小儿感染性心内膜炎治疗的现状

Current status of the management of pediatric infective endocarditis： a national survey

目的了解国内小儿感染性心内膜炎治疗的现状。方法多中心回顾性总结研究感染性心内膜炎268例临床资料，着重分析抗生素、外科治疗及治疗结果。平均年龄8．94岁（18d-18岁）。结果应用的抗生素共有56种，主要为头孢菌素类（15种）、青霉素类（8种）、B内酰胺酶抑制剂的复合制剂（8种）、氨基糖苷类（4种）及肽类抗生素（3种）等。应用1种抗生素33例（12．3％），2种抗生素83例（31．1％），3种抗生素44例（16．5％），4种抗生素57例（21，3％），5种抗生素25例（9．4％），6种及以上抗生素25例。应用时间为1～98d，〈2周19例（7．1％），2～〈4周74例（27．7％），4～6周122例（45．7％），〉6周52例（19．4％）。123例接受外科治疗。全组186例痊愈，4例转院手术治疗，60例自动出院，18例死亡（6．7％）。抗生素及手术治疗组中，除4例转院手术外，111例痊愈，5例死亡，3例自动出院。单纯抗生素治疗组中75例治愈，57例自动出院，13例死亡。二组的转归差异有统计学意义（χ^2=61．7，P=0．000）。多因素logistic回归分析显示，血培养为金黄色葡萄球菌（χ^2=4．40，P=0．036），先天性心脏病术后（χ^2=9．40，P=0．002）及伴发心力衰竭（χ^2=10．36，P=0．001）是与死亡相关的危险因素。结论本研究结果客观地反映了国内小儿感染性心内膜炎治疗的现状，目前应用的抗生素种类多而方法不一。迫切需通过多学科合作制定小儿感染性心内膜炎治疗方案，并组织开展随机对照研究评估和优化治疗方案，进一步提高小儿感染性心内膜炎的治疗水平。

Objective During recent years several changes have occurred in the clinical characteristics of infective endocarditis （IE） which has made a new challenge in the management of this disease. This study aimed to understand current practice pattern in the management of pediatric IE in China. Methods This retrospective, muhicenter study was conducted in 13 hospitals. Clinical data of 268 patients diagnosed as IE according to the new IE criteria （trial） between 2000 and 2006 were analysed, focusing particularly on management and outcome of patients. The mean age of patients was 8.94 years （ 18 d- 18 years）. Results Except for one patient who died after admission without treatment, 56 antimierobial agents were used in the management of this disease in the 267 patients, including cephalosporin group （ 15 ）, penicillin group （ 8 ）, beta-lactamase inhibitor combination （ 8 ）, aminoglycosides （ 4 ）, glycopeptide agents （3） etc. The most commonly used antibiotics were as follows： penicillin G （125 cases/times）, cefotaxime （ 113 ）, vancomycin （ 78 ） , ceftriaxoue （ 73 ）, ampicillin （ 66 ）, cefuroxime （ 56 ）, piracillin （48）, amikacin （39） etc. For management of this disease, only one antibiotic agent was used in 33（ 12. 3% ） patients, two antibiotic agents in 83 （ 31.1% ） patients, 3 antibiotic agents in 44 （ 16.5% ） patients, 4 antibiotic agents in 57（21.3% ） patients, 5 antibiotic agents in 25（9.4% ） patients, 6 or more antibiotic agents in 25 （9.4%） patients. The most commonly used antibiotic agents in patients with streptococci detected in blood culture were penicillin G, cephalosporins, vancomycin, beta-lactamase inhibitor combination, and aminoglycoside, in patients with staphylococcus detected in blood culture were cephalosporins, oxicillin, vaneomycin, aminoglycoside, and quinolones. Duration of antibiotic treatment was from 1 day to 98 days, less than 2 weeks in 19 （7%） patients, 2 weeks to less than 4 weeks in 74 （27.7%） patients, 4-6 weeks in 122 （45.7%） patients, more than 6 weeks in 52 （ 19.4% ） patients; 123 patients simultaneously underwent surgical management （for removal of vegetations and intraeardiac defects or residual shunt repair 105, and valve repair 8, valve replacement 6, intracardiac defect repair 4 ） Of the 268 patients, 186 patients were cured, 4 patients were referred to surgery, 18 patients died and 60 patients refused medical advice. In antibiotics and surgical treatment group （123 patients）, 111 patients were cured, d patients were referred to surgery, 5 patients died, 3 patients refused medical advice, in antibiotics treatment group （145 patients）, 75 patients were cured, 13 patients died, 57 patients refused medical advice. The outcomes were significantly different between the two groups （χ^2 =61.7 ,P =0. 000 ）. The results of multivariate logistic regression analysis showed that Staphylococcus aureus as a pathogen （ χ^2 = 4.40,P = 0. 036, OR = 9. 78,95% CI 1.16-82. 26 ）, children with repaired congenital heart disease （ χ^2 = 9.4,P =0. 002, OR = 9. 8,95% CI 2. 28-42. 16 ）, and complicated with heart failure （ χ^2 = 10. 36, P = 0. 001, OR = 0. 075,95% CI 0. 16-0. 36 ） were risk factors related to death. Conclusion This study revealed the current status in the management of pediatric IE in China. Wide range antibiotic agents and diverse regimens are used to manage children with IE. For improving management of pediatric IE, there is an urgent need for guidelines or recommendations or consensus for management of pediatric IE stipulated by multidiscipline specialists, and randomized controlled clinical trials are required to provide evidences.