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Ur12 4 5
Ur12 4 5
Ur12 4 5
Ur12 4 5
Ur12 4 5
Ur12 4 5
Ur12 4 5
Ur12 4 5
Ur12 4 5
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Ur12 4 5

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  • 1. Progress admit day 9 (31/3/53)
    • ระหว่างนอน รพ . ผู้ป่วยมีไข้ 38c, no organ specific symptoms
    • H/C: Gram positive cocci in chain x II
    • Repeat H/C: Grampositive cocci in chain x III
    • Identify = S.bovis I MIC sense to Penicillin
  • 2. W/U Infective endocarditis
    • Echo 31/3/53: dense echo mass at both mitral leaflet , mild MR, mild MS, LVEF 74%
    • Eye ground: Roth’s spot positive
    • Imp: subacute bacterial endocarditis
    • ให้การรักษาด้วย PGS 24 million units/day + Gentamicin 1 mg/kg q8hr
  • 3.  
  • 4. Onset of IE
    • 1+ ปีก่อน TTE 17/3/52: Normal LVEF, no RWMA, no clot nor vegetation, slightly thickened AV
    • TEE 18/3/52: Normal TEE study
    • 6 เดือนก่อน ( 22/10/52)
      • S.epidermidis xI
      • Anaerobic gram positive rods xII
      • ให้การรักษาด้วย Ceftriaxone IV 2 days then Omnicef 11 days
  • 5. Onset of IE
    • 4 เดือนก่อน (21/12/52-4/1/52)
      • H/C NG x II
    • 2 สัปดาห์ก่อน (9/3/53)
      • Microaerophilic streptococcus x II
      • ให้การรักษาด้วย Ceftazodime IV 4 days then Ciprofloxacin 10 days
  • 6. Stroke in Infective endocarditis
    • All neurologic complications occurred more often with S . a ureus infection (67%) than with viridans streptococci (22%)
    • In native-valve endocarditis, most (74%) ischemic strokes had occurred by the time of presentation .
    • Patients with infective endocarditis and ischemic stroke on presentation seldom had recurrent emboli after the infection was controlled .
    • A nticoagulants and surgery are not warranted to prevent recurrent stroke in these patients .
    Merrill C. Kanter and Robert G. Hart . Neurologic complications of infective endocarditis . Neurology 1991;41;1015 RG Hart, JW Foster, MF Luther and MC Kanter . S troke in infective endocarditis Stroke . 1990;21;695-700
  • 7. Anticoagulant in S. aureus IE
    • Left - sided S aureus IE (native valve 35 pt, prosthetic valve 21 pt)
    • Of the prosthetic valve IE, 19 (90%) were taking oral anticoagulant therapy at the time of diagnosis while no patient with native valve IE was receiving such treatment.
    • Mortality was higher in prosthetic valve IE than in native valve IE (71% vs 37%; P =.02). No patient with native valve IE died due to central nervous system complications, while 73% (11 of 15 patients) with prosthetic valve IE died due to central nervous system complications.
    Pilar Tornos, et al. Infective Endocarditis Due to Staphylococcus aureus . Arch Intern Med . 1999;159:473-475.
  • 8. Anticoagulatio n in IE
    • In pt with native valve disease, the benefit of anticoagulation has never been demonstrated convincingly.
    • C ontroversial, particularly in mechanical valve endocarditis.
    • In contrast, some authorities recommend continuation of therapy in patients with mechanical prosthetic valve IE; however, the general advice is to discontinue all anticoagulation in patients with S aureus prosthetic valve IE who have experienced a recent central nervous system embolic event for at least the first 2 weeks of antibiotic therapy .
    • Until further definitive data are available, the routine use of aspirin for established endocarditis is not r ecommended (Class III, Level of Evidence: B).
    Larry M. Baddour et al. Infective Endocarditis . Circulation . 2005; 111:e394-e433 .
  • 9. Anticoagulatio n in IE
    • There is no indication for the initiation of antithrombotic drugs (thrombolytic drugs, anticoagulant or antiplatelet therapy) during the active phase of IE. In patients already taking oral anticoagulants, there is a risk of intracranial haemorrhage which seems to be highest in patients with S. aureus PVE and those with a previous neurological event. The recommendations for the management of the anticoagulant therapy are based on low level of evidence .
    European Society of Cardiology . Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009) . European Heart Journal (2009) 30, 2369–2413

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