台灣中部某醫學中心感染性心內膜炎十年之分析

A Study of Infective Endocarditis over 10 Years at a Tertiary Care Hospital in Central Taiwan.

洪弘昌(Hung-Chang Hung)

指導教授 ： 吳得進

中山醫學大學/醫學院/醫學研究所/博士(2013年)

https://doi.org/10.6834/CSMU.2013.00061

摘要

研究背景：
感染性心內膜炎（Infective endocarditis）是最嚴重的感染性疾病之一，根據修訂後的Duke診斷標準(modified Duke criteria)被廣泛應用於心內膜炎診斷。我們想比較和分析心內膜炎確診的患者(definitely diagnosed)和心內膜炎可能診斷的患者(possibly diagnosed)之間的預後。
此外在台灣目前有靜脈注射毒品（intravenous drug）施用者快速增長的趨勢，靜脈注射毒品是心內膜炎的一個危險因素。因此我們比較靜脈注射毒品施用者與非施用者心內膜炎的和預後。
研究一：
目的：
研究的目的是比較分析心內膜炎確診者和可能診斷心內膜炎患者之間的危險因素與患者之間預後。
方法：
這項回顧性病例對照研究，從1999年1月至2009年12月在台灣的某家醫學中心進行，我們分析感染性心內膜炎患者的基本資料，相關的潛在性疾病，實驗室數據，診斷方法，合併症，感染之危險因素，感染致病菌，治療方法，與預後。進行比較和分析確診或可能的診斷心內膜炎的患者兩組的統計差異。
結果：
共有172例為確診或可能的診斷心內膜炎的患者。在住院中的死亡率為30.8％。由多變數分析結果發現，患有慢性腎臟病，中風病史及心內膜炎相關合併症的患者（即細菌性血栓，充血性心臟衰竭，腎功能不全和呼吸衰竭）有顯著統計上相關的死亡率較高。靜脈注射毒品施用者和接受外科手術治療統計上有顯著較好的生存預後。
結論：
在確診或可能的診斷心內膜炎的患者之間，有不同的臨床特徵，微生物感染，和預後，確診感染性心內膜炎的患者存在慢性腎臟病，中風病史，合併症與死亡率增加有關所有患者與感染性心內膜炎。
研究二：
目的：
研究的目的是評估台灣靜脈注射毒品施用者與非施用者心內膜炎的心臟超音波檢查特點，微生物培養結果，死亡的危險因素，與預後。
方法：
這項回顧性研究中，在台灣的某家醫學中心進行，我們從1999年1月至2009年12月，回顧了確診為感染性心內膜炎的病人，分靜脈注射毒品施用者與非施用者兩組，進行比較和分析兩組的在基本資料，相關的潛在性疾病，實驗室數據，診斷方法，心臟超音波檢查結果，合併症，感染之危險因素，感染致病菌，治療方法，與預後的統計差異。
結果：
根據修訂後的Duke診斷標準有108例確診感染性心內膜炎患者（26例靜脈注射毒品施用者）。分析結果發現，靜脈注射毒品施用者容易被金黃色葡萄球菌感染（P <0.001）。靜脈注射毒品施用者與非施用者比較有較高的血紅素(84.6％比62.2％，P = 0.033）和血小板低下（42.3％比73.2％，P = 0.004）。靜脈注射毒品施用者C型肝炎感染比率較高（73.1％比11％，P <0.001）。大多數非施用者二尖瓣和主動脈瓣被感染比率較高（分別為40/74，54.1％，35/74，47.3％），而靜脈注射毒品施用者，三尖瓣被感染比率較高（10/18，55.6％）。總住院中死亡率為33.3％（36/108），和靜脈注射毒品施用者比較死亡率為11.5％（3/26），顯著低於非施用者（40.2％，33/82）（P = 0.007）。多變數分析顯示，年齡（> 40）和腎功能肌酐酸大於1.2mg/L，明顯與更高的死亡率有關（勝算比為1.06和7.49，P 值分別為P <0.001）。當整個組進行多變數分析，靜脈注射毒品施用者和和接受外科手術治療統計上有顯著的有更好的存活率（勝算比為0.19和0.11，P值分別為 0.012和0.011）。
結論：
感染性心內膜炎的靜脈注射毒品施用者和非施用者有不同的臨床特徵和微生物學感染不同的致病菌。在所有患者中，年齡和腎功能肌酐酸上升統計上有顯著差異，是造成死亡的危險因素，而靜脈注射毒品施用者和和接受外科手術治療存活率較高。

