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Overview |
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Definition |
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Endocarditis, an infection and inflammation of the endocardium, usually
affects the external lining of heart valves (valvular endocarditis), although it
also can impact the lining of heart chambers (mural endocarditis). A complex
condition with a variety of causes, often a potentially serious complication of
prosthetic cardiac valve or tissue graft valve replacement. While endocarditis
does have nonbacterial etiologies, the condition generally is related to
bacterial infection and thus frequently is referred to as infective
endocarditis, infectious endocarditis, or bacterial endocarditis.
For purposes of diagnosis:
- Acute endocarditis (acute bacterial endocarditis, acute infective
endocarditis): begins abruptly, progresses aggressively, and is quite
life-threatening. Usually caused by virulent organisms.
- Subacute endocarditis (subacute bacterial endocarditis, subacute
infective endocarditis): often in patients with underlying cardiac condition
(e.g., valves damaged by rheumatic fever); progresses slowly.
- Intravenous (IV) drug user endocarditis: common in IV drug users,
usually with tricuspid valve involvement.
- Prosthetic valve endocarditis (early: <60 days after implantation;
late: >60 days after implantation)
- Culture-negative endocarditis: affects a small percentage of
patients.
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Etiology |
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Acute endocarditis:
- Staphylococcus aureus
- Streptococcus groups A, B, C, and G
- Haemophilus influenzae and H. parainfluenzae
- Streptococcus pneumoniae
- Staphylococcus lugdunensis
- Enterococcus
- Neisseria gonorrhoeae
Subacute endocarditis:
- Alpha-hemolytic streptococci (viridans streptococci)
- Streptococcus bovis
- Enterococcus
- Haemophilus aphrophilus and H. paraphrophilus
- Actinobacillus actinomycetemcomitans
- Cardiobacterium hominis
- Eikenella corrodens
- Kingella kingae
- Staphylococcus aureus
IV drug user endocarditis:
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Burkholderia cepacia
- Enterococcus
- Candida
Prosthetic valve endocarditis:
Early (60 days after implantation):
- Staphylococcus aureus and S. epidermidis
- Gram-negative bacilli
- Candida
- Aspergillus
Late (60 days after implantation):
- Alpha-hemolytic streptococci (viridans streptococci)
- Enterococcus
- Staphylococcus epidermidis
- Candida
- Aspergillus
Culture-negative endocarditis:
- Antibiotics (side effects)
- Bartonella quintana and B. henselae
- Brucella
- Fungi
- Coxiella burnetii (Q fever)
- Chlamydia trachomatis and C. psittaci
- Libman-Sachs associated with systemic lupus
erythematosus
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Risk Factors |
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Risk factors include patient's susceptibility and medical procedures.
Predisposing conditions:
- Prosthetic cardiac valves
- Previous endocarditis
- Congenital cardiac malformations
- Degenerative heart disease
- Hypertrophic cardiomyopathy
- Mitral valve prolapse
- Dental and surgical procedures resulting in transient
bacteremia
- Intravenous drug use
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Signs and Symptoms |
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Remittent fever (high or low) is the most common symptom of endocarditis;
often the only symptom in prosthetic valve endocarditis.
Other possible signs and symptoms include the following.
- Skin lesions (Janeway lesions)
- Chills, night sweats
- Malaise, fatigue
- Muscle, joint, and back pain; stiff neck
- Headache, delirium, seizures
- Myocardial infarction
- Aphasia
- Paralysis, hemiparesis, numbness, muscle weakness
- Cold, painful extremity
- Bloody urine or sputum
- Painful finger or toe tip (Osler node)
- Pulmonary infarction
- Shortness of breath
- Cough
- Pallor
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Differential
Diagnosis |
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- Cerebral embolus or hemorrhage
- Connective tissue disease
- Fever of unknown origin
- Glomerulonephritis
- Intra-abdominal infections
- Meningitis
- Myocardial infarction
- Osteomyelitis
- Pericarditis
- Salmonellosis
- Septic pulmonary infarcts
- Tuberculosis
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Diagnosis |
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Physical Examination |
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Common signs of endocarditis include cardiac murmur (generally new, possibly
absent), an old valvular heart lesion, and embolisms.
Other physical signs include:
- Weight loss
- Neck vein distension
- Gallops
- Arrhythmia
- Pericardial rub
- Osler's nodes
- Rales
- Pleural friction rub
- Hemorrhagic or necrotic pustule
- Conjunctival hemorrhage
- Roth's spots
- Splenomegaly
- Splinter hemorrhages
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Laboratory Tests |
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Hematologic, serologic, urine, and/or bacteremia tests may be
required. |
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Pathology/Pathophysiology |
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Repeated positive blood cultures are the primary indicator of endocarditis.
(Antibiotics can make cultures falsely negative.)
