编者按：感染性心内膜炎（IE）是一种严重的感染性心脏疾病。随着医疗技术的发展，IE的诊断和治疗模式发生了巨大的变化。在第34届欧洲临床微生物学与感染病学大会（ESCMID Global 2024）中，《感染医线》有幸在现场采访到了来自巴塞罗那Vall d'Hebron大学医院的Maria Nazarena Pizzi教授，Pizzi教授不仅是一位杰出的心脏病学家，还参与了欧洲心脏病学会（ESC）心内膜炎指南的更新工作。在本次采访中，Pizzi教授与我们分享了她对于2023年ESC心内膜炎指南流程更新、影像学技术应用、以及分子检测技术价值等方面的专业见解。
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《感染医线》：感谢您接受我们的采访。您能先向我们的中国读者介绍一下自己吗？
Pizzi教授：感谢您的邀请。我是一名来自巴塞罗那Vall d'Hebron大学医院的心脏病学家，专攻心脏成像。我们医院的团队特别关注心内膜炎，我有幸参与了2023年欧洲心脏病学会（ESC）关于该病的指南更新和2023年杜克标准更新。我的工作主要围绕整合新的诊断技术和改进临床路径，以更好地管理疾病。
Infectious Disease Frontier: We appreciate you joining us today. Could you begin by introducing yourself to our audience in China?
Dr. Pizzi: Thank you for inviting me. I am a cardiologist with a specialization in cardiac imaging, I work at Vall d'Hebron University Hospital in Barcelona. Our team at the hospital has a particular focus on endocarditis, and I have had the privilege to be involved in both, the updates of the 2023 European Society of Cardiology (ESC) guidelines related to this disease and the 2023 updated Duke Criteria. My role primarily revolves around integrating new diagnostic techniques and improving clinical pathways for better disease management.
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《感染医线》：能否请您介绍一下2023年ESC心内膜炎指南中在诊断流程方面有哪些新的变化或更新？这些变化对于临床医生在实际操作中有什么具体的影响或指导意义？
Pizzi教授：最新的指南是基于2015年建议的演变。我们采用了综合多模态成像方法，包括CT、核医学（如PET-CT、SPECT-CT、白细胞显像）、MRI，甚至头部CT等先进技术。我们细致组织了诊断过程，为不同的应用场景制定了特定的诊疗路径，包括原生瓣膜、人工瓣膜和心脏植入装置感染。这些诊疗路径旨在简化诊断方式，为临床医生提供清晰有序的指导。此外，我们还在补充材料中提供了大量关于解释这些复杂成像结果的提示，旨在提高诊断准确性并促进医学专业人员的教育发展。
Infectious Disease Frontier: Could you please elaborate on the new changes or updates in the diagnostic process outlined in the 2023 ESC Endocarditis Guidelines? How do these modifications specifically impact or serve as guidance for clinicians in their daily practice?
Dr. Pizzi: The latest guidelines are an evolution of the 2015 recommendations. We have incorporated a comprehensive multi-modality imaging approach, which includes advanced techniques such as CT, nuclear medicine like PET-CT and SPECT-CT, white blood cell imaging, MRI, and even brain CT scans. We've meticulously organized the diagnostic process with specific algorithms tailored for different scenarios—native valves, prosthetic valves, and cardiac device infections. These algorithms are designed to streamline the diagnostic pathway and provide clear, structured guidance to clinicians. Additionally, in our supplementary materials, we offer extensive tips on interpreting these complex imaging results, aiming to enhance diagnostic accuracy and facilitate educational growth among medical professionals.
