| BackgroundInfective endocarditis(IE)is a fatal infectious disease with a high in-hospital mortality,although with the improvement of diagnostic techniques,the application of broad-spectrum antibiotics and the implementation of cardiac surgery,the prognosis of IE is still very poor,with a hospital mortality of 18%and 25%,and there is no downward trend in 2 Mel within 5 months.Even after the acute phase of IE,the mortality and recurrence rate remain high,and its poor prognosis proves that it is necessary to identify patients with high risk factors and improve early diagnosis and treatment.In recent years,due to the changes in medical and health care and the extension of life expectancy,the epidemiology of IE has also changed,but there is still a lack of research on the clinical characteristics and epidemiological changes of IE in Shandong.ObjectiveThrough the statistical analysis of the clinical data of patients with IE,to understand the clinical characteristics,prognostic risk factors and epidemiological changes of IE,so as to improve the diagnosis and treatment of IE.MethodThe clinical data of all IE patients in Qilu Hospital of Shandong University from May 2008 to October 2019 were collected and analyzed retrospectively.Results1.Clinical distribution:Among the 360patients with IE,260males(72.2%)were higher than those of females(27.8%).The ratio of male to female was 2.6%.The age ranged from 0.6 to 88 years old,and the average age was 47.5±15.9 years old.The common basic heart diseases were congenital heart disease in 97 cases(26.9%),valvular heart disease in 21 cases(5.7%),cardiac surgery and interventional therapy in 49 cases(13.6%).The course of disease was more than 3 weeks in 322 patients(89.4%)with IE.The common clinical manifestations were fever in 310 cases(86.1%)and heart murmur in 304 cases(84.4%).The main complications of IE were heart failure in 286 cases(79.4%),embolic events in 72 cases(20.0%),mainly cerebral embolism in 48 cases(13.3%),renal embolism in 3 cases(0.8%),splenic embolism in 4 cases(1.1%),multiple organ embolism in 11 cases(3.1%),and other embolism in 6 cases(1.7%).Among them,13 cases were characterized by acute cerebral embolism(3.6%).Acute renal function injury occurred in 26 cases(7.2%),of which 5 cases(1.4%)had elevated hematuria or creatinine as the first manifestation,and 3 cases(0.8%)developed acute renal failure.Neurological complications occurred in 16 cases(4.4%),including hemorrhagic stroke in 10 cases(2.8%),white matter lesions in 1 case(0.3%),intracranial infection in 5 cases(1.4%),including 2 cases of brain abscess(0.6%).Other risk factors included 33 cases of diabetes(9.2%),6 cases of tumor(1.7%),5 cases of immunosuppressant(1.4%),3 cases of renal insufficiency and 2 cases of pregnancy(0.6%).2.Distribution of pathogens:A total of 173strains of pathogenic bacteria were isolated from 169cases(46.9%)of IE patients with positive blood culture,and two kinds of pathogens were simultaneously detected in 4 cases(2.5%)of blood culture,including 97 strains of Streptococcus(56.0%),55 strains of Staphylococci(31.8%),8 strains of Enterococci(4.6%),8 strains of fungi(4.6%),3 strains of Gram-negative bacilli(1.7%)and 1 strain of anaerobes(0.6%).One strain of Gram-positive bacilli(0.6%).41 cases(17.4%)were positive for vegetative culture,of which 23 cases(56.1%)were negative for blood culture,10 cases(24.4%)were consistent with blood culture,and 8 cases(19.5%)were inconsistent with blood culture.3.Drug resistance analysis:The resistance rates of Streptococcus to penicillins,cephalosporins,quinolones,clindamycin and erythromycin were 10.1%,1.4%,8.1%,68.3%,71.4%and 0%,respectively.The resistance rates of staphylococci to penicillins,gentamicin,quinolones,clindamycin and erythromycin were 81.2%,26.5%,38.8%,59.6%and 66.6%,respectively.The resistance rate of vancomycin,daptomycin and tegacycline was 0%.The resistance rates of enterococci to gentamicin and rifampicin were 25%and 50%,respectively.Penicillin,streptomycin,vancomycin,daptomycin and linezolid were all sensitive.Fungi were sensitive to fluconazole,itraconazole,voriconazole and amphotericin B.4.Echocardiography:The positive rate of(TTE)in transthoracic echocardiography was 89.7%(310 cases of vegetations,13 cases of perivalvular leakage and perivalvular abscess).7 cases of IE were found by transesophageal echocardiography(TEE),and 236 cases(65.5%)were treated by operation.the position of vegetation was completely the same as that of TTE,and no vegetation was found by TTE and TEE in 27 cases(11.4%)of IE.However,the presence of vegetations was confirmed during the operation,misdetection of TEE in 14 cases(5.9%)and missed detection of TTE in 30 cases(12.7%)of multi-valvular lesions.The results of TTE analysis showed that 78.4%of the