Endocarditis

Overview

What is endocarditis?

Infective endocarditis (IE) is a potentially fatal inflammation of your heart valves’ lining and sometimes heart chambers’ lining. This occurs when germs (usually bacteria) from elsewhere in your body enter your bloodstream and attach to and attack the lining of your heart valves and/or chambers. Infective endocarditis is also called bacterial endocarditis (BE) or acute, subacute (SBE) or chronic bacterial endocarditis.

How does this condition affect my body?

Infective endocarditis causes growths (vegetations) on the valves, produces toxins and enzymes that kill and break down the tissue to cause holes in the valve, and spreads outside your heart and blood vessels. The resulting complications are:

Without treatment, endocarditis is a fatal disease.

Who does endocarditis affect?

Endocarditis happens to twice as many people assigned male at birth than people assigned female at birth. Also, people older than 60 make up more than 25% of cases.

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

  • Acquired valve disease (for example, rheumatic heart disease) including mitral valve prolapse with valve regurgitation (leaking) and/or thickened valve leaflets.
  • An artificial (prosthetic) heart valve, including bioprosthetic and homograft valves.
  • Previous bacterial endocarditis.
  • Certain congenital (present at birth) heart issues.
  • A device, such as a pacemaker.
  • A suppressed immune system.
  • An intravenous drug abuse habit.
  • Hypertrophic cardiomyopathy (HCM).

How common is endocarditis?

Endocarditis rarely happens in people whose hearts are healthy. According to the American Heart Association, about 47,000 people in the United States get an endocarditis diagnosis each year.

Symptoms and Causes

What are the endocarditis symptoms?

Signs of an endocarditis infection include:

  • Fever above 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 your upper cheekbones.
  • Persistent dry or a moist cough that lasts more than two days.
  • White patches in your mouth or on your tongue.
  • Nausea, vomiting or diarrhea.
  • Emboli (small blood clots), hemorrhages (internal bleeding) or stroke.
  • Shortness of breath.
  • Poor appetite or weight loss.
  • Muscle and joint aches.

What causes endocarditis?

Most of the time, a bacterial infection causes endocarditis. Dental procedures (particularly tooth extractions) and endoscopic examinations can cause bacteria to get into your blood. Sometimes, bacteria from your mouth, skin, intestines, respiratory system or urinary tract may be able to get into your bloodstream when you’re:

  • Eating.
  • Brushing your teeth.
  • Flossing your teeth.
  • Pooping.

This can cause endocarditis. The bacteria rapidly form colonies, grow vegetation and produce enzymes, destroying the surrounding tissue and opening the path for invasion.

Normal heart valves are very resistant to infection. However, bacteria can attach to defects on the surface of diseased valves. Replacement heart valves are more prone to infection than normal valves.

Diagnosis and Tests

How is bacterial endocarditis diagnosed?

Your healthcare provider will diagnose bacterial endocarditis after:

  • Confirming that you have symptoms of endocarditis.
  • Getting the results of a physical examination.
  • Getting diagnostic test results.

What tests will be done to diagnose endocarditis?

Diagnostic tests for endocarditis include:

  • Blood cultures that show bacteria or microorganisms that healthcare providers often see with endocarditis. Blood cultures — blood tests taken over time — allow a laboratory to isolate the specific bacteria that are causing your infection. To secure a diagnosis, the lab must take blood cultures before you start taking antibiotics.
  • Complete blood count, which can tell your provider if you have an unusually high number of white blood cells. This can mean you may have an infection.
  • Blood tests for substances like C-reactive protein can show you have inflammation.
  • Echocardiogram (ultrasound of the heart), which may show growths (vegetations on your valve), abscesses (holes), new regurgitation (leaking) or stenosis (narrowing), or an artificial heart valve that has begun to pull away from your heart tissue. Sometimes providers insert an ultrasound probe into your esophagus or “food pipe” (transesophageal echo) to get a closer, more detailed look at your heart.
  • Checking heart valve tissue to find out which kind of microbe you have.
  • Positron emission tomography (PET) or nuclear medicine scans to create images using radioactive material that can show an infection’s location.

Management and Treatment

How is bacterial endocarditis treated?

Endocarditis can be life-limiting. Once you get it, you’ll need quick treatment to prevent damage to your heart valves and more serious complications.

After taking your blood cultures, your healthcare provider will start you on intravenous (IV) antibiotic therapy. They’ll use a broad-spectrum antibiotic to cover as many suspected bacterial species as possible. As soon as they know which specific type of organism you have, they’ll adjust your antibiotics to target it. Usually, you’ll receive IV antibiotics for as long as six weeks to cure your infection.

Your provider will monitor your symptoms throughout your therapy to see if your treatment is effective. They’ll also repeat your blood cultures.

If endocarditis damages your heart valve and any other part of your heart, you may need surgery to fix your heart valve and improve your heart function.

