What Is Endocarditis And Infective Endocarditis?

Endocarditis

What Is Endocarditis?

Effects of endocarditis on the heart

Bacteria are all around us, and many live on different parts of our body. But if you have heart problems, bacteria in your bloodstream can attach to damaged tissue and cause an infection called endocarditis.

Endocarditis is inflammation of your heart’s inner lining, called the endocardium. It’s usually caused by bacteria. When the inflammation is caused by infection, the condition is called infective endocarditis. Endocarditis is uncommon in people with healthy hearts.

Endocarditis is an infection of the endocardium, which is the inner lining of your heart chambers and heart valves.

The inner lining of your heart and surface of its valves is called the endocardium. If germs or bacteria from other parts of your body, such as your mouth, spread through your blood and attach to this lining, it causes endocarditis. If the infection isn’t treated with antibiotics or surgery, it can do permanent damage and can even be deadly.

Endocarditis generally occurs when bacteria, fungi or other germs from another part of your body, such as your mouth, spread through your bloodstream and attach to damaged areas in your heart. If it’s not treated quickly, endocarditis can damage or destroy your heart valves and can lead to life-threatening complications. Treatments for endocarditis include antibiotics and, in certain cases, surgery.

Since there are many ways to develop endocarditis, your doctor might not be able to pinpoint the exact cause of your condition. However, people at greatest risk of endocarditis usually have damaged heart valves, artificial heart valves or other heart defects.

Endocarditis

Symptoms

If you develop endocarditis, you may get sudden symptoms, or you may develop them over time. The way you feel will depend on how healthy your heart is and what caused your infection. The symptoms can also vary from person to person, but you may:

Feel like you have the flu. You may develop a fever, chills, and night sweats. You might also feel achiness in your muscles and joints.

Have a new heart murmur. Endocarditis can cause a new or additional heart murmur, or unusual sound in your heartbeat, or changes to an existing one.

See changes in your skin. Tiny bumps or spots may show up on your hands or feet. You might also see spots on the whites of your eyes or the roof of your mouth because of broken blood vessels. Your skin could be pale.

Feel nauseated. You could lose interest in food, feel sick to your stomach, or vomit.

Have pain on the left side of your body under your rib cage. This may be a sign your spleen is trying to fight the infection.

See blood in your urine. You might be able to see it on your own, or your doctor might see it under a microscope.

Endocarditis may develop slowly or suddenly, depending on what germs are causing the infection and whether you have any underlying heart problems. Endocarditis signs and symptoms can vary from person to person.

Common signs and symptoms of endocarditis include:

  • Flu-like symptoms, such as fever and chills
  • A new or changed heart murmur, which is the heart sounds made by blood rushing through your heart
  • blood in your urine
  • Fatigue
  • Aching joints and muscles
  • weight loss
  • Night sweats
  • Shortness of breath
  • Chest pain when you breathe
  • an enlarged spleen, which may be tender to touch
  • Swelling in your feet, legs or abdomen

These include:

  • Unexplained weight loss
  • Blood in your urine, which you might be able to see or that your doctor might see when he or she views your urine under a microscope
  • Tenderness in your spleen, which is an infection-fighting abdominal organ just below your rib cage on the left side of your body
  • Janeway lesions, which are red spots on the soles of your feet or the palms of your hands
  • Osler’s nodes, which are red, tender spots under the skin of your fingers or toes
  • Petechiae (puh-TEE-key-e), which are tiny purple or red spots on the skin, whites of your eyes, or inside your mouth

Changes in the skin may also occur, including:

  • tender red or purple spots below the skin of fingers or toes
  • tiny red or purple spots from blood cells that leaked out of ruptured capillary vessels, which usually appear on the whites of the eyes, inside the cheeks, on the roof of the mouth, or on the chest

Other signs can include:

  • Small areas of bleeding under the nails (splinter hemorrhages)
  • Red, painless skin spots on the palms and soles (Janeway lesions)
  • Red, painful nodes in the pads of the fingers and toes (Osler nodes)
  • Shortness of breath with activity
  • Swelling of feet, legs, abdomen

The signs and symptoms of infectious endocarditis vary greatly from person to person. They can change over time, and they depend on the cause of your infection, heart health, and how long the infection has been present.

If you have a history of heart problems, heart surgery, or prior endocarditis, you should contact your doctor immediately if you have any of these symptoms. It’s especially important to contact your doctor if you have a constant fever that will not break or you’re unusually tired and don’t know why.

