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Infective Endocarditis

What is bacterial endocarditis?

Bacterial endocarditis (BE, also called infective endocarditis) is an infection of the heart valves or the heart’s inner lining (endocardium). Bacterial endocarditis occurs when germs (especially bacteria but occasionally fungi and other microbes) enter the blood stream and attack the lining of the heart or the heart valves. Bacterial endocarditis causes growths or holes on the valves or scarring of the valve tissue, most often resulting in a leaky heart valve. Without treatment, bacterial endocarditis can be a fatal disease.

Normally, bacteria can be found in the mouth, on the skin, in the intestines, respiratory system, and in the urinary tract. Endocarditis can occur if certain types of bacteria enter the bloodstream.

Signs of infection:

Call your doctor if you have any of these signs of an infection:

  • Fever over 100°F(38.4°C)
  • Sweats or chills, particularly night sweats
  • Skin rash
  • Pain, tenderness, redness or swelling
  • Wound or cut that won't heal
  • Red, warm or draining sore
  • Sore throat, scratchy throat or pain when swallowing
  • Sinus drainage, nasal congestion, headaches or tenderness along upper cheekbones
  • Persistent dry or moist cough that lasts more than two days
  • White patches in your mouth or on your tongue
  • Nausea, vomiting or diarrhea

Who is at risk for developing bacterial endocarditis?

Patients most at risk of developing bacterial endocarditis include those who have:

  • An artificial (prosthetic) heart valve, including bioprosthetic and homograft valves
  • Previous bacterial endocarditis
  • Certain congenital heart diseases
  • Acquired valve disease (for example, rheumatic heart disease)
  • Heart valve disease that develops after heart transplantation
  • Hypertrophic cardiomyopathy (HCM)
  • Mitral valve prolapse with valve regurgitation (leaking) and/or thickened valve leaflets

According to the American Heart Association, about 29,000 patients are diagnosed with endocarditis each year.

How is bacterial endocarditis diagnosed?

The diagnosis of bacterial endocarditis is based on the presence of symptoms, the results of a physical examination and the results of diagnostic tests:

  • Symptoms of infection (see list to the right), particularly a fever over 100°F (38.4°C)
  • Blood cultures show bacteria or microorganisms commonly found with endocarditis. Blood cultures are blood tests taken over time that allow the laboratory to isolate the specific bacteria that is causing your infection. They must be taken before antibiotics are started to determine if you have endocarditis.
  • Echocardiogram (ultrasound of the heart) may show growths, abscesses (holes), new regurgitation (leaking) or stenosis (narrowing), or an artificial heart valve that has begun to pull away from the heart tissue. Sometimes doctors insert an ultrasound probe into the esophagus or “food pipe” (transesophageal echo) to obtain a very detailed look at the heart.
  • Other signs and symptoms of bacterial endocarditis include:
    • Emboli (small blood clots), hemorrhages (internal bleeding), or stroke
    • Shortness of breath
    • Night sweats
    • Poor appetite or weight loss
    • Muscle and joint ache

How is bacterial endocarditis treated?

After the specific bacteria causing the endocarditis are identified from blood culture tests, a course of intravenous (IV) antibiotic therapy is started. IV antibiotics may be given for as long as 6 weeks to control the infection. Symptoms are monitored throughout therapy and blood tests are performed to determine the effectiveness of treatment.

If heart valve damage has occurred, surgery may be required to fix the heart valve and improve heart function.

Bacterial endocarditis treatment starts with prevention. Once endocarditis occurs, quick treatment is necessary to prevent damage to the heart valves and more serious complications, such as death.

How can bacterial endocarditis be prevented?

Traditionally, patients who were considered at risk of developing endocarditis (such as those listed above in the section, “Who is at risk of developing bacterial endocarditis?”) were advised to take antibiotics as a preventive measure before any dental, gastrointestinal or urinary tract procedure. Recently, a group of experts appointed by the American Heart Association conducted a review of the scientific literature to determine the value and effectiveness of antibiotic prophylaxis (preventive antibiotics) before such procedures in reducing the risk of bacterial endocarditis.

They found the following information to be proven true, and therefore revised the guidelines for bacterial endocarditis prevention.

Summary of Infective Endocarditis (IE) Prevention Guidelines from the American Heart Association*
  1. Endocarditis is more likely a result of daily exposure to bacteria, rather than exposure during a dental, gastrointestinal tract or genitourinary tract procedure. There may be greater risks from preventive antibiotic therapy than potential benefits, if any.
  2. You can reduce the risk of bacterial endocarditis by practicing good oral hygiene habits every day. Good oral health is generally more effective in reducing your risk of bacterial endocarditis than is taking preventive antibiotics before certain procedures. Take good care of your teeth and gums by:
  3. Not all endocarditis can be prevented. Call your doctor if you have symptoms of an infection (See box above). Do not wait a few days until you have a major infection to seek treatment. Colds and the flu do not cause endocarditis. But infections that may have the same symptoms (sore throat, general body aches, and fever) do. To be safe, call your doctor.
  4. Only the people who have the highest risk for bacterial endocarditis will reasonably benefit from taking preventive antibiotics before certain procedures. The highest risk group for bacterial endocarditis includes those with:
    • An artificial (prosthetic) heart valve, including bioprosthetic and homograft valves
    • Previous bacterial endocarditis
    • Certain congenital heart diseases, including:
      • Complex cyanotic congenital heart disease such as single ventricle states, transposition of the great arteries, Tetralogy of Fallot
      • Unrepaired cyanotic congenital heart disease, including patients with palliative shunts and conduits
      • Congenital heart disease that is completely repaired by surgery or with a transcatheter device. Endocarditis prevention is reasonable for at least 6 months following the device implant. According to the American Heart Association, after 6 months, there is insufficient data to make recommendations for preventive antibiotic therapy.
      • Repaired congenital heart disease with defects still remaining at the site or next to the site of a prosthetic patch or prosthetic device
      • Heart valve disease that develops after heart transplantation
  5. Importantly, the AHA no longer recommends antibiotic prophylaxis for gastrointestinal and genitourinary procedures, such as gastroscopy, colonoscopy, and cystoscopy.

(Reference: Wilson W., et al. Prevention of infective endocarditis: Guidelines from the American Heart Association. Circulation. May 8, 2007; 115(8).

If you are in the high risk group above, please follow these additional guidelines:
  1. Tell your doctors and dentists you have heart disease that places you at greater risk of developing endocarditis.
  2. Take antibiotics before the following procedures (as recommended by the American Heart Association):
    • All dental procedures that involve manipulation of gingival tissue or the peri-apical region of teeth, or perforation of the oral mucosa.
    • Procedures of the respiratory tract or infected skin, tissues just under the skin, or musculoskeletal tissue
  3. Link to Prevention of Bacterial Endocarditis Wallet Card
  4. Check with your doctor about the type and amount of antibiotics you should take. Plan ahead to find out what steps you must take before the day of your procedure.
  5. Carry a wallet identification card. A wallet card may be obtained from the American Heart Association* with specific antibiotic guidelines. Visit their website or call your local American Heart Association office or nationally, 1.800.AHA.USA1.*

Resources:

*a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operator

Reviewed by Gosta Pettersson, MD, PhD and James Thomas, MD

Reviewed: 11/13

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This information is provided by Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

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