Bacterial Endocarditis

 

The heart, a four chambered muscular organ, that indefatigably pumps blood to the entire throughout life can also get infected and inflamed. Infections in the heart pose a more challenging clinical situation. Prompt treatment and prevention of further episodes is essential to keep the heart in good health.

Bacterial endocarditis (BE) is an inflammation of the heart valves and the inner most lining of the heart, called the endocardium. In addition, the septae that separate the chambers of the heart and the chordae tendineae (fibrous supports that enable the opening and closing of the valves) may be inflamed. The inflammation occurs due to infection with microorganisms called bacteria.

An inflammation that may occur suddenly, called acute bacterial endocarditis, is caused by a bacterium called staphylococci. At other times, the inflammation may have a slower onset and a longer course, called subacute endocarditis, is caused by viridans streptococci, enterococci, and coagulase negative staphylococci.

Bacterial endocarditis typically occurs in people who have defective heart valves. The heart valves may be defective since birth (congenital defects), or may have been damaged due to disease like a heart attack or rheumatic heart disease later in life.

Any implanted devices like an artificial valve or pacemaker implanted to replace the defective natural ones pose a higher risk for bacterial endocarditis. A tubing or catheter left in the blood vessels for long periods allow entry of bacteria in to the blood stream and hence cause endocarditis. Drug abusers who inject drugs into the blood vessels are similarly at high risk.

Dental and medical procedures can increase the risk for BE. The causative bacteria like the Streptococcus viridans are a part of the resident flora in the crevices between teeth and the skin. Any procedures done on teeth or in the urinary system or digestive tract allow invasion into blood stream due to exposure of blood vessels during these procedures.

Teeth that are in poor health and hygiene when brushed vigorously enough to cause micro abrasions or bleeding, can lead to invasion of bacteria into the blood stream. Having tubings inserted into blood vessels for long for infusions of medicines and fluids makes a portal of entry of bacteria into blood stream and then to the heart.

BE can cause signs and symptoms which may vary over time and may differ in individuals. A few endocarditis symptoms are mentioned below.

The commonest ones are the flu like symptoms such as;

  • Fever
  • Chills
  • Body ache
  • Night sweats
  • Tiredness
  • Persistent cough
  • Prolonged shortness of breath
  • Change in heart sounds
  • Pale skin
  • Rash with tiny bleeding spots
  • Small, painless, red or purple spots or bumps may develop on fingers and toes (Osler's nodes), or soles and palms (Janeway lesions)
  • Blood may appear in urine
  • Nausea
  • Vomiting
  • Loss in weight
  • Swelling in the feet, hand and abdomen

There are several potential complications in BE. The bacterial colonies growing along the edges of the valves may fragment and then be carried away in the blood stream. These fragments called emboli can block other smaller blood vessels in the lungs, spleen, kidneys, or the brain. This can cause death of tissues called infarction in these organs.

Bleeding into the brain, called brain hemorrhage, and the failure of heart or kidneys may occur. If blood vessels in the bones are occluded by these emboli, it can cause bone pains. The emboli may be infected with bacteria and hence may spread the infection throughout the body causing sepsis.

BE is diagnosed by using a battery of tests. The most common initial test is a blood culture. Samples of blood drawn at regular intervals are tested for causative organisms which are then allowed to grow under laboratory conditions. These may then be isolated and tested for their sensitivities to anti-infective medicines.

Other blood tests include a count of different cells in the blood, called a complete blood count (CBC), and tests for some markers of inflammation.

An analysis of the inner heart lining and valves is done with an echocardiogram that works on the reflection of sound waves. This may be done through the chest (transthoracic echo) or through the food pipe (transesophageal echo). The latter is more precise as it allows a closer and more direct view of the heart.

An electrocardiogram (ECG) may be done to check the electrical activity, beating, and rhythmicity of the heart though it is not conclusively diagnostic of BE. This is done by placing sensor containing paddings at some specific points on the body. The diagnosis of BE is made in accordance to the Duke’s criteria which comprises major and minor criteria.

The presence of typical organisms, positive spread of bacteria in blood stream (bacteremia), positive testing for bacteria called Coxiella brunetii, positive culture, and a positive result on echo are the major criteria.

The minor criteria include the presence of fever greater than 38° C, valvular heart disease, skin lesions, drug abuse using injections into blood vessels, the presence of a single positive blood culture, and suggestive findings on echo. BE is diagnosed in presence of one major and three minor criteria.

BE is treated with medicines to fight infection called antibiotics which are given as injections into the blood vessels (Intravenous or IV route) for up to 6 weeks.

The common antiobiotics used for treatment are penicillin, ceftriaxone, vancomycin, and combination of penicillin, ceftriaxone, or vancomycin and gentamicin.

A damaged or heavily infected heart valve, whether natural or artificial, may need to be replaced surgically. Surgery may be done to clean up the heavy growing colonies.

BE can be prevented. It is important to seek medical help at the very first suggestive symptoms.

  • Regular brushing, flossing, and dental checkups are essential for a good oral hygiene and to prevent BE.
  • Body piercing, tattoos, injections for drug abuse should be avoided.
  • People at increased risk should take preventive endocarditis treatment with antibiotics before any medical or dental procedures.
  • The common antibiotics used for prevention are amoxicillin, ampicillin, ceftriaxone, cephalexin, clindamycin, azithromycin, cefazolin, vancomycin or ceftriaxone. Some of these may need to be injected.
  • People with heart defects, or artificial valves or pacemakers need special precautions.