關鍵字

infective endocarditis ； intravenous drug use ； mortality ； Modified Duke criteria

並列摘要

Background:
Infective endocarditis (IE) is one of the most severe infectious disease and the modified Duke criteria was wildly used to diagnose it. We would like to study the prognosis comparison and the analysis between patients with definitely diagnosed and possibly diagnosed with IE.
Taiwan has experienced a rapid increase in the prevalence of intravenous drug (IVD) use, a risk factor for development of IE. We compared the characteristics and outcomes among patients with IE who used IVDs with those who did not.
Objectives: (1) Study 1: The objective of study 1 is to analyze the outcome and risk factors between patients with definitely diagnosed and possibly diagnosed with IE.
(2) Study 2: The objective of study 2 is to evaluate the echocardiographic findings, microbiologic profiles, risk factors for mortality, and outcomes of IVD users and non-users with definitely diagnosed IE in Taiwan.
Methods: (1) Study 1: In this retrospective, case-control study conducted in a hospital in Taiwan from January 1999, to December 2009, we analyzed demographic data, underlying diseases, laboratory data, diagnosis, complications, etiologic agents, treatment, and outcomes. Statistically significant differences between patients with definitely diagnosed and possibly diagnosed with IE were examined. (2) Study 2: In this retrospective study, we reviewed the charts of IVD users and non-users who were treated for definitely diagnosed IE between January 1999 and December 2009 in a hospital in Taiwan.
Results: (1) Study 1: One hundred seventy-two patients with definite or possible diagnoses of IE were enrolled. The in-hospital mortality rate was 30.8%. Multivariate analysis showed underlying chronic kidney disease, a history of stroke, and complications (i.e., septic emboli, congestive heart failure, or renal and respiratory insufficiency) were significantly associated with higher mortality. Significantly better survival was associated with IVD user and surgical intervention.
(2) Study 2: One hundred eight patients (26 IVD users) with definite diagnoses of IE according to the modified Duke criteria were enrolled. IVD users were significantly more likely to be infected with Staphylococcus aureus (P <0.001). More IVD users had higher levels of hemoglobin (84.6% vs. 62.2%; p=0.033) and lower percentage with high platelet counts (42.3% vs. 73.2%; p=0.004) when compared to non-users. A higher percentage of IVD users had Hepatitis C when compared to non-users (73.1% vs. 11%; p<0.001). Most non-users had vegetations in the mitral and aortic valves (40/74, 54.1% and 35/74, 47.3%, respectively), whereas IVD users had significantly more vegetations in the tricuspid valve (10/18, 55.6%). The overall in-hospital mortality rate was 33.3% (36/108), and the rate for IVD users (11.5%, 3/26) was significantly lower than that for non-users (40.2%, 33/82) (P=0.007). Multivariate analysis showed that age (>40) and creatinine levels 1.2 mg/dL were significantly associated with higher mortality (odds ratios, 1.06 and 7.49, respectively; P <0.001 for both). When the whole group was analyzed, significantly better survival was associated with IVD use and surgical intervention (odds ratios, 0.19 and 0.11; P = 0.012 and 0.011, respectively).

Conclusions: (1) Study1: The clinical features, microbiologic spectra, and outcomes of patients who were definitely diagnosed IE were different from those of possibly diagnosed with IE. The presence of CKD, history of stroke, and complications were significantly associated with increased mortality among all patients with IE. (2)
Study2: The clinical features, microbiologic spectra, and outcomes of IVD users with IE were different from those of non-users. Among all patients, age and elevated creatinine levels were significant risk factors for mortality whereas IVD user and surgical intervention were associated with higher rates of survival.

並列關鍵字

感染性心內膜炎 ； 靜脈注射毒品施用者 ； 死亡率 ； 修訂後的Duke診斷標準

參考文獻

Staphylococcus aureus infective endocarditis. Ann Thorac Surg 2007;83(4):1295-1302

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