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Infectious endocarditis: general information
Last reviewed: 18.10.2021
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Infective endocarditis is infective damage to the endocardium, usually bacterial (usually streptococcal and staphylococcal) or fungal. It leads to fever, noises in the heart, petechiae, anemia, embolic episodes and vegetation on the endocardium. Vegetations can lead to failure of the valves or obstruction, myocardial abscess, mycotic aneurysm. For diagnosis, it is necessary to identify microorganisms in the blood and (usually) echocardiography. Treatment of infective endocarditis consists of long-term antimicrobial therapy and (sometimes) surgical methods.
Endocarditis can develop at any age. Men suffer 2 times more often. Individuals with immunodeficiency and drug addicts who inject drugs on their own are a group of the highest risk.
[What causes infective endocarditis?
Normally, the heart is relatively resistant to infections. Bacteria and fungi are difficult to attach to the surface of the endocardium, as this is prevented by a constant flow of blood. For the development of endocarditis, two factors are necessary: predisposing changes in the endocardium and the presence of microorganisms in the blood (bacteremia). Sometimes massive bacteremia and / or especially pathogenic microorganisms cause endocarditis of intact valves.
Symptoms of infective endocarditis
Initially, the symptoms are uncertain: moderate fever (<39 ° C), night sweats, fast fatigue, malaise and weight loss. Symptoms of colds and arthralgia may appear. Manifestations of valvular insufficiency can be the first finding. Initially up to 15% of patients have a fever or noise, but in the end almost all of them have both signs. Data from a physical examination can be normal or include pallor, fever, changes in the existing noise, or the development of new regurgitation noise and tachycardia.
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Diagnosis of infective endocarditis
Since the symptoms are nonspecific, they change greatly and can develop unnoticeably, a high degree of alertness is required in diagnosis. Endocarditis should be suspected in patients with fever without obvious sources of infection, especially if there is noise in the heart. Suspicion of endocarditis should be very high if the bacteriological examination of the blood is positive in a patient who has a history of heart valve damage, recently undergoing invasive procedures or injecting drugs intravenously. Patients with reported bacteraemia are shown a multiple complete examination to identify new valve sounds and symptoms of embolism.
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How to examine?
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Treatment of infective endocarditis
Treatment consists of a long course of antimicrobial therapy. Surgical intervention may be necessary for complications that disrupt the biomechanics of the valve apparatus, or resistant microorganisms. As a rule, antibiotics are prescribed intravenously. Since the duration of therapy is 2-8 weeks, intravenous injections are often performed on an outpatient basis.
Actively eliminate any sources of bacteremia: surgical excision of necrotic tissues, drainage of abscesses, removal of foreign materials and infected devices. Intravenous catheters (especially central venous catheters) must be replaced. If endocarditis develops in a patient with a newly established central venous catheter, it must be removed. Microorganisms present on catheters and other devices are unlikely to respond to antimicrobial therapy, leading to treatment failure or relapse. If continuous infusions are used in place of fractional bolus administration, the interruption between such infusions should not be too long.
Prognosis of infective endocarditis
Without treatment, infective endocarditis is always fatal. Even against the background of treatment, death is very likely, and the forecast is generally poor for the elderly and people who have an infectious disease with resistant microorganisms, previous illnesses or a prolonged lack of treatment. The prognosis is also worse in patients with lesions of the aortic valve or several valves, large vegetation, polymicrobial bacteremia, infection of the prosthetic valve, mycotic aneurysms, valve ring abscesses and massive embolism. Mortality with streptococcal endocarditis without serious complications is below 10%, but actually 100% with aspergillus endocarditis, which occurred after surgical valve replacement.
The prognosis is better for right-sided than for left-sided endocarditis, because dysfunction of tricuspid valve is better tolerated, systemic embolisms are absent and right-sided endocarditis caused by golden staphylococcus responds better to antimicrobial therapy.