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.

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

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

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

• 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

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

Hematologic, serologic, urine, and/or bacteremia tests may be required.

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:

• Leukocytosis

Subacute endocarditis:

• Anemia
• Leukopenia
• Decreased C3, C4, CH50
• Rheumatoid factor

Culture-negative endocarditis:

• Chlamydia, Q fever (Coxiella), and Bartonella

• Echocardiography (transesophageal/transthoracic)
• Pulmonary ventilation perfusion scan
• Cinefluoroscopy
• CAT scan
• Endoscopy

• Cardiac catheterization
• Aortic root injection

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.

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

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.

• 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.

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.

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.

May improve immunity and strengthen cardiac function.

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.

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.

• 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

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%.

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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