Endocarditis treatment guidelines

Endocarditis—Overview

Endocarditis is inflammation of the heart's inner lining (endocardium) and valves caused by bacteria or fungi entering the bloodstream, forming growths (vegetations) that damage heart tissue, and presenting with flu-like symptoms, fever, fatigue, and sometimes skin changes. Treatment with antibiotics and possibly surgery is needed to prevent valve destruction or heart failure.

What is the primary cause of endocarditis?

The most prevalent cause of endocarditis is bacterial infection, where Staphylococcus aureus and Streptococcus enter the bloodstream from the skin, mouth, or stomach and infect injured heart tissue or artificial valves. Fungi and other pathogens can cause it less often, especially in immunocompromised individuals or those using IV medications. Bacteria are the main cause.

How it happens:

• Bloodstream bacteria: Bacteria from your skin, mouth, or other areas enter your blood.
• These germs adhere to injured heart valves, prosthetic valves, and other tissue.
• Bacteria grow, generating microbes, fibrin, and platelet vegetation that harm cardiac tissue and create problems.

Common Bacteria:

• A common cause in wealthy countries is Staphylococcus aureus.
• Common oral colonizers: Streptococci (viridans).
• Another important bacterial group: Enterococci.

Key Risk Factors: Artificial heart valves.

• Damage to the heart valve or congenital abnormalities are significant risk factors.
• The use of IV medications, which typically involve Staph or Candida, is also a risk factor.
• Poor oral hygiene is also a contributing factor.
• Certain medical procedures.
• A weakened immune system is a contributing factor.

What are the three stages?

• Disease develops in 3 stages:
• Bacteremia: Blood microorganisms.
• Microorganisms cling to defective or injured endothelium via surface adhesions.
• Colonisation: Organism proliferation and inflammation lead to mature vegetation.

How to spot endocarditis?

Endocarditis is diagnosed through physical exams, blood tests (especially blood cultures to find the germ), echocardiograms (TTE/TEE) to see "vegetations" (infection clumps) on heart valves, and other tests (ECG, CT) to check heart function and complications.

First steps: 

• Physical Exam: The Doctor listens for new murmurs and checks the skin for petechiae or Roth spots.

Key Diagnostics

• Blood cultures: Multiple samples obtained over time to identify infection-causing bacteria/fungi.
• Echocardiogram (Echo): The best imaging test for vegetation, valve disease, and heart function.
• Transthoracic: Chest probe.
• Transesophageal (TEE): Probe the esophagus for better views, especially prosthetic valves.
• A complete blood count (CBC) checks for infection (high white blood cells) or anemia.

Other Useful Tests

• ECG/EKG: Checks heart rhythm via electrical activity.
• A chest X-ray checks for heart enlargement or lung fluid.
• CT scans detect abscesses and sequelae, especially when the echo is ambiguous.
• An MRI of the heart can reveal its structure.

Verifying Diagnosis

Doctors employ Duke Criteria to combine these observations to make a diagnosis, frequently necessitating positive cultures and Echo results.

Do endocarditis symptoms emerge quickly?

• Endocarditis symptoms can appear quickly (acute) or slowly (subacute) over weeks or months. Congenital cardiac condition increases subacute endocarditis.

Telltale indications of endocarditis?

Endocarditis symptoms

A mild fever, hurting joints, weakness, exhaustion, and tiny dotlike regions on the back, chest, fingers, and toes may indicate a problem. A cardiac murmur often indicates a valve or heart problem.

If endocarditis goes untreated, what happens?

Most untreated infective endocarditis patients die. The infection can damage the heart valve(s), causing significant blood leaking (regurgitation) and an inability to pump blood to the body.

Endocarditis confirmation: how?

Endocarditis is diagnosed by a doctor's exam, history, blood cultures, and echocardiograms. Doctors utilise the Duke Criteria to confirm a diagnosis by combining clinical indicators (fever, murmur, risk factors) with lab (blood tests, inflammatory markers) and imaging findings. If blood cultures are negative, other investigations may be needed.

Important Diagnostic Tools

Blood Tests:

• Blood cultures: Required to identify infection-causing bacteria or fungus.
• CBC: Checks for infection-related elevated white blood cells or anemia.
• Inflammation markers include CRP and ESR.

Imaging Exams:

• Echocardiogram (TTE/TEE): Picture heart valves, check pumps, and discover vegetation or abscesses.
• CT scans can detect abscesses and other issues.
• Diagnostic Criteria (Modified Duke)

Combine these to diagnose:

• Blood culture and echocardiography for endocarditis (vegetation, abscess) are major criteria.
• Minor requirements: Predisposing circumstances, fever, vascular/immunologic symptoms (Osler's nodes, Roth spots), a single positive culture, or echocardiographic indications not matching major requirements.
• A definitive diagnosis can be made based on two major criteria, one major and three minor criteria, or five minor criteria.
• When Difficult. Culture-negative. If prior antibiotics or slow-growing organisms (fungi, Coxiella) are implicated, specialist tests are needed.
• Early Stage: Early diagnoses require close supervision and repeated tests.