- Elevated erythrocyte sedimentation rate
- Hematuria (gross or microscopic)
- Blood in sputum (from septic pulmonary emboli)
- Positive echocardiography for vegetations, abscess, valve
dehiscence
- Emboli and/or infarction in body organs
- Abscesses and microabscesses in body organs
- Embolic and/or immune-complex glomerulonephritis in
kidneys
- Valvular endocardium destruction
- Valve leaflet perforation
- Chordae tendineae rupture
- Myocardium abscesses
- Sinus of Valsalva rupture
- Pericarditis
Acute endocarditis:
Subacute endocarditis:
- Anemia
- Leukopenia
- Decreased C3, C4, CH50
- Rheumatoid factor
Culture-negative endocarditis:
- Chlamydia, Q fever (Coxiella), and
Bartonella
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Imaging |
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- Echocardiography (transesophageal/transthoracic)
- Pulmonary ventilation perfusion scan
- Cinefluoroscopy
- CAT scan
- Endoscopy
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Other Diagnostic
Procedures |
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- Cardiac catheterization
- Aortic root
injection
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Treatment Options |
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Treatment Strategy |
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Historically, endocarditis patients have been hospitalized for IV therapy
(intensive care if critical and oxygen treatment, treatment for congestive heart
failure, and hemodialysis is required). Oral and outpatient therapy for stable
and reliable patients are being considered more frequently. |
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Drug Therapies |
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Drug treatment is generally two to six weeks of IV antibiotics. The drug of
choice depends on the type of endocarditis (antibodies tested against the causal
bacteria), the patient's medical conditions, and drug allergies.
Endocarditis caused by streptococci and Streptococcus bovis that
responds to penicillin:
- Uncomplicated patients: penicillin G plus gentamicin
- Patients older than 65 or with impairment of the eighth nerve,
impairment of renal function, heart failure, or CNS complications: penicillin G
only
- Patients nutritionally deficient, in relapse, or with complications
(e.g., shock, extracardiac focus): penicillin G plus gentamicin
- Patients with penicillin allergy: vancomycin or
cefazolin
Endocarditis caused by strains of streptococci and Streptococcus bovis
resistant to penicillin:
- Patients with prosthetic valve infection: penicillin G plus
gentamicin
- Patients with penicillin allergy who should avoid gentamicin:
vancomycin or cefazolin
Endocarditis caused by Enterococci:
- Uncomplicated patients: penicillin G plus gentamicin
- Patients with penicillin allergy: vancomycin and
gentamicin
Endocarditis caused by Staphylococcus aureus:
- Patients with methicillin-susceptible strain: nafcillin and
gentamicin
- Patients with methicillin-susceptible strain but significant renal
impairment: nafcillin
- Patients with methicillin-resistant strain or penicillin allergy:
vancomycin
- Patients with penicillin allergy: cefazolin or oxacillin
- Patients with prosthetic valve infected with methicillin-susceptible
strain: oxacillin or nafcillin and rifampin and gentamicin
- Patients with prosthetic valve infected with methicillin-resistant
strain: vancomycin and rifampin and gentamicin
Endocarditis caused by coagulase-negative staphylococci or prosthetic valve
infection:
- Patients with methicillin-susceptible strain: nafcillin and rifampin
and gentamicin
- Patients with methicillin-resistant strain: vancomycin and rifampin
and gentamicin
- Patients with methicillin-resistant strain and penicillin allergy:
vancomycin and rifampin and gentamicin
Endocarditis caused by HACEK organisms:
- Uncomplicated patients: ampicillin and gentamicin
- Patients with penicillin allergy:
ceftriaxone
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Complementary and Alternative
Therapies |
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Endocarditis has serious ramifications and requires aggressive medical
treatment. Alternative therapies may be used concurrently to help support immune
function, reduce severity, duration, and progression of disease, as well as
improve overall cardiac health. |
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Nutrition |
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- Avoid foods that may compromise optimal health such as refined foods,
sugar, and saturated fats (meat and dairy products).
- To support immune function, include vitamins C (1,000 mg up to tid),
E (400 to 800 IU/day), A (10,000 IU/day) or beta-carotene (100,000 IU/day),
selenium (200 mcg/day), and zinc (30 mg/day).
- Coenzyme Q10 (100 mg bid) is a powerful antioxidant and has
cardioprotective properties.
- Magnesium (200 to 500 mg bid to tid) is essential for normal cardiac
function. Magnesium is contraindicated if the patient has kidney
damage.
- Bromelain (250 to 500 mg tid between meals) is a proteolytic enzyme
which may increase the effectiveness of antibiotic
therapy.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. of herb per cup of hot
water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes
for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination
as noted. The goals of herbal therapies are to fight infection, enhance immune
function, reduce cardiac damage, and restore the integrity of cardiac
tissue.
- For long-term cardiac support combine the following herbs in a tea (3
cups/day) or tincture (30 to 60 drops tid): 2 parts of hawthorn (Crataegus
monogyna) with 1 part each of motherwort (Leonurus cardiaca) and
linden flowers (Tilia cordata). Use additional herbs from the following
categories as needed.
