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For enterococcal endocarditis, penicillin alone is inadequate; either streptomycin or gentamicin must be included in the regimen Because aminoglycoside resistance occurs in enterococci, susceptibility should be documented Gentamicin is the aminoglycoside of choice, because streptomycin resistance is more common and the nephrotoxicity of gentamicin is generally more easily managed than the vestibular toxicity of streptomycin Ampicillin, 2 g intravenously every 4 hours, or penicillin G, 3 4 million units intravenously every 4 hours (or, in the penicillin-allergic patient, vancomycin, 15 mg/kg intravenously every 12 hours), plus gentamicin, 1 mg/kg intravenously every 8 hours, are recommended The recommended duration of combination therapy is 4 6 weeks (the longer duration for patients with symptoms for more than 3 months, relapse, or prosthetic valve endocarditis), although a study from Sweden found that discontinuing the aminoglycoside before 4 weeks did not reduce efficacy Experience is more extensive with penicillin and ampicillin than with vancomycin for treatment of enterococcal endocarditis, and penicillin and ampicillin are superior to vancomycin in vitro Thus, whenever possible, either ampicillin or penicillin should be used Endocarditis caused by strains resistant to penicillin, vancomycin, or aminoglycosides is particularly difficult to treat Such cases should be treated according to recent American Heart Association guidelines (see reference below) and managed in consultation with an infectious diseases specialist



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If the phase voltage at the receiving end is assumed to be at a phase angle of 0 , then the phase voltage at the receiving end will be VR = 127 0 kV , and the phase current at the receiving end will be

streptococci, and enterococci Vancomycin 1 g every 12 hours intravenously plus ceftriaxone 2 g every 24 hours provides appropriate coverage pending definitive diagnosis





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For penicillin-susceptible viridans streptococcal endocarditis (ie, MIC 01 mcg/mL), penicillin G, 2 3 million units intravenously every 4 hours for 4 weeks, is recommended The duration of therapy can be shortened to 2 weeks if gentamicin, 1 mg/kg intravenously every 8 hours, is used with penicillin Ceftriaxone, 2 g once daily intravenously or intramuscularly for 4 weeks, is also effective therapy for penicillinsusceptible strains and is a convenient regimen for home therapy For the penicillin-allergic patient, vancomycin, 15 mg/kg intravenously every 12 hours for 4 weeks, is given The 2-week regimen is not recommended for patients with symptoms of more than 3 months duration or with complications such as myocardial abscess or extracardiac infection Prosthetic valve endocarditis is treated with a 6-week course of penicillin with at least 2 weeks of gentamicin Viridans streptococci relatively resistant to penicillin (ie, MIC > 01 mcg/mL but 05 mcg/mL) should be treated for 4 weeks Penicillin G, 3 million units intravenously every 4 hours, is combined with gentamicin, 1 mg/ kg intravenously every 8 hours for the first 2 weeks In the

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For methicillin-susceptible S aureus, nafcillin or oxacillin, 15 2 g intravenously every 4 hours for 6 weeks, is the preferred therapy Uncomplicated tricuspid valve endocar-

Table 33 4 Recommendations for administration of bacterial endocarditis prophylaxis for high and moderate risk patients according to type of procedure1

The early days of networking software saw several competing standards that did not work well together Novell NetWare, Microsoft Windows, and Apple Macintosh ran networking software to share folders and printers, while the UNIX/Linux world did crazy things like sharing terminals handy for the UNIX/Linux users, but it made no sense to the Windows folks and there was this new thing called e-mail (like that was ever going to go anywhere) The Internet had just been opened to the public The World Wide Web was just a plaything for programmers and scientists All of these folks made their own software, interpreting (or totally ignoring) the OSI model the way they wanted to, and all trying (arguably) to become THE WAY the whole world was going to network It was an unpleasant, ugly world for guys like me who had the audacity to try to make, for example, a UNIX box work with a Windows computer The problem was that no one agreed on how a network should run Everyone s software had its own set of Rules of What a Network Should Do and How to Do It These sets of rules and the software written to follow these rules were broken down into individual rules called protocols Each set of rules had many protocols lumped together under the term protocol suite Novell NetWare called its protocol suite IPX/SPX, Microsoft called its NetBIOS/NetBEUI, Apple called its AppleTalk, and the UNIX folks used this wacky protocol suite called TCP/IP Well, TCP/IP has won Sure, you may find the occasional network still running one of these other protocol suites, but they re rare these days To get ahead in today s world, to get on the Internet, and to pass the CompTIA Network+ exam, you only need to worry about TCP/IP Novell, Microsoft, and Apple no longer actively support anything but TCP/IP You live in a one-protocol-suite world, the old stuff is forgotten, and you kids don t know how good you got it! TCP/IP fits nicely into the OSI seven-layer model, occupying Layers 3 5: Network, Transport, and Session, respectively (Figure 7-1) Starting from the bottom up, the.

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