Symptoms and signs are common

• Common symptoms and signs include night sweats, fever, chills, tiredness, and muscle/joint pain.
• The patient may experience a new or altered cardiac murmur.
• Breathlessness, as well as swelling in the legs and feet, are common symptoms.
• These symptoms can include Janeway lesions, Osler's nodes, Roth spots, and stroke.

How long do people with damaged heart valves live?

With medication or valve surgery, many live decades, often with life expectancy near normal for their age, though the specific valve (aortic or mitral), overall health, age, and treatment type all heavily influence the outcome, requiring regular monitoring and personalised care.

Untreated Severe Cases

• Aortic Stenosis/Regurgitation: Shortness of breath and chest pain might reduce survival to 2-3 years. Survival is limited to 2 years without therapy for severe regurgitation, causing heart failure.
• Mitral Regurgitation: Without intervention, severe cases with pulmonary hypertension can die within 3 years.

Medical and surgical treatment

• Medication can manage symptoms and increase survival, with 75% of severe aortic leak patients living at least 5 years.
• Valve Replacement Surgery: Improves results and generally extends life.
• Adults in their 60s may live 16 years longer after aortic valve replacement, while those 85+ may live 6 years longer.
• Long-term: Valve abnormalities can resurface or require another surgery in 10-15 years; thus, lifelong medication and checkups are essential.

Outlook-influencing factors

• Valve type: Prognoses vary for aortic, mitral, and tricuspid problems.
• Severity & Symptoms: Mild disease may never cause problems, but severe symptoms imply urgency.
• Age and Health: Younger people recover better from surgery.
• Early diagnosis and treatment extend life and quality.

In conclusion, a "bad" valve has a spectrum of lifespans. Living a long, healthy life with a heart valve issue requires early diagnosis, continuous medical management, and timely, appropriate surgery (repair or replacement).

Nail endocarditis

In endocarditis, splinter hemorrhages are common; these are thin, red-to-brown lines under the nails caused by septic debris clogging microscopic blood vessels. These occur when contaminated material breaks off heart valves, travels in the circulation, and gets trapped, indicating valve damage. Minor trauma can create splinter hemorrhages, but endocarditis requires immediate medical treatment with fever and exhaustion.

Endocarditis Nail Signs

• Splinter Hemorrhages: The most prevalent indication is vertical reddish-brown streaks under the nail and nail development.
• Petechiae: Microemboli-caused red spots on the skin, nails, or eye whites.
• Osler's Nodes, Janeway Lesions: Fingers/toes with crimson Osler's nodes or painless Janeway lesions.
• Clubbing: Rare, late indication of finger/toe expansion and nail curving.

Their Causes?

• Infection: Bacteria or fungi enter the circulation from incisions or dentistry and cling to heart valves.
• Infected clots breach valves and lodge in nail veins, causing bleeding.

Why They Matter

• They indicate bacterial endocarditis, a severe condition that needs immediate treatment.
• Microemboli (tiny clots/debris) from the sick heart harm minor vessels.

When to consult a Doctor

• If these nail changes are accompanied by fever, chills, exhaustion, or flu-like symptoms, seek medical attention.
• Recovery depends on early identification and treatment (typically weeks of IV antibiotics).

Endocarditis therapy

Endocarditis treatment usually entails weeks of high-dose IV antibiotics, starting experimentally and then targeted once blood cultures identify the bacteria or fungus, with close monitoring. Surgery may be needed to replace heart valves, drain abscesses, or treat heart failure. To avoid serious consequences, infectious disease, cardiology, and surgical professionals must work together for urgent therapy.

Medical Care

• Depending on the bug, high-dose antibiotics like penicillin, cephalosporins, or vancomycin are given intravenously for weeks, occasionally at home following hospitalization. Fungal infections need antifungals.
• Blood cultures identify the organism, allowing targeted therapy with the proper medicine and dosage.
• Surgery may be necessary for persistent infections, serious valve damage, massive vegetations, heart failure, or recurrent emboli.
• Valve repair, replacement, or abscess drainage is possible.

Conclusion

Treatment must begin early. Speedy treatment prevents major damage and consequences. The infectious disease, cardiology, and cardiac surgery teams collaborate. Regular blood and symptom checks assure therapy efficacy. After treatment, recurrence can be prevented with regular dental appointments and hygiene.