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《感染医线》：新版指南特别强调了影像学技术的重要性，尤其是在血培养阴性感染性心内膜炎（BCNIE）的诊断中。能否介绍一下不同影像学技术在感染性心内膜炎（IE）诊断中的价值？
Pizzi教授：诊断BCNIE特别具有挑战性，因为它经常缺乏微生物学标准，而微生物学标准对于明确诊断至关重要。传统主要标准包括微生物学证据，但在血培养阴性的情况下，我们主要依靠影像学检查。指南将不同成像技术的结果归类为一个主要标准，强调了每种方式的重要性。例如，超声心动图、CT和PET成像发挥着关键作用。这些技术不仅仅是辅助性的，在很多情况下，还起着决定性的作用，特别是在先前的抗菌治疗已使培养结果无效时。这也强调了持续改进和调整成像技术的必要性，以更好地支持临床诊断。
Infectious Disease Frontier: The updated guidelines place a strong emphasis on the significance of imaging techniques, particularly in the diagnosis of blood culture-negative infective endocarditis (BCNIE). Could you discuss the value of various imaging modalities in the diagnosis of infective endocarditis (IE)?
Dr. Pizzi: Diagnosing BCNIE is notably challenging because it often lacks microbial criteria, which are crucial for a definitive diagnosis. Traditionally, major criteria would include microbial evidence, but with negative cultures, we lean heavily on imaging. The guideline categorizes findings from different imaging techniques under a single major criterion, which emphasizes the importance of each modality. For instance, echocardiography, CT, and PET scans play pivotal roles. These technologies are not just supplementary; in many cases, they are decisive, especially when prior antibiotic treatment has negated culture effectiveness. This reliance underscores the need for ongoing improvements and adaptations in imaging technology to better support clinical diagnoses.
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《感染医线》：您如何看待mNGS、16S rRNA这些分子检测技术在IE诊断中的价值？
Pizzi教授：虽然我的主要研究领域是成像，但分子检测技术的重要性也是不容忽视的。这些方法侧重于检测病原体的遗传物质，是微生物诊断的一大进步。它们为确定病原微生物提供了另一种途径，尤其是在传统培养失败的情况下。在我们继续整合和支持新成像技术的同时，分子诊断技术的类似改进对于整体诊断方法同样是至关重要的。
Infectious Disease Frontier: What is your opinion on the utility of molecular detection techniques such as mNGS and 16S rRNA in the diagnosis of IE?
Dr. Pizzi: While imaging is my primary field, the importance of molecular techniques is paramount. These methods, which focus on detecting genetic material of pathogens, represent a significant advancement in microbiological diagnosis. They provide an alternative pathway to identify causative agents, especially when traditional cultures fail. As we continue to integrate and support new technologies in imaging, similar enhancements in molecular diagnostics are crucial for a holistic diagnostic approach.
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《感染医线》：新版指南还特别关注了心血管植入型电子器械（CIED）相关IE的发病增加，您认为此类感染的诊断应该注意哪些问题？
Pizzi教授：心脏植入装置感染确实是一个日益令人担忧的问题，它们与传统的心内膜炎有些不同，尽管它们在同一指南中讨论。我们的方法是包括使用PET/CT等新技术来检测设备部分（如发生器或囊袋）感染的具体建议。但是，我们承认在检测导线感染方面的证据有限。因此，虽然我们在这个领域取得了重大进展，但还需要进一步的研究和证据来完善这些诊断技术。重要的是，随着新证据的出现，我们要继续调整指南，确保我们的建议能够反映最佳临床实践。
Infectious Disease Frontier: The new guidelines also highlight the increasing incidence of cardiovascular implantable electronic devices (CIED)-related IE. What key considerations do you believe should be taken into account when diagnosing such infections?
Dr. Pizzi: Cardiac device infections are indeed a growing concern and are somewhat distinct from traditional endocarditis, though they are discussed within the same guidelines. Our approach includes specific recommendations for using new technologies like PET/CT to detect infections in parts of the device, such as the generator or the pocket. However, we acknowledge the limited evidence for detecting infections in the leads. Thus, while we have made significant strides in this area, further research and evidence are needed to refine these diagnostic techniques. It’s crucial that we continue to adapt our guidelines as new evidence emerges, ensuring that our recommendations reflect the best possible practices.
Maria Nazarena Pizzi 教授
MD，PhD
Vall d'Hebron大学医院