University of California San Francisco

Endocarditis

Endocarditis (EN-do-kar-DI-tis) is an infection of the inner lining of your heart chambers and valves. This lining is called the endocardium. The condition also is called infective endocarditis (IE).

The term "endocarditis" also is used to describe an inflammation of the endocardium due to other conditions. This article only discusses endocarditis related to infection.

IE occurs if bacteria, fungi, or other germs invade your bloodstream and attach to abnormal areas of your heart. The infection can damage the heart and cause serious and sometimes fatal complications.

IE can develop quickly or slowly. How the infection develops depends on what type of germ is causing it and whether you have an underlying heart problem. When IE develops quickly, it's called acute infective endocarditis. When it develops slowly, it's called subacute infective endocarditis.

Overview

IE mainly affects people who have:

  • Damaged or artificial heart valves
  • Congenital heart defects (defects present at birth)
  • Implanted medical devices in the heart or blood vessels

People who have normal heart valves also can get IE. However, the condition is much more common in people who have abnormal hearts.

Certain factors make it easier for bacteria to enter your bloodstream. These factors also put you at higher risk for the infection. For example, if you've had IE before, you're at higher risk for the infection.

Other risk factors include having poor dental hygiene and unhealthy teeth and gums, using intravenous (IV) drugs, and having catheters or other medical devices in your body for long periods.

Common symptoms of IE are fever and other flu-like symptoms. Because the infection can affect people in different ways, the signs and symptoms vary. IE also can cause complications in many other parts of the body besides the heart.

If you're at high risk for IE, seek medical care if you have signs or symptoms of the infection, especially a fever that persists or unexplained fatigue (tiredness).

Outlook

IE is treated with antibiotics for several weeks. You also may need heart surgery to repair or replace heart valves or remove infected heart tissue.

Most people who are treated with the proper antibiotics recover. But if the infection isn't treated, or if it persists despite treatment (for example, if the bacteria are resistant to antibiotics), it's usually fatal.

If you have signs or symptoms of IE, you should see your doctor as soon as you can, especially if you have abnormal heart valves.

What Causes Endocarditis?

Infective endocarditis (IE) occurs when bacteria, fungi, or other germs invade your bloodstream and attach to abnormal areas of your heart. Certain factors increase the risk of germs attaching to a heart valve or chamber and causing an infection.

A common underlying factor in IE is a structural heart defect, especially faulty heart valves. Usually your immune system will kill germs in your bloodstream. However, if your heart has a rough lining or abnormal valves, the invading germs can attach and multiply in the heart.

Other factors, such as those that allow germs to build up in your bloodstream, also can play a role in causing IE. Common activities, such as brushing your teeth or having certain dental procedures, can allow bacteria to enter your bloodstream. This is even more likely to happen if your teeth and gums are in poor condition.

Having a catheter or other medical devices 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 infections due to 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.

Endocarditis Complications

As the bacteria or other germs multiply in your heart, they form clumps with other cells and matter found in the blood. These clumps are called vegetations (vej-eh-TA-shuns).

As IE worsens, pieces of the vegetations can break off and travel to almost any other organ or tissue in the body. There, the pieces can block blood flow or cause a new infection. As a result, IE can cause a wide range of complications.

Heart Complications

Heart problems are the most common complication of IE. They occur in one-third to one-half of all people who have the infection. These problems may include a new heart murmur, heart failure, heart valve damage, heart block, or, rarely, a heart attack.

Central Nervous System Complications

These complications occur in as many as 20 to 40 percent of people who have IE. Central nervous system complications most often occur when bits of the vegetation, called emboli (EM-bo-li), break away and lodge in the brain.

There, they can cause local infections (called brain abscesses) or a more widespread brain infection (called meningitis).

Emboli also can cause a stroke or seizures. This happens if they block blood vessels or affect the brain's electrical signals. These complications can cause long-lasting damage to the brain and may even be fatal.

Complications in Other Organs

IE also can affect other organs in the body, such as the lungs, kidneys, and spleen.

Lungs. The lungs are especially at risk when IE affects the right side of the heart. This is called right-sided infective endocarditis.

A vegetation or blood clot going to the lungs can cause a pulmonary embolism and lung damage. Other lung complications include pneumonia and a buildup of fluid or pus around the lungs.

Kidneys. IE can cause kidney abscesses and kidney damage. IE also can cause inflammation of the internal filtering structures of the kidneys.