Causes

The main cause of endocarditis is an overgrowth of bacteria. Although these bacteria normally live on the inside or outside surfaces of your body, you might bring them inside to your bloodstream by eating or drinking. Bacteria could also enter through cuts in your skin or oral cavity. Your immune system normally fights off germs before they cause a problem, but this process fails in some people.

In the case of infective endocarditis, the germs travel through your bloodstream and into your heart, where they multiply and cause inflammation. Endocarditis can also be caused by fungi or other germs.

Endocarditis occurs when germs enter your bloodstream, travel to your heart, and attach to abnormal heart valves or damaged heart tissue. Certain types of bacteria cause most cases, but fungi or other microorganisms also may be responsible.

Usually, your immune system destroys harmful bacteria that make it into your bloodstream. Even if bacteria reach your heart, they may pass through without causing an infection. However, bacteria that live in your mouth, throat or other parts of your body, such as your skin or your gut, can sometimes cause serious infections like endocarditis under the right circumstances.

Eating and drinking aren’t the only ways that germs can enter your body. They can also get into your bloodstream through:

  • brushing your teeth
  • having poor oral hygiene or gum disease
  • having a dental procedure that cuts your gums
  • contracting a sexually transmitted disease
  • using a contaminated needle
  • through an indwelling urinary catheter or intravenous catheter

Bacteria, fungi or other germs that cause endocarditis might enter your bloodstream through:

  • Everyday oral activities. Activities such as brushing your teeth, or other activities that could cause your gums to bleed, can allow bacteria to enter your bloodstream — especially if you don’t floss or your teeth and gums aren’t healthy.
  • An infection or other medical condition. Bacteria may spread from an infected area, such as a skin sore. Other medical conditions, such as gum disease, a sexually transmitted infection or certain intestinal disorders — such as inflammatory bowel disease — can also give bacteria the opportunity to enter your bloodstream.
  • Catheters. Bacteria can enter your body through a catheter — a thin tube that doctors sometimes use to inject or remove fluid from the body. This is more likely to occur if the catheter is in place for a long period of time.
  • Needles used for tattoos and body piercing. The bacteria that can cause endocarditis can also enter your bloodstream through the needles used for tattooing or body piercing.
  • Intravenous (IV) illegal drug use. Contaminated needles and syringes are a special concern for people who use illegal intravenous (IV) drugs, such as heroin or cocaine. Often, individuals who use these types of drugs don’t have access to clean, unused needles or syringes.
  • Certain dental procedures. Some dental procedures that can cut your gums may allow bacteria to enter your bloodstream.

Bacteria can more easily attach to the lining of your heart (endocardium), if the lining’s surface is rough. You’re also more likely to develop endocarditis if you have faulty, diseased or damaged heart valves. However, endocarditis does occasionally occur in previously healthy individuals.

Risk factors

Endocarditis

If your heart is healthy, you could be less likely to develop endocarditis, although it is still possible. The germs that cause infection tend to stick to and multiply on damaged or surgically implanted heart valves, or on endocardium that has a rough surface.

Risk factors for developing endocarditis include the following:

  • injecting illicit intravenous drugs with a needle contaminated with bacteria or fungi
  • scarring caused by heart valve damage, which allows bacteria or germs to grow
  • tissue damage from having endocarditis in the past
  • having a heart defect
  • having an artificial heart valve replacement

A person may be at higher risk of developing endocarditis if they:

  • have an existing heart condition or disease
  • have had heart replacement surgery or received an artificial heart valve
  • have had a disease, such as rheumatic fever, which damaged at a heart valve
  • have received a pacemaker
  • have regularly received drugs intravenously
  • are convalescing after a serious bacterial illness, such as meningitis or pneumonia
  • have an immune system that is chronically suppressed, for example, because of diabetes or HIV, or if they have cancer or are receiving chemotherapy

People at highest risk of endocarditis are those who have:

  • Artificial heart valves. Germs are more likely to attach to an artificial (prosthetic) heart valve than to a normal heart valve.
  • Congenital heart defects. If you were born with certain types of heart defects, such as an irregular heart or abnormal heart valves, your heart may be more susceptible to infection.
  • A history of endocarditis. Endocarditis can damage heart tissue and valves, increasing the risk of a future heart infection.
  • Damaged heart valves. Certain medical conditions, such as rheumatic fever or infection, can damage or scar one or more of your heart valves. This can make them more prone to endocarditis.
  • A history of intravenous (IV) illegal drug use. People who use illegal drugs by injecting them are at a greater risk of endocarditis. The needles used to inject drugs can be contaminated with the bacteria that can cause endocarditis.