- Cardiac arrhythmias: Add 1 part each of lily of the valley
(Convalleria majalis) and night-blooming cereus (Selinicereus
grandiflorus) to the cardiac formula above. These herbs must be used with
caution and under a health care provider's supervision. Side effects may include
nausea, vomiting, headache, and cardiac arrhythmias.
- Hawthorn berry (Crataegus laevigata) can be helpful in
promoting cardiac output and decreasing arrhythmias. Use 1/2 tsp. of
the solid extract, or 1,000 mg tid.
- Infection: Combine equal parts of four to six of the following herbs:
coneflower (Echinacea purpurea), goldenseal root (Hydrastis
canadensis), wild indigo (Baptisia tinctoria), myrrh (Commiphora
molmol), garlic (Allium sativum), rosemary (Rosmarinus
officinalis). For acute infection take 60 drops of tincture every 2 hours.
For chronic infections or for prophylaxis, take 30 to 60 drops tid.
- Renal involvement: Combine equal parts of bearberry
(Arctostaphylos uva ursi), cleavers (Galium aparine), dandelion
leaf (Taraxacum officinale), black cohosh (Cimicifuga racemosa),
yarrow (Achillea millefolium), and corn silk (Zea mays). Drink as
a tea 3 cups/day. Flaxseed oil or fish oil (3 to 5 g bid) is also helpful to
decrease inflammation in the kidney.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Aconite if patient fears death, has tachycardia with full, hard
bounding pulse of sudden onset.
- Cactus grandiflorus for endocarditis with mitral insufficiency.
Patient has feeble, irregular pulse and feels a constriction as if an iron band
is around the chest.
- Digitalis if patient has irregular pulse with a sensation as if
the heart would stop if they moved. Pulse is quickened by the least movement and
patient feels compelled to walk.
- Spongia if patient has a sensation of the heart swelling as if
it would explode; especially for hypertrophy of the heart and valvular
insufficiency.
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Acupuncture |
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May improve immunity and strengthen cardiac
function. |
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Patient Monitoring |
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Bedrest initially, ambulation after clinical improvement. Patient follow up
is critical to assess for relapse, determine if another course of antibiotics
(or surgery) is required, and avoid complications.
Blood levels should be performed if gentamicin is used for more than five
days or with renal dysfunction, and BUN and serum creatinine should be performed
twice a week while the drug is being administered. For patients receiving
vancomycin, blood levels should be performed with renal dysfunction. Audiometry
baseline and periodic testing is advisable with long-term aminoglycoside
therapy. |
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Other
Considerations |
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Prevention |
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Prophylaxis antibiotics for medical procedures that could cause transient
bacteremia (see "Risk Factors") may be advantageous, although the effectiveness
of this practice is unproven. Also, discuss the importance of dental hygiene
with endocarditis patients and avoid having dental caries treated during
endocarditis treatment. |
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Complications/Sequelae |
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- Cardiologic: congestive heart failure, sinus of Valsalva aneurysm,
aortic root abscesses, myocardial abscesses, myocardial infarction,
pericarditis, cardiac arrhythmia, arterial emboli
- Neurologic: stroke, hemorrhage, brain abscesses, meningitis, cerebral
emboli
- Other: septic pulmonary infarcts, splenic infarcts,
glomerulonephritis, acute renal failure, mesenteric
infarct
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Prognosis |
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The prognosis of endocarditis depends on its complications. For streptococcal
endocarditis, patients usually exhibit a negative blood culture quickly, with a
clinical response within two days; for staphylococcal endocarditis, fever and
positive blood culture may continue for up to 10 days after treatment begins.
Endocarditis mortality is about 20%. |
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Pregnancy |
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Gentamicin should be avoided or used with caution during pregnancy. Herbs
containing berberine (e.g., goldenseal) are not recommended during
pregnancy. |
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References |
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Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory
Medicine. 4th ed. Baltimore, Md: Williams & Wilkins; 1995:379-381.
Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:99,167-168,220.
Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md:
Lippincott Williams & Wilkins; 1999:358-361.
Endocarditis: a rare but serious disease. Drug Ther Perspect.
1998;12(4):6-9.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998:772-773, 1130-1131.
Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North
Atlantic Books; 1992:58-61.
Murray MT. Encyclopedia of Nutritional Supplements. Rocklin, Calif:
Prima Publishing; 1996:401,404, 463-464.
Snow JM. Hydrastis canadensis L. (Ranunculaceae). Protocol J Botan
Med. 1997;2:25-28.
Stein JK, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year
Book; 1994:189-201.
Stoller JK, Ahmad M, Longworth DL, eds. The Cleveland Clinic Intensive
Review of Internal Medicine. Baltimore, Md: Williams & Wilkins;
1998:137-141, 299.
Walker LP, Brown EH. The Alternative Pharmacy. Paramus, NJ: Prentice
Hall Press; 1998:239-240.
Werback MR. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing, Inc; 1987:252-262. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |