血培养阴性感染性心内膜炎的临床治疗

Clinical therapy for blood culture-negative infective endocarditis

目的总结血培养阴性感染性心内膜炎的临床治疗经验，对血培养阴性感染性心内膜炎的诊断及外科手术时机进行讨论。方法回顾性分析2008年7月至2013年12月我科收治的166例血培养阴性患者的临床资料，所有感染性心内膜炎患者人院时均常规行血培养检查，在结果明确之前经验用药，如头孢呋辛钠＋左氧氟沙星等，如血培养结果为阴性，目前抗生素可以较好地控制患者症状，暂不考虑调整抗生素应用，如仍有发热等，则升级抗生素，同时积极准备手术。术中彻底清除赘生物，注意心肺功能的保护。术后给予广谱抗生素应用，患者体温正常、血常规、红细胞沉降率、C反应蛋白（CRP）等指标下降后调整抗生素，直至出院，出院后继续抗生素治疗4～6周。结果本组患者死亡5例，1例为低心排血量综合征、2例死于多器官功能衰竭，败血症1例，脑栓塞1例。其余患者均康复顺利出院。结论血培养阴性感染性心内膜炎患者应迅速控制病情，给予足量、足疗程的抗生素治疗，积极手术治疗，可降低院内病死率。

Objective To summarize the clinical treatment experience of blood culture-negative infective endocarditis, and to explore the surgery chance and therapeutic strategy of blood culture-negative endocarditis. Methods One hundred and sixty-six patients who were diagnosed blood culture-negative endocarditis in the Aisa Heart Hospital of Wuhan from Jul. 2008 to Dec. 2012 were recruited in the study. Broad- spectrum antibiotics including cefuroxime axetil and levofloxacin were used before the result of blood culture, and sensitive antibiotics were selected to control patient＇s condition when getting the result of blood culture. But broad-spectrum antibiotics were continuously used to the blood culture-negative endocarditis until stable condition. When the conditions were stable, active preparation before surgery should be carried out. Thoroughly clear the vegetation and protect the cardiorespiratory function during operating. Kata-step antibiotics were used to control patient＇s condition until normal temperature, as well as the number of leukocytes decreased, blood sedimentation normalized and C-reaction protein decreased. Then, the narrow-spectrum antibiotics were selected including cephalosporin until discharged from hospital, and continued treatment of antibiotics for 4 - 6 weeks. Results Five patients died after the operation,including 1 case died of low cardiac output syndrome,2 cases died of multiple organ failure, 1 case died of septicemia and the 1 case died of cerebral embolism. All the other patients discharged from hospital successfully. Conclusion The patients with blood culture-negative IE should be controlled rapidly. The duration and dose of antibiotics should be enough. Active operative preparation should be taken and then surgery timely. Thus, the hospital mortality could decrease and prompt the long-term outcome.