Infective Endocarditis

Infective Endocarditis - What it is

Infective Endocarditis (IE), also known as bacterial endocarditis (BE), is an infection typically caused by bacteria which enters the bloodstream and remain in the heart lining, blood vessel or heart valve. There are two categories of IE: acute IE and chronic IE. Acute IE is an infection that occurs suddenly and may worsen drastically within days. Meanwhile, chronic IE occurs over a few weeks or months. While it is an uncommon condition, patients with certain heart conditions have a higher risk of developing IE.

Possible Complications of Infective Endocarditis (IE)

Diseased or damaged heart valves: IE may damage heart valves resulting in abnormal valve function.
Abnormal heart rhythm/Arrhythmia: IE is one of the many heart conditions that can cause abnormal heart rhythms.
Heart failure: When valvar function is significantly affected, the heart might be unable to pump sufficient blood around the body.
Stroke: Infection “clumps” may dislodge and block off the brain’s blood flow, causing a stroke.
Sepsis: A life-threatening condition where the infection is very severe, resulting in multi-organ failure or even death.

Infective Endocarditis - Symptoms

There are numerous symptoms of infective endocarditis (IE) and these may differ based on the cause of the infection and whether the patient has underlying heart problems. The common symptoms of IE include:

Pain in the joints and muscles
Fever
Chills
Night sweats
Swelling in the legs, feet or abdomen
Breathlessness
Fatigue
Heart murmurs
Rapid heart rate
Persistent cough

However, some patients might experience less common symptoms such as:

Unexplained weight loss
Tenderness near the left ribcage
Flat spots that are red, purple or brown, on the palms or soles of the feet (Janeway lesions)
Painful bumps or patches of darkened skin on the tips of fingers or toes (Osler nodes)
Red, purple or brown spots on the skin, inside the mouth or the whites of the eyes

Infective Endocarditis - How to prevent?

There are a number of ways to prevent or reduce your risk of getting infective endocarditis (IE).

1) Be attentive to signs and symptoms of IE

If you experience any of the common symptoms of IE such as a persistent fever, unexplained tiredness or any wounds that do not heal properly, please see your doctor immediately.

2) Practice good oral hygiene

Brush and floss your teeth regularly and do not let gum disease go untreated.

Dental Hygiene is important to prevent IE; please visit your dentist at least once a year.

3) Care for your wounds

If you have any cuts or grazes that show early signs of an infection, please wash them. If you begin to develop symptoms of a skin infection, please see your doctor immediately. Some of these symptoms include:

Inflammation of the affected area
Sore and warm skin
Discharge of pus or fluid
Fever
Chills and shivering

To avoid this, refrain from cosmetic procedures like piercings or tattoo that involve breaking the skin.

4) Prophylactic (preventive) antibiotics

Prophylaxis (taking preventive antibiotics) against IE is recommended for the following patients with:

Prosthetic cardiac valves, including transcateter implanted prostheses and homografts
Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
Previous infective endocarditis
Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
Cardiac transplant with valve regurgitation due to a structurally abnormal valve.

There is no evidence for endocarditis prophylaxis in gastrointestinal or genitourinary procedures unless there is active infection.

Dental procedures for which endocarditis prophylaxis is recommended:

Any dental procedures that involve manipulation of gingival tissue, manipulation of the

periapical region of teeth, or perforation of the oral mucosa in patients.

Infective Endocarditis - Causes and Risk Factors

Infective endocarditis (IE) is caused by germs that enter the bloodstream through a wide variety of ways. Bad oral hygiene, minor injury in the mouth or gums, implanted heart devices, and chronic skin disorders are some of the common ways bacteria enter the bloodstream.

