Resurgence of Pseudomonas Endocarditis in Detroit, 2006-2008
Resurgence of Pseudomonas Endocarditis in Detroit, 2006-2008
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DOI：
10.1097/md.0b013e3181b8bedc
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发表时间：
2009-09-01
期刊：
影响因子：
1.6
通讯作者：
Biedenbach, Douglas J.
中科院分区：
文献类型：
--
作者：
Reyes, Milagros P.;Ali, Ammar;Biedenbach, Douglas J.
2006 年至 2008 年间，底特律的 10 名注射吸毒者（IDU）（6 名男性，4 名女性；平均年龄，48.1 岁）发现铜绿假单胞菌引起的心内膜炎复发。所有患者的人类免疫缺陷病毒（HIV）检测均为阴性。 5 名患者患有二尖瓣和/或主动脉瓣左侧心内膜炎； 5 名患者中有 3 名患有人工瓣膜心内膜炎。 10 名患者中有 4 名仅患有右侧三尖瓣心内膜炎。一名患者双侧主动脉瓣和三尖瓣受累。 9 名患者患有假单胞菌心内膜炎 (PsE)； 1 名患者患有铜绿假单胞菌和近平滑念珠菌混合性心内膜炎。10 名患者中的 7 名接受静脉注射头孢吡肟联合治疗，4-6 g/d。加用大剂量妥布霉素 (HDT) 至少 6 周。妥布霉素每天 8 mg/kg，每日单剂量静脉注射，目标血清峰值水平为 18-22 μg/mL，谷值水平 < 11 μg/mL。混合性心内膜炎患者也接受了氟康唑治疗。两名患者最初接受其他抗假单胞菌治疗方案（包括单独使用头孢吡肟和哌拉西林/他唑巴坦加妥布霉素）治疗失败，并改用头孢吡肟和 HDT。第三名患者因肾毒性而改用头孢吡肟和环丙沙星。两名患者出现妥布霉素肾毒性； 1 名患者出现耳毒性。左侧和右侧疾病的总体治愈率为 80% (4/5)。 5 名需要手术的患者全部存活（5/5；100%）。总体结果为 90% (9/10)。瓣膜置换术的适应症是复发性假单胞菌菌血症（n = 3）、复发性菌血症和充血性心力衰竭（n = 1）。以及持续性菌血症和真菌血症（n = 1）。两名患者成功进行了三尖瓣切除术并进行瓣膜置换术，第三名患者因复发性菌血症和充血性心力衰竭而成功置换了三尖瓣和主动脉瓣。两名患有单纯左侧人工瓣膜心内膜炎的患者成功接受了重复瓣膜置换术。虽然这是一个小系列，但总体死亡率（1/10；10%）较低。未能幸存的患者左侧主动脉瓣受累，因大面积栓塞性脑梗塞而无法接受手术。当前系列中左侧疾病的死亡率为 16.7%（1/6 包括三尖瓣和主动脉瓣 PsE 患者），而 1990 年报告的 15 名患者系列中的死亡率为 60%。我们目前的 PsE 抗菌治疗方案包括头孢吡肟，6 g/d，分 3 次剂量，加上 HDT，每天 8 mg/kg，每日单剂量给药，持续 6 周。对于头孢吡肟耐药的假单胞菌，亚胺培南 4-6 g/d，或美罗培南 6 g/d，加上 HDT 已成功。对于药物治疗难治的右侧疾病，如果假单胞菌菌血症在适当的抗菌治疗后持续 2 周，或者在 6 周疗程后菌血症复发，建议进行手术干预。三尖瓣修复/重建或瓣膜切除术联合瓣膜置换加联合抗假单胞菌治疗方案可能是难治性右侧心内膜炎的最佳治疗方法。这种方法不仅可以防止右心室功能严重和永久性损伤（这是单纯瓣膜切除术而不进行瓣膜置换术的并发症），而且还可以治愈感染。对于左侧疾病，如果在适当的抗菌治疗后 7 天血培养仍呈阳性，或者在完成 6 周的联合治疗方案后再次出现假单胞菌菌血症，则建议进行手术。
A resurgence of endocarditis due to Pseudomonas aeruginosa was seen in 10 injection drug users (IDUs) in Detroit between 2006 and 2008 (6 men, 4 women; mean age, 48.1 yr). All patients tested negative for the human immunodeficiency virus (HIV). Five patients had left-sided endocarditis of the mitral valve and/or the aortic valve; 3 of 5 patients had prosthetic valve endocarditis. Four of 10 patients had right-sided endocarditis of the tricuspid valve alone. One patient had bilateral involvement of the aortic and tricuspid valves. Nine patients had Pseudomonas endocarditis (PsE); 1 patient had mixed endocarditis with P. aeruginosa and Candida parapsilosis.Seven of 10 patients were treated with a combination of intravenous cefepime, 4-6 g/d. plus high-dose tobramycin (HDT) for at least 6 weeks. Tobramycin, 8 mg/kg per day, was given as a single daily dose intravenously, aiming for peak serum levels of 18-22 mu g/mL and trough levels of < 11 mu g/mL. The patient with mixed endocarditis was also treated with fluconazole. Two patients initially treated with other antipseudomonal regimens, including cefepime alone and piperacillin/tazobactam plus tobramycin, failed treatment and were switched to cefepime and HDT A third patient was switched to cefepime and ciprofloxacin because of nephrotoxicity. Two patients developed nephrotoxicity to tobramycin; 1 patient developed ototoxicity.The overall medical cure rate for both left-sided and right-sided disease was 80% (4/5). All 5 patients who required surgery survived (5/5; 100%). Overall outcome was 90% (9/10). Indications for valve replacement were recurrent Pseudomonas bacteremia (n = 3), recurrent bacteremia and congestive heart failure (n = 1). and persistent bacteremia and fungemia (n = 1). Tricuspid valvulectomy with valve replacement was successful in 2 patients and in a third patient who had successful replacement of both the tricuspid and the aortic valve,for recurrent bacteremia and congestive heart failure. Two patients with pure left-sided prosthetic valve endocarditis underwent successful repeat valve replacements. Although this is a small series, the overall mortality rate (1/10; 10%) was low. The patient who did not survive had left-sided involvement of the aortic valve and Could not undergo surgery because of a large embolic cerebral infarct. The mortality rate of left-sided disease in the current series was 16.7% (1/6 including the patient with tricuspid and aortic valve PsE) compared to 60% in a series of 15 patients reported in 1990.Our current antimicrobial regimen for PsE consists of a combination of cefepime, 6 g/d, in 3 divided doses, plus HDT, 8 mg/kg per day, given as a single daily dose for 6 weeks. For cefepime-resistant Pseudomonas, imipenem, 4-6 g/d, or meropenem, 6 g/d, plus HDT has been successful. For right-sided disease refractory to medical therapy, surgical intervention is recommended if Pseudomonas bacteremia persists for 2 weeks on appropriate antimicrobial therapy or if bacteremia recurs after a 6-week course of treatment. Tricuspid repair/reconstruction or valvulectomy with valve replacement plus combined antipseudomonal regimen may be the optimal therapy for refractory right-sided endocarditis. This approach not only may prevent the development of severe and permanent impairment of right ventricular function, which is a complication of valvulectomy alone without valve replacement, but also may cure the infection. For left-sided disease, surgery is recommended if blood cultures remain positive for 7 days on appropriate antimicrobial therapy or if Pseudomonas bacteremia recurs after completion of a 6-week course of the combined regimen.