patients had vegetation involving the left ventricular system,and the most affected were simple mitral valve in 117 cases(37.7%),followed by simple aortic valve in 102cases(32.9%).5.Treatment,outcome and influencing factors:Of the 360 patients with IE,124(34.4%)were treated with antibiotics,and the other 236(65.6%)were treated with internal medicine combined with surgery.295 cases(81.9%)of IE patients were improved and discharged from hospital,46 cases(12.8%)were discharged automatically due to various reasons,and 19 cases(5.3%)died during hospitalization.Univariate analysis showed that age ?60 years old,staphylococcal infection,cerebral embolism,cerebral embolism and simple medical treatment were associated with the prognosis of IE patients.Multivariate Logistic regression analysis showed that medical treatment alone was 17.305%OR 17.305%8.336-35.924)and cerebral embolism was 2.418,0,022 OR 2.418,respectively,and the multivariate analysis showed that the prognosis was correlated with age?60 years old,staphylococcal infection(0.004),cerebral embolism(0.004),cerebral embolism(0.000)and cerebral embolism(2.418).95%CI:1.136-5.149)is an independent risk factor for the prognosis of IE.6.Epidemiological changes:In terms of age,the average age of the 2008-2013 group was 43.8±16.9 years,and that of the 2014-2019 group was 49.7±15.1 years.The average age of the 2008-2013 group was lower than that of the 2014-2019 group,and the average age of onset increased,and the difference was statistically significant(P<0.05).In terms of basic diseases,the number of patients with coronary heart disease in the 2014-2019 group(29 cases)was higher than that in the 2008-2013 group(4 cases),and the difference was statistically significant(P<0.05).In terms of clinical manifestations,the proportion of chest tightness and splenomegaly showed an increasing trend,and the difference was statistically significant(P<0.05).From 2008 to 2013,there were 80 cases of chest tightness(60.6%)and 22 cases of splenomegaly(16.7%).From 2014 to 2019,there were 102 cases of chest tightness(44.7%)and 59 cases of splenomegaly(25.9%).The difference was statistically significant(P<0.05).In terms of complications,there were 10 cases(7.6%)of cerebral embolism and 3 cases(2.3%)of acute renal function injury in 2008-2013 group,and 46 cases(20.2%)of cerebral embolism and 23 cases(10.1%)of acute renal function injury in 2014-2019 group.The difference was statistically significant(P<0.05).In terms of pathogens and drug resistance rates,there were 21 cases of green streptococci(15.9%)and 15 cases of other streptococci(11.4%)from 2008 to 2013;13 cases of green streptococci from 2014 to 2019(5.7%)and 48 cases of other streptococci(21.1%).Compared with the two groups,from 2014 to 2019,the proportion of green streptococci decreased,the difference was statistically significant(P<0.05),while the overall proportion of other streptococci increased,the difference was statistically significant(P<0.05).Compared with the drug resistance rate of Streptococcus between the two groups,the penicillin resistance rate showed a downward trend,and the difference was statistically significant(P&1t;0.05).Conclusion1.Congenital heart disease and cardiac surgery and interventional therapy are the main basic diseases of IE,and the risk factors such as diabetes,immunosuppression and tumor can not be ignored.2.The typical clinical manifestations of IE are fever and heart murmur,but it can also be the first manifestation of hematuria or nervous system symptoms,if there are hematuria and acute nervous system symptoms,accompanied by fever of unknown origin and heart murmur,the possibility of IE should be considered.3.Streptococcus was still the main pathogen.The results of drug sensitivity showed that the resistance rate of Streptococcus to penicillins was low,and penicillin was still the main drug for the treatment of streptococcal IE.4.TTE is still an important method for the diagnosis of IE,and it is easy to miss and misdetect multi-valvular diseases,which can improve TEE to increase the accuracy.5.Cerebral embolism and simple medical treatment are independent risk factors affecting the prognosis of patients with IE.Timely surgical treatment should be performed in accordance with the surgical indications.6.The epidemiological characteristics of IE have changed,the average age of onset has significantly increased,and the main pathogens are still Streptococcus,but the proportion of green streptococcus gradually decreased,while the proportion of other streptococci(Streptococcus sanguis,Streptococcus bradylidis,oral streptococcus,etc.)gradually increased,and the incidence of acute renal function injury and cerebral embolism increased in complications. |
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