Ur12 4 5


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Ur12 4 5

  1. 1. Progress admit day 9 (31/3/53) <ul><li>ระหว่างนอน รพ . ผู้ป่วยมีไข้ 38c, no organ specific symptoms </li></ul><ul><li>H/C: Gram positive cocci in chain x II </li></ul><ul><li>Repeat H/C: Grampositive cocci in chain x III </li></ul><ul><li>Identify = S.bovis I MIC sense to Penicillin </li></ul>
  2. 2. W/U Infective endocarditis <ul><li>Echo 31/3/53: dense echo mass at both mitral leaflet , mild MR, mild MS, LVEF 74% </li></ul><ul><li>Eye ground: Roth’s spot positive </li></ul><ul><li>Imp: subacute bacterial endocarditis </li></ul><ul><li>ให้การรักษาด้วย PGS 24 million units/day + Gentamicin 1 mg/kg q8hr </li></ul>
  3. 3.  
  4. 4. Onset of IE <ul><li>1+ ปีก่อน TTE 17/3/52: Normal LVEF, no RWMA, no clot nor vegetation, slightly thickened AV </li></ul><ul><li>TEE 18/3/52: Normal TEE study </li></ul><ul><li>6 เดือนก่อน ( 22/10/52) </li></ul><ul><ul><li>S.epidermidis xI </li></ul></ul><ul><ul><li>Anaerobic gram positive rods xII </li></ul></ul><ul><ul><li>ให้การรักษาด้วย Ceftriaxone IV 2 days then Omnicef 11 days </li></ul></ul>
  5. 5. Onset of IE <ul><li>4 เดือนก่อน (21/12/52-4/1/52) </li></ul><ul><ul><li>H/C NG x II </li></ul></ul><ul><li>2 สัปดาห์ก่อน (9/3/53) </li></ul><ul><ul><li>Microaerophilic streptococcus x II </li></ul></ul><ul><ul><li>ให้การรักษาด้วย Ceftazodime IV 4 days then Ciprofloxacin 10 days </li></ul></ul>
  6. 6. Stroke in Infective endocarditis <ul><li>All neurologic complications occurred more often with S . a ureus infection (67%) than with viridans streptococci (22%) </li></ul><ul><li>In native-valve endocarditis, most (74%) ischemic strokes had occurred by the time of presentation . </li></ul><ul><li>Patients with infective endocarditis and ischemic stroke on presentation seldom had recurrent emboli after the infection was controlled . </li></ul><ul><li>A nticoagulants and surgery are not warranted to prevent recurrent stroke in these patients . </li></ul>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. 7. Anticoagulant in S. aureus IE <ul><li>Left - sided S aureus IE (native valve 35 pt, prosthetic valve 21 pt) </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>Pilar Tornos, et al. Infective Endocarditis Due to Staphylococcus aureus . Arch Intern Med . 1999;159:473-475.
  8. 8. Anticoagulatio n in IE <ul><li>In pt with native valve disease, the benefit of anticoagulation has never been demonstrated convincingly. </li></ul><ul><li>C ontroversial, particularly in mechanical valve endocarditis. </li></ul><ul><li>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 . </li></ul><ul><li>Until further definitive data are available, the routine use of aspirin for established endocarditis is not r ecommended (Class III, Level of Evidence: B). </li></ul>Larry M. Baddour et al. Infective Endocarditis . Circulation . 2005; 111:e394-e433 .
  9. 9. Anticoagulatio n in IE <ul><li>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 . </li></ul>European Society of Cardiology . Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009) . European Heart Journal (2009) 30, 2369–2413