Signs and symptoms of kidney complications include back or side pain, blood in the urine, or a change in the color or amount of urine. In a small number of people, IE can cause kidney failure.

Spleen. The spleen is an organ located in the left upper part of the abdomen near the stomach. In as many as 25 to 60 percent of people who have IE, the spleen enlarges (especially in people who have long-term IE).

Sometimes, emboli also can damage the spleen. Signs and symptoms of spleen problems include pain or discomfort in the upper left abdomen and/or left shoulder, a feeling of fullness or the inability to eat large meals, and hiccups.

Who Is At Risk for Endocarditis?

Infective endocarditis (IE) is an uncommon condition that can affect both children and adults. It's more common in men than women.

IE typically affects people who have abnormal hearts or other conditions that make them more likely to get the infection. In some cases, IE does affect people who were healthy before the infection.

Major Risk Factors

The germs that cause IE tend to attach and multiply on damaged, malformed, or artificial heart valves and implanted medical devices. Certain conditions put you at higher risk for IE. These include:

  • Congenital heart defects (defects that are present at birth). Examples include a malformed heart or abnormal heart valves.
  • Artificial heart valves; an implanted medical device in the heart, such as a pacemaker wire; or an intravenous (IV) catheter in a blood vessel for a long time.
  • Heart valves damaged by rheumatic fever or calcium deposits that cause age-related valve thickening. Scars in the heart from a previous case of IE also can damage heart valves.
  • IV drug use, especially if needles are shared or reused, contaminated substances are injected, or the skin isn't properly cleaned before injection.

What Are the Signs and Symptoms of Endocarditis?

Infective endocarditis (IE) can cause a range of signs and symptoms that can vary from person to person. Signs and symptoms also can vary over time in the same person.

Signs and symptoms differ depending on whether you have an underlying heart problem, the type of germ causing the infection, and whether you have acute or subacute IE.

Signs and symptoms of IE may include:

  • Flu-like symptoms, such as fever, chills, fatigue (tiredness), aching muscles and joints, night sweats, and headache.
  • Shortness of breath or a cough that won't go away.
  • A new heart murmur or a change in an existing heart murmur.
  • Skin changes such as:
    • Overall paleness.
    • Small, painful, red or purplish bumps under the skin on the fingers or toes.
    • Small, dark, painless, flat spots on the palms of the hands or the soles of the feet.
    • Tiny spots under the fingernails, on the whites of the eyes, on the roof of the mouth and inside of the cheeks, or on the chest. These spots are from broken blood vessels.
  • Nausea (feeling sick to your stomach), vomiting, a decrease in appetite, a sense of fullness with discomfort on the upper left side of the abdomen, or weight loss with or without a change in appetite.
  • Blood in the urine.
  • Swelling in the feet, legs, or abdomen.

How Is Endocarditis Diagnosed?

Your doctor will diagnose infective endocarditis (IE) based on your risk factors, your medical history and signs and symptoms, and the results from tests.

Diagnosis of the infection often is based on a number of factors, rather than a single positive test result, sign, or symptom.

Diagnostic Tests

The results from blood tests, echocardiography, and an EKG (electrocardiogram) can help diagnose IE.

Blood Tests

Blood cultures are the most important blood tests used to diagnose IE. Blood is drawn several times over a 24-hour period. It's put in special culture bottles that allow bacteria to grow.

Doctors then identify and test the bacteria to see which antibiotics will kill them. Sometimes the blood cultures don't grow any bacteria, but the person still has IE. This is called culture-negative endocarditis, and it requires antibiotic treatment.

More standard blood tests also are used to diagnose IE. For example, a complete blood count may be used to check the number of red and white blood cells in your blood. Blood tests also may be used to check your immune system and to check for inflammation.

Echocardiography

Echocardiography is a painless test that uses sound waves to create pictures of your heart. Two types of echocardiography are useful in diagnosing IE.

Transthoracic (tranz-thor-AS-ik) echocardiogram. For this painless test, gel is applied to the skin on your chest. A device called a transducer is moved around on the outside of your chest.

This device sends sound waves called ultrasound through your chest. As the ultrasound waves bounce off the structures of your heart, a computer converts them into pictures on a screen.

Your doctor uses the pictures to look for vegetations, areas of infected tissue (such as an abscess), and signs of heart damage.

Because the sound waves have to pass through skin, muscle, tissue, bone, and lungs, the pictures may not have enough detail. Thus, your doctor may recommend a transesophageal (tranz-ih-sof-uh-JEE-ul) echocardiogram (TEE).

