Overview

Endocarditis is a rare and potentially fatal infection of the inner lining of the heart (the endocardium). It's most commonly caused by bacteria entering the blood and travelling to the heart.

Although the heart is usually well protected against infection, it may be easier for bacteria to bypass the immune system in people who have:

  • a prosthetic (artificial) heart valve – valve replacement surgery is increasingly being used when people experience narrowing of one of their heart valves
  • congenital heart disease – where a person is born with heart defects
  • hypertrophic cardiomyopathy – where the heart muscle cells have enlarged and the walls of the heart chambers thicken
  • damaged heart valves – because of infection or heart disease
  • People who inject drugs are also more likely to develop endocarditis.

  • Endocarditis is caused by bacteria in the bloodstream multiplying and spreading across the inner lining of your heart (endocardium). The endocardium becomes inflamed, causing damage to your heart valves.

    Your heart is usually well protected against infection so bacteria can pass harmlessly by. However, if your heart valves are damaged or you have an artificial valve, it's easier for bacteria to take root and bypass your normal immune response to infection.

  • Small clumps of bacteria can develop at the site of the infection. There's a risk of these clumps acting in a similar way to blood clots, travelling away from the heart and blocking the blood supply to the organs. This can cause organ failure or trigger a stroke.

    How bacteria reach the heart

    There are several ways that bacteria can enter your blood

  • Mouth

    Everyday activities, such as brushing your teeth or chewing your food, can sometimes allow bacteria to enter the bloodstream. The risk is increased if your teeth and gums are in bad condition, because it makes it easier for bacteria to enter.

    Infection

    Bacteria can spread from the site of a pre-existing infection, such as a skin infection or a gum infection.

    Bacteria can also enter your body as a result of a sexually transmitted infection (STI), such as chlamydia or gonorrhoea.

    Needles and tubes

    Any medical procedure that involves placing a medical instrument inside the body carries a small associated risk of introducing bacteria into your bloodstream.

    Instruments that have been linked to endocarditis include:

    syringes

    catheters – a tube used to drain the bladder

    the tubes used during dialysis – a treatment that involves replicating the functions of the kidneys

    laparoscopes – a small, flexible tube with a light source and a camera at one end, used to help diagnose a wide range of conditions

     

     

     

     


     

Title
Endocarditis

Symptoms

The symptoms of endocarditis can develop rapidly over the course of a few days (acute endocarditis) or slowly, over the course of a few weeks or possibly months (subacute endocarditis).

Subacute endocarditis is more common in people with congenital heart disease.

Symptoms of endocarditis

The most common symptoms of endocarditis include:

  • a high temperature (fever) of 38C (100.4F) or above
  • chills
  • night sweats
  • headaches
  • shortness of breath, especially during physical activity
  • cough
  • heart murmurs – where your heart makes a whooshing or swishing noise between beats
  • tiredness (fatigue)
  • muscle and joint pain

Other symptoms can include:

  • the appearance of a spotty red rash on the skin (this is known as petechiae)
  • narrow, reddish-brown lines of blood that run underneath the nails
  • painful raised lumps that develop on the fingers and toes
  • painful red spots that develop on the palms of your hand and soles of your feet
  • mental confusion
Diagnosis

To diagnose endocarditis, your GP will look closely at your medical history, paying particular attention to any problems you may have had with your heart.

Taking a medical history also allows your GP to identify whether you've undergone any recent medical procedures that may have put you at risk of developing endocarditis, such as surgery to the heart valves.

Physical examination

Your GP will check for the symptoms of endocarditis, such as fever or nodules (small lumps) on your fingers and toes.

They'll also listen to your heart using a stethoscope to see if you've developed a heart murmur. A heart murmur is where your heartbeat has an extra, or unusual, sound caused by a disturbed blood flow through the heart.

The symptoms of endocarditis are similar to those of other conditions, so it's important that other possible causes are ruled out. Sometimes, you may be referred for further tests.

Blood tests

Blood tests may be used to help diagnose endocarditis, or to help identify the most effective treatment. Blood tests may include:

  • a blood culture test – to check for a specific bacteria or fungi
  • an erythrocyte sedimentation rate (ESR) test
  • a C reactive protein (CRP) test

ESR and CRP tests can be used to check for inflammation. About 90% of endocarditis patients have an elevated ESR or CRP.

Echocardiogram

An echocardiogram uses sound waves to scan your heart. The waves can produce accurate images of the heart muscle, chambers and valves. This allows your doctor to examine the structure and function of your heart more closely.

An echocardiogram is often used to check for any clumps of bacteria that may have formed, and can help detect infected or damaged heart tissue.

These scans can be performed by either:

  • directly placing a probe on your chest
  • swallowing a probe to allow your heart to be studied from inside the gullet (transoesophageal echo)

The transoesophageal echo allows much clearer images of your heart as the gullet is just behind the heart.

Computerised tomography (CT) scan

A computerised tomography (CT) scan uses X-rays to take pictures of the inside of your body. A computer is then used to piece the images together.

A CT scan can be useful for identifying any abscesses(collections of pus) that may have developed in your body

Treatment

Most cases of endocarditis can be treated with a course of antibiotics.

You'll usually have to be admitted to hospital so the antibiotics can be given through a drip in your arm (intravenously).

While you're in hospital, regular blood samples will be taken to see how well the treatment is working. Once your fever and any severe symptoms subside, you may be able to leave hospital and continue taking your antibiotics at home.

If you're taking antibiotics at home, you should have regular appointments with your GP to check that the treatment is working and you're not experiencing any side effects.

Depending on the severity of your condition, you'll usually have to take antibiotics for between two and six weeks.