Complications

In endocarditis, clumps of bacteria and cell fragments form in your heart at the site of the infection. These clumps, called vegetation, can break loose and travel to your brain, lungs, abdominal organs, kidneys or limbs. As a result, endocarditis can cause several major complications, including:

  • Heart problems, such as heart murmur, heart valve damage, and heart failure
  • Stroke
  • Seizure
  • Loss of the ability to move part of all of your body (paralysis)
  • Pockets of collected pus (abscesses) that develop in the heart, brain, lungs and other organs
  • Pulmonary embolism — infected vegetation that travels to the lungs and blocks a lung artery
  • Kidney damage
  • Enlarged spleen

Complications are more likely if endocarditis is left untreated, or if treatment is delayed.

  • Damaged heart valves increase the risk of heart failure.
  • If heart rhythms are affected, arrhythmia, or irregular heartbeat, may occur.
  • The infection can spread within the heart and to other organs, such as the kidneys, lungs, and brain.
  • If vegetations break off, they can travel through the bloodstream to other parts of the body and cause infections and abscesses elsewhere.

Vegetation that finds its way to the brain and gets stuck there can cause stroke or blindness. A large fragment of vegetation can get stuck in an artery and block blood flow.

Prevention

You can help prevent endocarditis in several ways, including:

Know the signs and symptoms of endocarditis. See your doctor immediately if you develop any signs or symptoms, especially a fever that won’t go away, unexplained fatigue, any type of skin infection, or open cuts or sores that don’t heal properly.

Untreated endocarditis is always fatal, but with early treatment, involving an aggressive use of antibiotics, most patients survive.

However, it can still be fatal in older people, patients with an underlying condition, and those whose infection involves a resistant type of bacteria.

The National Heart, Lung and Blood Institute (NHLBI) encourages those who are at risk of endocarditis to have regular dental checkups and to brush and floss their teeth regularly.

Pay special attention to your dental health — brush and floss your teeth and gums often, and have regular dental checkups.

Avoid procedures that may lead to skin infections, such as body piercings or tattoos.

Preventive antibiotics

Certain dental and medical procedures may allow bacteria to enter your bloodstream. For some people with heart disease or damaged or diseased heart valves, taking antibiotics before these procedures can help destroy or control the harmful bacteria that may lead to endocarditis. This is because these people are more at risk of developing endocarditis after having these procedures.

In the past, doctors gave antibiotics to many people before dental or other surgical procedures, such as procedures involving the intestinal or urinary tracts, even if they weren’t at high risk of developing endocarditis.

However, antibiotics are no longer recommended before all dental or other surgical procedures, or for all people. As doctors have learned more about endocarditis prevention, they’ve realized endocarditis is much more likely to occur from exposure to random germs than from a standard dental exam or surgery.

If you’re at risk of endocarditis, let your doctor and dentist know before having any dental work. They will decide whether you need antibiotics before any dental procedures.

It’s still important to take good care of your teeth through brushing and flossing since doctors have some concern that infections in your mouth from poor oral hygiene might increase the risk of germs entering your bloodstream. In addition to brushing and flossing, regular dental exams are an important part of maintaining good oral health.

The American Heart Association recommends preventive antibiotics for people at risk for infectious endocarditis, such as those with:

  • Certain birth defects of the heart
  • Heart transplant and valve problems
  • Prosthetic heart valves (heart valves inserted by a surgeon)
  • Past history of endocarditis

These people should receive antibiotics when they have:

  • Dental procedures that are likely to cause bleeding
  • Procedures involving the breathing tract
  • Procedures involving the urinary tract system
  • Procedures involving the digestive tract
  • Procedures on skin infections and soft tissue infections

Diagnosis

Your doctor will go over your symptoms and medical history before conducting any tests. After this review, they’ll use a stethoscope to listen to your heart. The following tests may also be done:

Your doctor may suspect endocarditis based on your medical history, signs, and symptoms you’re experiencing and your test results. A diagnosis of endocarditis is usually based on several factors instead of a single positive test result or symptom.