Certain risk factors can increase one’s chances of getting IE, including:

Age: IE often occurs in older adults, especially those above the age of 60, who make up 25% of all IE patients.
Artificial heart valves: Artificial or prosthetic heart valves tend to have risks of IE.
Congenital heart defects: Having certain heart defects from birth such as faulty valves or a hole in the septum can increase one’s risks of having IE.
Damaged heart valves: Rheumatic fever or other infections can cause scarring to the heart valves, increasing the risk of IE. A history of IE also increases the chances of recurrent infections.
Diabetes mellitus: Those with type II diabetes were shown to have higher incidence of IE than patients without.
Gender: Men are two times more likely to suffer from IE compared to women.
Immunosuppression: Those with weakened immune systems are more likely to get IE.
Implanted devices: Bacteria and germs can attach to cardiac devices like pacemakers, thus infecting the lining of the heart.
Use of illegal IV drugs: Those who consume banned drugs via IV needles are at higher risk of developing IE because of contaminated needles and syringes.
Poor oral hygiene or dental health: Poor oral hygiene increases the chances of bacteria growing inside the mouth and entering the bloodstream through any wounds on your gums. Certain dental procedures may cause injuries to the gums and allow bacteria to enter the bloodstream, leading to IE.

Infective Endocarditis - Diagnosis

Diagnosis of infective endocarditis (IE) normally starts with a physical examination by a doctor, assessing your medical history and conducting routine tests. Other tests recommended may include:

Chest X-ray: Helps determine if the infection from IE has spread to the lungs or caused swelling in the heart.
Blood tests: Demonstrates elevated inflammatory markers such as C-reactive protein. Results from a blood cultures (blood tests taken over time) can help identify germs or bacteria in the bloodstream and thus allow the doctor to prescribe the relevant antibiotics for treatment.
Complete blood count: A high count of white blood cells indicates infection. A low count of red blood cells can also be a sign of IE.
Echocardiogram: An ultrasound scan of the heart can show how well the heart, its chambers and its valves are functioning. An echocardiogram is mostly used to check for clumps of bacteria, damage to heart valves or heart tissue. In some cases, a transoesophageal echocardiogram (TEE) might be used to provide clearer images of the heart.
Cardiac Computed Tomography (CT): Allows the doctor to check if the infection has spread to any other parts of the body.
Cardiac MRI: Usually requested if other modes of imaging are inadequate.

Infective Endocarditis - Treatments

If left untreated, infective endocarditis (IE) can result in life-threatening complications. As such, IE is typically treated with medication or surgical intervention.

Medication

Most people with infective or bacterial endocarditis can be treated with a high dose of antibiotics administered via an IV drip. Blood cultures will continue be taken throughout the patient’s stay in the hospital to monitor his/her symptoms and the treatment progress. When the symptoms have largely gone away, the patient might be discharged. However, the patient will have to continue with the IV antibiotics at home or with their doctor for several weeks.

If IE is caused by a fungal infection, antifungal medication might have to be taken for life to prevent the infection from recurring.

Surgical procedures

Surgical procedures might be required for those with severe IE infections or to replace a damaged heart valve. The key surgical procedures used to treat IE are valve repair/replacement, fluid or pus drainage, and repair of any unusual passageways (fistula) that have developed. Generally, surgery will be recommended to patients with the following:

Persistent symptoms like a high fever even with medication
IE due to fungal infections
Prosthetic (artificial) heart valve
Potential heart failure due to valve issues
Build-up of pus or fluid
Opening of an unusual passageway (fistula) in the heart
Valve disease or damage

Generally, the benefits of surgical intervention include:

Increased chances of survival
Lower risk of recurrent IE infections
Prolonged symptom relief
Preservation of heart function which can prevent heart failure

Despite the benefits of surgical intervention for those with IE, this may not always be suitable. Those who are older, have chronic conditions or weaker immune systems might be unable to undergo surgery. Please speak with your doctor to discuss your suitability for these surgical procedures.

Infective Endocarditis - Preparing for surgery

Dental Surgeon / Doctor should confirm that the patient would / would not require antibiotic prophylaxis for dental extraction or operation.

Overview

Adult Congenital Heart Disease

Article contributed by Department of Cardiology, National Heart Centre Singapore; NHCS Cardiology @ SKH

The information provided is not intended as medical advice. Terms of use. Information provided by SingHealth

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