Infective endocarditis (patient information)

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Overview
Infective endocarditis is an infection of the lining of the heart chambers and heart valves that is caused by bacteria, fungi, or other infectious substances. Having a catheter (tube) or another medical device inserted through your skin, especially for long periods, also can allow bacteria to enter your bloodstream. People who use intravenous (IV) drugs also are at risk for infective endocarditis because of the germs on needles and syringes.

Bacteria also may spread to the blood and heart from infections in other parts of the body, such as the gut, skin, or genitals.

What are the symptoms?
Symptoms of endocarditis may develop slowly (subacute) or suddenly (acute). Fever is the classic symptom and may persist for days before any other symptoms appear.

Other symptoms may include:


 * Abnormal urine color
 * Blood in the urine
 * Chills
 * Excessive sweating
 * Fatigue
 * Joint pain
 * Muscle aches and pains
 * Nail abnormalities (splinter hemorrhages under the nails)
 * Night sweats (may be severe)
 * Paleness
 * Red, painless skin spots on the palms and soles (Janeway lesions)
 * Red, painful nodes in the pads of the fingers and toes (Osler's nodes)
 * Shortness of breath with activity
 * Swelling of the feet, legs, abdomen
 * Weakness
 * Weight loss

What are the causes?
Endocarditis is usually a result of a blood infection. Bacteria or other infectious substance can enter the bloodstream during certain medical procedures, including dental procedures, and travel to the heart, where it can settle on damaged heart valves. The bacteria can grow and may form infected clots that break off and travel to the brain, lungs, kidneys, or spleen.

Most people who develop infectious endocarditis have underlying heart disease or valve problems.

However, an organism commonly found in the mouth, Streptococcus viridans, is responsible for about 50% of all bacterial endocarditis cases. This is why dental procedures increase your chances for developing this condition. Such procedures are especially risky for children with congenital heart conditions. As a result, it is common practice for children with some forms of congenital heart disease and adults with certain heart-valve conditions to take antibiotics before any dental work.

Other common culprits include Staphylococcus aureus and enterococcus. Staphylococcus aureus can infect normal heart valves, and is the most common cause of infectious endocarditis in intravenous drug users.

Less common causes of infectious endocarditis include pseudomonas, serratia, and candida.

Who is at highest risk?
The following increase your chances for developing endocarditis:
 * Artificial heart valves
 * Congenital heart disease (atrial septal defect, patent ductus arteriosus, and others)
 * Heart valve problems (such as mitral insufficiency)
 * History of rheumatic heart disease
 * Intravenous drug users are also at risk for this condition, because unsterile needles can cause bacteria to enter the bloodstream.

When to seek urgent medical care?
Call your health care provider if you note the following symptoms during or after treatment:


 * Weight loss without change in diet
 * Blood in urine
 * Chest pain
 * Weakness
 * Numbness or weakness of muscles
 * Fever

Diagnosis
The health care provider may hear abnormal sounds, called murmurs, when listening to your heart with a stethoscope.

A physical exam may also reveal:


 * Enlarged spleen
 * Splinter hemorrhages in the fingernails

A history of congenital heart disease raises the level of suspicion. An eye exam may show bleeding in the retina a central area of clearing. This is known as Roth's spots.

The following tests may be performed:


 * Blood culture and sensitivity (to detect bacteria)
 * Chest x-ray
 * Complete blood count (may show mild anemia)
 * CT scan of the chest
 * Echocardiogram (ultrasound of the heart)
 * Erythrocyte sedimentation rate (ESR)
 * Transesophageal echocardiogram

Treatment options
You will be admitted to the hospital so you can receive antibiotics through a vein. Long-term, high-dose antibiotic treatment is needed to get rid of the bacteria. Treatment is usually given for 4 - 6 weeks, depending on the specific type of bacteria. Blood tests will help your doctor choose the best antibiotic.

Surgery may be needed to replace damaged heart valves.

Where to find medical care for infective endocarditis?
Directions to Hospitals Treating Infective Endocarditis

What to expect (Outlook/Prognosis)?
Early treatment of bacterial endocarditis generally has a good outcome. Heart valves may be damaged if diagnosis and treatment are delayed.

Possible complications

 * Blood clots or emboli that travel to brain, kidneys, lungs, or abdomen
 * Brain abscess
 * Congestive heart failure
 * Glomerulonephritis
 * Jaundice
 * Neurological changes
 * Rapid or irregular heartbeats, including atrial fibrillation
 * Severe valve damage
 * Stroke

Prevention
The American Heart Association recommends preventive antibiotics for people at risk for infectious endocarditis before:


 * Certain dental procedures
 * Surgeries on respiratory tract or infected skin, skin structures, or musculoskeletal tissue

Antibiotics are more likely to be recommended those with the following risk factors:


 * Artificial heart valves
 * Certain congenital heart defects, both before or possibly after repair
 * History of infective endocarditis
 * Valve problems after a heart transplant

Continued medical follow-up is recommended for people with a previous history of infectious endocarditis.

Persons who use intravenous drugs should seek treatment for addiction. If this is not possible, use a new needle for each injection, avoid sharing any injection-related paraphernalia, and use alcohol pads before injecting to reduce risk.