Your doctor may order several tests to help make a positive diagnosis, including:

  • Blood tests. A blood culture test is used to identify any bacteria or fungi in your bloodstream, and it’s the most important test your doctor will perform. Blood tests can also help your doctor identify certain conditions that can be a sign of endocarditis, such as anemia — a shortage of healthy red blood cells.
  • Echocardiogram. An echocardiogram uses sound waves to produce images of your heart while it’s beating. This test is often used to check for signs of infection. Your doctor may use two different types of echocardiograms to help diagnose endocarditis.

In a transthoracic echocardiogram, sound waves directed at your heart from a wandlike device (transducer) held on your chest produce video images of your heart in motion. This test can help your doctor look at your heart’s structure and check it for any signs of infection or damage.

Doctors may conduct another type of echocardiogram called a transesophageal echocardiogram to get a closer look at your heart valves. During this test, a small transducer attached to the end of a tube is inserted down the tube leading from your mouth to your stomach (esophagus). This test can allow your doctor to get much more detailed pictures of your heart than is possible with a transthoracic echocardiogram.

  • Electrocardiogram (ECG).

An electrocardiogram (ECG or EKG) may be requested to get a better view of your heart’s electrical activity. This test can detect an abnormal heart rhythm or rate. A technician will attach 12 to 15 soft electrodes to your skin. These electrodes are attached to electrical leads (wires), which are then attached to the EKG machine.

While an ECG isn’t specifically used to diagnose endocarditis, it can show your doctor if something is affecting your heart’s electrical activity. During an ECG, sensors that can detect your heart’s electrical activity are attached to your chest, arms, and legs. This test is used to measure the timing and duration of each electrical phase in your heartbeat.

  • Chest X-ray.

X-ray images help your doctor see the condition of your lungs and heart. Your doctor can use X-ray images to see if endocarditis has caused your heart to enlarge or if any infection has spread to your lungs. A collapsed lung or other lung problems can cause some of the same symptoms as endocarditis.

A chest X-ray may be used to view your lungs and see if they’ve collapsed or if the fluid has built up in them. A buildup of fluid is called pulmonary edema. The X-ray can help your doctor tell the difference between endocarditis and other conditions involving your lungs.

  • Computerized tomography (CT) scan or magnetic resonance imaging (MRI).

You may need a CT scan or an MRI scan of your brain, chest or other parts of your body if your doctor thinks that infection has spread to these areas.

  • Blood test

If your doctor suspects you have endocarditis, a blood culture test will be ordered to confirm whether bacteria, fungi, or other microorganisms are causing it. Other blood tests can also reveal if your symptoms are caused by another condition, such as anemia.

  • Transthoracic echocardiogram

A transthoracic echocardiogram is a non-radiating imaging test used to view your heart and its valves. This test uses ultrasound waves to create an image of your heart, with the imaging probe placed on the front of your chest. Your doctor can use this imaging test to look for signs of damage or abnormal movements of your heart.

  • Transesophageal echocardiogram

When a transthoracic echocardiogram doesn’t provide enough information to assess your heart accurately, your doctor might order an additional imaging test called a transesophageal echocardiogram. This is used to view your heart by way of your esophagus.

Treatment

Many cases of endocarditis are successfully treated with antibiotics. Sometimes, surgery may be required to fix damaged heart valves and clean up any remaining signs of the infection.

Antibiotics

If your endocarditis is caused by bacteria, it will be treated with intravenous antibiotic therapy. Your doctor will advise you to take antibiotics until your infection and related inflammation are effectively treated. You will likely receive these in a hospital for at least a week until you show signs of improvement.

You will need to continue antibiotic therapy upon discharge from the hospital. You may be able to transition to oral antibiotics later in your treatment. Antibiotic therapy typically takes up to six weeks Trusted Source to complete.

If you have endocarditis, your doctor might recommend high doses of intravenous (IV) antibiotics in the hospital. Your doctor will use blood culture tests to help identify the organism that’s causing your infection. Based on the results of your blood tests, your doctor will choose the most appropriate antibiotic or combination of antibiotics to fight the infection.

You’ll generally spend a week or more in the hospital when you start taking IV antibiotics. This gives your doctor time to see if the antibiotics are working against your infection. You’ll usually take antibiotics for several weeks to clear up the infection.

