.0% of cases). Of these, 3 were not infective (2.2%) and 1 was diagnosed as having Mycobacterium bovis BCG endocarditis. By adding specific PCR assays from blood and valvular biopsies, which exhibited a significantly greater sensitivity (P < 10−2) than other methods, causative agents, mostly enterococci, streptococci, and zoonotic microorganisms, were identified in an additional 27 patients (14 from valves only, 11 from blood only, and 2 from both). Finally, in another 107 patients, a pathogen was detected using serology in 37, valve culture in 8, broad spectrum PCR from valvular biopsies and blood in 19 and 2, respectively, immunohistochemistry from valves in 3, and a combination of several assays in 38. By adding specific RT-PCR assays to our systematic PCR testing of patients with BCNE, we increased the diagnostic efficiency by 24.3%, mostly by detecting enterococci and streptococci that had not been detected by other diagnostic methods, but also agents requiring specific management such as Mycoplasma hominis and Tropheryma whipplei.