1. Infective Endocarditis By: Katie Walton

2. Infective Endocarditis An infection in the endothelium (the innermost lining of the heart). 2 to 4 people out of every 100,000 are infected every year with endocarditis. It most frequently occurs in males over 50. Of people who are infected with endocarditis, 65 percent have been diagnosed with a predisposing heart condition.

3. Signs and Symptoms It doesn’t present to be life threatening, but it is very important to recognize. Develops rather slowly in many cases, however, it may develop quickly. Speed of infection depends on the bacteria which is causing the infection. Some early symptoms include: rash, headache, fever, weight loss, backaches, anemia, fatigue, night sweats, confusion, and joint pains.

4. Signs and Symptoms (Continued) As the infection advances, little dark lines, referred to as splinter hemorrhages, appear beneath the fingernails.

5. Signs and Symptoms (Continued) A more prominent symptom of this disease is a heart murmur caused by irregular flow of blood through flawed or damaged valves. The change of blood flow across the valves is due to bundles of bacteria, fibrin and cellular debris which accumulate on the valves of the heart. The two most common valves affected during heart murmurs are the mitral valve and the aortic valve. The doctor also may detect an enlarged spleen and mild anemia included in his findings.

7. Etiology The cause is usually transient bacteremia, which is the existence of bacteria in the blood. This frequently occurs during dental, surgical, upper respiratory, urologic, and lower gastrointestinal procedures. The infection could cause build up on the heart valves, lining of the heart, or the lining of the blood vessels. If the build up were to be dislodged it could send clots to the brain, lungs, kidneys, or spleen.

8. Etiology (Continued) There are several different kinds of bacteria which could be the root cause of endocarditis. An organism frequently found in the mouth called Streptococcus viridans is accountable for about half of all bacterial endocarditis. Further widespread organisms include Staphylococcus and Group D Streptococcus. Studies have suggested that 60% to 80% of patients with bacterial endocarditis will be diagnosed with some form of predisposing cardiovascular defect.

9. Etiology (Continued) Rheumatic heart disease is found in about 30% of bacterial endocarditis cases. Congenital heart disease is found in approximately 10% to 20% and mitral valve prolapse in about 10% to 33% of cases. Reports verified an increased threat of bacterial endocarditis among drug abusers. There is a 30% chance of developing endocarditis within 2 years of becoming an intravenous drug addict. This is due to the use of non-sterile needles which permit bacteria to flow directly into the bloodstream.

10. Pathogenesis Endocarditis takes place when bacteria enter into the bloodstream. Bacteria are usually introduced into the bloodstream through an infection found in another branch of the body. This bacterium then contaminates damaged endocardium or endothelial tissue, situated close to high-flow shunts, between the arterial and venous channels. Additional microorganisms including fungi and viral infections, could infect these areas, but it is rare.

11. Pathogenesis (Continued) Bacteria can also be forced into the bloodstream in the event of a surgical procedure, dental treatment, or even while brushing your teeth. Many of the bacteria that invade the bloodstream are destroyed by the immune system. The ones that survive will bunch together on a heart valve or a different segment of the endocardium. Infection will occur shortly after and the immune system is unable to clear it out.

12. Pathogenesis (Continued) Shortly after, little bunches of matter called vegetations will build up on the infected valves. This vegetation includes bacteria, small blood clots, and additional waste from the infection, which might prevent the affected valves from opening and closing properly. It is also possible for the infection to damage these affected valves and move into additional areas of the endocardium or heart tissue.

14. Prognosis The expected outcome depends on whether it is detected before the heart function begins to deteriorate. It can usually be cured if diagnosed and treated by an early stage. In some cases, if detected soon enough it can be treated with antibiotics. In other cases, however, the infection may be too advanced and the heart could sustain serious damage. The patient needs to get treatment as soon as possible.

15. Prognosis (Continued) Patients may also die from serious complications such as damaged heart valves which lead to heart failure. A large piece of vegetation could also break off and obstruct the current in a main artery causing death. If an artery in the brain were to be obstructed it could lead to a stroke or sudden failure of vision in one eye. Patients who develop vegetation larger than 10 mm, have a greater chance of morbidity and mortality than patients with minor vegetation.