Once your fever and the worst of your signs and symptoms have passed, you might be able to leave the hospital and continue IV antibiotic therapy with visits to your doctor’s office or at home with home-based care. You’ll still need to see your doctor regularly to make sure your treatment is working.

You may need to be in a hospital to get antibiotics through a vein (IV or intravenously). Blood cultures and tests will help your provider choose the best antibiotic.

You will then need long-term antibiotic therapy.

  • People most often need therapy for 4 to 6 weeks to kill all the bacteria from the heart chambers and valves.
  • Antibiotic treatments that are started in the hospital will need to be continued at home.

Surgery to replace the heart valve is often needed when:

  • The infection is breaking off in little pieces, resulting in strokes.
  • The person develops heart failure as a result of damaged heart valves.
  • There is evidence of more severe organ damage.

It’s important to tell your doctor about any signs or symptoms that may mean your infection is getting worse, such as:

  • Fever
  • Chills
  • Headaches
  • Joint pain
  • Shortness of breath

Also, if you develop diarrhea, a rash, itching or joint pain, let your doctor know as soon as possible. These signs and symptoms may indicate you’re having a reaction to your prescribed antibiotic.

If you have shortness of breath or swelling in your legs, ankles or feet after you start antibiotic treatment, see your doctor immediately. These signs and symptoms can be indicators of heart failure.

Surgery

Prolonged infective endocarditis or damaged heart valves caused by endocarditis may require surgery to correct. Surgery may be done to remove any dead tissue, scar tissue, fluid buildup, or debris from infected tissue.

Surgery may also be done to repair or remove your damaged heart valve, and replace it with either man-made material or animal tissue. If the infection damages your heart valves, you may have symptoms and complications for years after treatment.

Sometimes surgery is needed to treat persistent infections or to replace a damaged valve. Surgery is also sometimes needed to treat endocarditis that’s caused by a fungal infection.

Depending on your condition, your doctor may recommend either repairing your damaged valve or replacing it with an artificial valve made of cow, pig or human heart tissue (biological tissue valve) or man-made materials (mechanical valve).

What is Infective Endocarditis?

Infective endocarditis (IE), also called bacterial endocarditis (BE), is an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel. IE is uncommon, but people with some heart conditions have a greater risk of developing it.

Infective endocarditis refers specifically to infection in the lining of the heart, but IE also affects the valves and often affects the muscles of the heart.

How do people contract infective endocarditis?

The infection can be caused by bacteria introduced into the bloodstream, usually through normal activity such as tooth brushing which causes minor injury to the lining of the mouth or gums. These bacteria can lodge on heart valves and cause infection of the endocardium. One study found that people with poor dental health or who bleed during tooth brushing had a higher risk of developing bacteria in the blood (bacteremia).

Why does endocarditis pose a threat to the heart valves?

The heart valves are not supplied directly with blood. Therefore, the body’s immune response system, such as the infection-fighting white blood cells, cannot directly reach the valves through the bloodstream. If bacteria begins to grow on the valves (this occurs most often in people with already diseased heart valves), it is difficult to fight the infection, whether through the body’s own immune system or through medications that rely on the blood system for delivery.

The risk for Infective Endocarditis?

Risk factors for children and young adults include birth defects of the heart such as malformed valves or a hole in the septum, which allow blood to leak from one part of the heart to another.

Risk factors for adults include previous valve surgeries or transplants, calcium deposits in the mitral valve or in the aortic valve, congenital heart defects or a history of endocarditis.

Illegal drug use and IE

If the cause of IE is the injection of illicit drugs or prolonged use of I.V. drugs, the tricuspid valve is most often affected. Street drugs, including narcotics, can also affect the mitral or aortic valve.

What are the symptoms of infective endocarditis?

The symptoms of acute IE usually begin with fever (102°–104°F), chills, fast heart rate, fatigue, night sweats, aching joints and muscles, persistent cough or swelling in the feet, legs or abdomen.

The symptoms of chronic IE may be such things as fatigue, mild fever (99°–101°F), a moderately fast heart rate, weight loss, sweating, a low red blood cell count (anemia) and can take place over as much as a period of months.

Treatment usually consists of at least two weeks and as much as six weeks of high doses of I.V. antibiotics.

Prevention for those at risk usually involves awareness of the risks, and preventative antibiotics prior to certain surgical, dental and medical procedures.

Resources:

https://en.wikipedia.org/wiki/Endocarditis

https://www.ncbi.nlm.nih.gov/pubmed/7671924

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