After you complete your treatment, your provider will determine the sources of bacteria in your blood (for example, dental infections) and treat them. In the future, you should take prophylactic (preventive) antibiotics according to national guidelines.

What medications/treatments are used?

Antibiotics treat bacterial endocarditis. For other types of endocarditis, you may need blood thinners or antifungal medicines. Medicines can have side effects, but this treatment is necessary to protect your life. Some people feel better within a few days of starting treatment. For others, it can take longer.

Prevention

How can I reduce my risk?

By practicing good oral hygiene habits every day, you can reduce your risk of bacterial endocarditis. Good oral health is generally more effective in reducing your risk of bacterial endocarditis than taking preventive antibiotics before certain procedures. Take care of your teeth and gums by:

  • Seek professional dental care every six months.
  • Regularly brush and floss your teeth.
  • Make sure your dentures fit properly.

How can I prevent bacterial endocarditis?

The American Heart Association revised its guidelines for antibiotic prophylaxis (preventive antibiotics) before certain procedures to reduce the risk of bacterial endocarditis in high-risk people. The AHA no longer recommends antibiotic prophylaxis for non-dental procedures.

The organization considers endocarditis to be more likely a result of daily exposure to bacteria, rather than exposure during a procedure. Preventive antibiotic therapy may present greater risks than potential benefits if any.

Only 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.
  • Artificial material from a cardiac valve repair.
  • Previous bacterial endocarditis.
  • Unrepaired cyanotic congenital heart disease.
  • Repaired congenital heart disease with shunts or regurgitation at the site or next to the site of an artificial patch or device.
  • Heart valve disease (regurgitation) that develops after a heart transplant.

Additional guidelines for people in the high-risk group above

Tell your medical and dental providers you have heart disease that places you at a greater risk of developing endocarditis.

Take antibiotics before all dental procedures that involve manipulation of your gums or the periapical (roots) area of your teeth or perforation of your oral mucosa (tissue that lines the inside of your mouth).

Check with your medical provider 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.

Carry a wallet identification card you can get from the American Heart Association with specific antibiotic guidelines.

Outlook / Prognosis

What can I expect if I have this condition?

You can expect to take antibiotics for two to eight weeks to get rid of your infection. Most people survive endocarditis when they get aggressive treatment, but your risk of endocarditis being fatal depends on:

  • Your age.
  • Whether you have an artificial valve in your heart.
  • How long you have had the infection.
  • What type of organism made you sick.
  • How badly your heart valve is damaged.

Endocarditis is fatal without treatment.

Living With

How do I take care of myself?

Endocarditis can happen more than once. You’ll need to do your part to make sure you recover from endocarditis and stay well.

  • You may need a blood test every day or two to check for bacteria until it’s gone.
  • You may need to have another echocardiogram now and then to see how well your heart is functioning.
  • Keep taking any medicines your healthcare provider prescribed.
  • Make sure you go to all follow-up appointments with your provider.
  • Go to dental checkups regularly.
  • Wash cuts on your skin so they don’t get infected.

When should I see my healthcare provider?

Contact your provider if you have symptoms of an infection. Don’t wait a few days until you have a major infection to seek treatment. Colds and the flu don’t cause endocarditis. But infections do, and they may have the same symptoms (sore throat, general body aches and fever). To be safe, contact your provider.

When should I go to the ER?

Call 911 if you think you’re having a stroke, which endocarditis can cause.

What questions should I ask my doctor?

  • After leaving the hospital, can I get IV medicines at home or switch to a pill form of medicine?
  • What’s my risk of getting endocarditis again?
  • Do I need to take preventive antibiotics before dental appointments?

A note from Cleveland Clinic

With aggressive treatment, most people recover from endocarditis. Know the symptoms of endocarditis and contact your healthcare provider right away if you think you have it. Taking good care of your teeth and mouth can lower your risk of endocarditis. That includes daily care as well as visiting your dental provider on a regular basis.

Last reviewed by a Cleveland Clinic medical professional on 05/12/2022.

References

  • American Heart Association. Infective Endocarditis. (https://www.heart.org/en/health-topics/infective-endocarditis) Accessed 11/10/2021.
  • American Heart Association. What Is Infective Endocarditis? (https://www.heart.org/-/media/Files/Health-Topics/Answers-by-Heart/What-is-Infective-Endocarditis.pdf) Accessed 11/10/2021.
  • Merck Manual Consumer Version. Infective Endocarditis. (https://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/endocarditis/infective-endocarditis) Accessed 11/10/2021.
  • National Heart, Lung, and Blood Institute. Heart Inflammation. (https://www.nhlbi.nih.gov/health-topics/heart-inflammation) Accessed 11/10/2021.
  • Nishimura, RA, et. al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000503) Circulation. 2017; 135 (25) e1159-e1195. Accessed 11/10/2021
  • Otto CM, Nishimura RA, Bonow RO. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. (https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923) Circulation. 2021;143:e72-e227. Accessed 11/10/2021.

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