16. Prognosis (Continued) Surveys have established an outcome of patient recovery following successful therapy. Native valve vegetation which is resolved in patients is 25% to 30%. Decrease in vegetation accumulation is 15% to 20%. Vegetation with unchanged accumulation is 35% to 40%. Increase in vegetation accumulation in patients is 10% to 15%. Continual vegetation usually become fibrosed and seldom calcified.

17. Prognosis (Continued) Patients who develop major valve dysfunction have a 15% to 30% risk of dying in surgery and 50% to 70% chance of overall survival if they live 1 to 2 years following surgery.

18. Diagnostic Tests & Treatment Endocarditis can be identified by recognizing symptoms as mentioned earlier, particularly if the patient has a predisposing condition. It is especially important to hospitalize patients who are suspected of having endocarditis, and provide treatment as needed. Diagnostic tests may consist of X-rays of the heart and lungs, an echocardiogram, laboratory blood counts and blood cultures, which are tested for bacteria, or an ultrasound scan of the heart (electrocardiogram).

19. Diagnostic Tests & Treatment (Continued) Echocardiography and electrocardiograms are the most reliable tests to diagnose infective endocarditis. Echocardiography is used to see valve structure and function, heart wall motion, and overall heart size. Ultrasound (electrocardiograms) provide reflected sound waves to produce a representation of the heart. This allows the physician to spot any damage in the heart valves or vegetation that has built up.

21. Diagnostic Tests & Treatment (Continued) Medications called antibiotics, which kill the microorganisms in your bloodstream and within the vegetations, are the first line of treatment. Antibiotics may be given for as long as six weeks to control the infection. If the vegetation has damaged the heart valves surgery may be needed to repair or replace the damaged valve.

22. Conclusion Infective endocarditis is a very serious heart disease. It is important that people recognize and understand the risks involved. Certain precautions can be taken in order to prevent this disease. If you have any heart valve damage or a heart murmur it is important that you request antibiotics prior to any medical procedures that may introduce bacteria into the blood.

23. Conclusion (Continued) This includes dental work, childbirth, and surgery of the urinary or gastrointestinal tract. Don’t use illicit drugs such as heroin or cocaine. Consumption of alcohol should be in moderation and remember to always maintain good oral hygiene. Thank you are there any questions?

24. References AllRefer Health. “Infective Endocarditis.” A.D.A.M. 2003. Retrieved February 10, 2006 from http://health.allrefer.com/health/infective- endocarditis-info.htmlhttp://health.allrefer.com/health/infective- endocarditis-info.html Beckerman, James M.D. “Infective Endocarditis.” Personal MD 2000. Retrieved February 1, 2006 from http://www.personalmd.com/news/inf_endo_041100.shtml http://www.personalmd.com/news/inf_endo_041100.shtml Endocarditis. “Bacterial or Infective Endocarditis.” General Illness Information 2004. Retrieved on February 10, 2006 from http://www.rxmed.com/b.main/b1.illness/b1.1.illnesses/ENDOCARDI TIS%20 http://www.rxmed.com/b.main/b1.illness/b1.1.illnesses/ENDOCARDI TIS%20 Little, James and Falace, Donald. 1997. Dental Management of the Medically Compromised Patient. St. Louis, Missouri: Mosby, Inc. Patient UK. “Infective Endocarditis.” EMIS and PIP 2004. Retrieved February 10, 2006 from http://www.patient.co.uk/showdoc/27000162/ http://www.patient.co.uk/showdoc/27000162/ Roldan, Carlos A. 2005. The Ultimate Echo Guide. Philadelphia: Lippincott Williams & Wilkins. Texas Heart Institute. “Infective Endocarditis.” Heart Information Center 2005. Retrieved February 1, 2006 from http://www.tmc.edu/thi/endocard.html http://www.tmc.edu/thi/endocard.html