Your doctor will usually take a blood sample before prescribing antibiotics to make sure you're given the most effective treatment. If your symptoms are particularly severe, you may be prescribed a mixture of different antibiotics before the results of the blood samples. This is a precautionary measure to prevent your symptoms becoming worse.

If your blood sample shows that fungi are causing your infection, you'll be prescribed an antifungal medicine.

Surgery

Endocarditis can cause serious damage to your heart. You may be referred to a cardiologist (a specialist in diseases of the heart and blood vessels) so the condition of your heart can be assessed more thoroughly.

Between 15% and 25% of people with endocarditis need some form of surgery. This is usually to repair damage to the heart. Surgery will usually be recommended if:

  • your symptoms and/or test results suggest you've experienced heart failure – a serious condition where your heart isn't pumping blood around your body efficiently
  • you continue to have a high temperature (fever) despite treatment with antibiotics or antifungals
  • your endocarditis is caused by particularly aggressive fungi or drug-resistant bacteria
  • you experience one or more blood clots despite treatment with antibiotics or antifungals
  • you have a prosthetic (artificial) heart valve
  • the results of your echocardiogram suggest that an abscess (a collection of pus) or a fistula (an abnormal passageway) has developed inside your heart

The three main surgical procedures that are used to treat endocarditis are:

  • the repair of the damaged heart valve
  • the replacement of the damaged heart valves with prosthetic ones
  • the draining of any abscesses and the repair of any fistulas that may have developed in the heart muscle

Surgery for endocarditis can be very challenging, not least because a person who needs surgery will usually be very ill to begin with.

Despite the best efforts of their surgical teams, approximately one in 10 people will die during or shortly after surgery for endocarditis.

Prevention

If you have an increased risk of developing endocarditis, it's important to limit your exposure to any infection that could trigger it.

The same is true if you've previously been affected by endocarditis, as the condition can often reoccur in certain people.

Practise good oral hygiene

If you're at increased risk of developing endocarditis, it's important that you practise good oral and dental hygiene.

Don't let abscesses and gum disease go untreated.

You should visit your dentist on a regular basis to ensure you maintain good oral health and to minimise the risk of bacteria entering your bloodstream through your mouth.

Take care of your skin

Regularly washing your skin with an antibacterial soap will help to lower your risk of developing a skin infection. It's also very important to wash any cuts or grazes carefully as soon as you notice them to prevent them becoming infected.

Contact your GP for advice if you develop the symptoms of a skin infection (see below). Your GP may prescribe antibiotics as a precaution. Symptoms of a skin infection include:

  • redness and inflammation (swelling) of the affected area of skin
  • the skin feels tender and warm to the touch
  • a discharge of pus or fluid from the affected area of skin

A skin infection may also make you feel generally unwell, leading to symptoms such as:

  • a high temperature (fever) of 38C (100.4F) or above
  • feeling sick
  • shivering
  • chills

You should also avoid any cosmetic procedure that involves breaking the skin, such as body piercing and tattooing.

The role of antibiotics

Research has found that the benefits of antibiotics in preventing endocarditis are outweighed by the risks that they'll cause serious side effects.

Antibiotics should only be used when absolutely necessary. Each time antibiotics are used, the chances that bacteria will become resistant to them are increased.

Antibiotics will only be prescribed as a precautionary measure if a medical procedure is taking place at a site in your body where there's a suspected infection, such as your:

  • gullet, stomach or intestines
  • reproductive or urinary system
Risks

There are a number of things that can make your heart more vulnerable to infection and increase your chances of developing endocarditis. These are discussed below.

Heart valve disease

Heart valve disease is a general term describing conditions that damage the valves of the heart. Two types of heart valve disease known to increase your risk of endocarditis are:

  • valvular stenosis – where the valve(s) of the heart become narrowed, disrupting the blood flow through the heart
  • valvular regurgitation – where the valve(s) of the heart don't close properly, causing blood to leak back in the wrong direction

Heart valve disease can be either:

  • congenital – where you're born with the condition
  • acquired – where you develop the condition in later life

Causes of acquired heart valve disease include:

  • a previous heart attack – a heart attack can damage the muscles that surround and support the valve, preventing the valves from functioning properly
  • high blood pressure – without treatment, high blood pressure (hypertension) can weaken the tissue around the valves
  • rheumatic fever – a type of bacterial infection that can damage the heart

Rheumatic fever is rare since the introduction of antibiotics. However, older people who had rheumatic fever during childhood may go on to develop heart valve disease.

Prosthetic valves

Prosthetic (artificial) valves are used to replace heart valves that have been damaged by heart valve disease.

However, bacteria can also take root around prosthetic valves, which can occasionally trigger endocarditis. This risk is relatively low, estimated to be less than one in 100.

Hypertrophic cardiomyopathy

In hypertrophic cardiomyopathy, the heart muscle cells have enlarged and the walls of the heart chambers thicken. The chambers are reduced in size so they can't hold much blood, and the walls can't relax properly and may stiffen.

Hypertrophic cardiomyopathy is thought to affect 1 in 500 people in the UK.

Intravenous drug use

People who habitually inject illegal drugs such as heroin or methamphetamine (crystal meth) into their veins have an increased risk of developing endocarditis.

This is because unsterilised needles allow bacteria to enter the bloodstream and repeated injections make the skin more vulnerable to infection.

Fungal endocarditis

Endocarditis caused by a fungal infection is rarer than bacterial endocarditis, and usually more serious. You're more at risk of fungal endocarditis if you:

  • inject drugs
  • have a history of heart surgery
  • have a central venous catheter – a tube connected to a vein in the neck, groin or chest, which is used to deliver medicines and/or fluids to people who are seriously ill
  • have a weakened immune system – either as a result of a condition affecting the immune system, such as HIV, or as a side effect of certain types of treatments, such as chemotherapy