Transesophageal echocardiogram. For this test, a much smaller transducer is attached to the end of a long, narrow, flexible tube. The tube is passed down your throat. Before the procedure, you're given medicine to help you relax, and your throat is sprayed with numbing medicine.

The doctor then passes the transducer down your esophagus (the passage from your mouth to your stomach). Because this passage is right behind the heart, the transducer can get clear pictures of the heart's structures.

EKG

An EKG is a simple, painless test that detects heart's electrical activity. It shows how fast your heart is beating, whether your heart rhythm is steady or irregular, and the strength and timing of electrical signals as they pass through your heart.

An EKG typically isn't used to diagnose IE. However, it may be done to see whether IE is affecting your heart's electrical activity.

For this test, soft, sticky patches called electrodes are attached to your chest, arms, and legs. You lie still while the electrodes detect your heart's electrical signals. A machine records these signals on graph paper or shows them on a computer screen. The entire test usually takes about 10 minutes.

How Is Endocarditis Treated?

Infective endocarditis (IE) is treated with antibiotics and sometimes with heart surgery.

Antibiotics

Antibiotics usually are given for 2 to 6 weeks through an intravenous (IV) line inserted into a vein. You're often hospitalized for at least the first week or more of treatment. This allows your doctor to make sure your infection is responding to the antibiotics.

If you're allowed to go home before the treatment is done, the antibiotics are almost always continued by vein at home. You'll need special care if you get IV antibiotic treatment at home. Before you leave the hospital, your medical team will arrange for you to receive home-based care so you can continue your treatment.

You also will need close medical followup, usually by a team of doctors. This team often includes a doctor who specializes in infectious diseases, a cardiologist (heart specialist), and a heart surgeon.

Surgery

In some cases, surgery is needed to repair or replace a damaged heart valve or to help clear up the infection. IE due to an infection with fungi often requires surgery. This is because this type of IE is harder to treat than IE due to bacteria.

How Can Endocarditis Be Prevented?

If you're at risk for infective endocarditis (IE), you can take steps to prevent the infection and its complications.

  • Be alert to the signs and symptoms of IE. Contact your doctor right away if you have any of these signs or symptoms, especially a persistent fever or unexplained fatigue.
  • Brush and floss your teeth regularly, and have regular dental checkups. Germs from a gum infection can enter your bloodstream.
  • Avoid body piercing, tattoos, or other procedures that may allow germs to enter your bloodstream.

New research shows that not everyone at risk for IE needs to take antibiotics before routine dental exams and certain other dental or medical procedures.

Let your health care providers, including your dentist, know if you're at risk for IE. They can tell you whether you need such antibiotics before exams and procedures.

Key Points

  • Endocarditis is an infection of the inner lining of your heart chambers and valves. The condition also is called infective endocarditis (IE).
  • IE occurs if bacteria, fungi, or other germs invade your bloodstream and attach to abnormal areas of your heart. The infection can damage the heart and cause serious and sometimes fatal complications.
  • IE can develop quickly or slowly depending on what type of germ is causing it and whether you have an underlying heart problem.
  • IE mainly affects people who have damaged or artificial heart valves, congenital heart defects (defects that are present at birth), or implanted medical devices in the heart or blood vessels.
  • IE is an uncommon condition that can affect both children and adults. It's more common in men than women.
  • IE can cause a range of signs and symptoms that can vary from person to person. Signs and symptoms also can vary over time. Common symptoms are fever and other flu-like symptoms.
  • Your doctor will diagnose IE based on your risk factors, your medical history and signs and symptoms, and the results from tests. Diagnosis of the infection often is based on a number of factors, rather than a single positive test result, sign, or symptom.
  • IE is treated with antibiotics and sometimes with heart surgery. Antibiotics usually are given for 2 to 6 weeks through an intravenous (IV) line inserted into a vein. You're often hospitalized for at least the first week or more of treatment. In some cases, surgery is needed to repair or replace a damaged heart valve or to help clear up the infection.
  • If you're at risk for IE, you can take steps to prevent the infection and its complications. Be alert to the signs and symptoms of IE. Contact your doctor right away if you have any of these signs and symptoms. Brush and floss your teeth regularly, and have regular dental checkups. Avoid body piercing, tattoos, or other procedures that may allow germs to enter your bloodstream.
  • Let your health care providers, including your dentist, know if you're at risk for IE. They can tell you whether you need antibiotics before routine dental exams and certain other dental or medical procedures that can let germs into your bloodstream.