In this post, we continue with our discussion of Infective Endocarditis with its signs and symptoms and diagnosis.

SYMPTOMS OF INFECTIVE ENDOCARDITIS

Acute bacterial endocarditis usually begins suddenly with a high fever (102° to 104°F); tachycardia;  fatigue; and rapid and extensive damage to the heart valves which cause  symptoms of heart failure, like shortness of breath and lower extremity edema.  

Subacute bacterial endocarditis symptoms may occur subtly for months before it results in blockage of an artery or damage to heart valves that will then alert the provider to a clear diagnosis.  These symptoms include fatigue, mild fever (99° to 101° F), a moderately fast heart rate, weight loss, sweating, and anemia. 

In both acute and subacute bacterial endocarditis, arteries may become blocked if vegetations and blood clots on the valves loosen, travel through the bloodstream to other parts of the body and block an artery. These emboli can cause stroke, heart attack, pulmonary embolism, and abscess.  Larger emboli may cause stomach pain, blood in the urine, or pain or numbness in an arm or a leg.  Other symptoms of acute and subacute bacterial endocarditis may include chills, joint pain, pallor, painful nodules under the skin and confusion.  Tiny reddish spots that resemble freckles may appear on the skin and in the whites of the eyes. Small streaks of red (splinter hemorrhages) may appear under the fingernails. These spots and streaks are caused by tiny emboli that have broken off the heart valves. Heart murmurs may develop, or preexisting ones may change. The spleen may enlarge.

DIAGNOSIS OF INFECTIVE ENDOCARDITIS

Because many of the symptoms are vague and general, providers may have difficulty making a diagnosis.  Providers should consider endocarditis in their differentials for individuals with a fever and no obvious source of infection, especially if they have  any of the following: 

• Reddish spots on fingers or the whites of the eyes
• A heart valve disorder 
• A replacement heart valve
• Recent medical, surgical, or dental procedures
• A history of injected illicit drugs
• Development of a heart murmur or a change in a preexisting heart murmur 

Diagnostics that assist with the diagnosis of endocarditis include the electrocardiogram, the echocardiogram, and blood tests/cultures.  An echocardiogram uses ultrasound waves to  produce images showing the heart, any valve clots/clumps, and damage to the heart. A computed tomography (CT scan) may be used if the transesophageal echocardiogram is inconclusive, and the Positron Emission Tomography (PET) is being used more often for the diagnosis of infective endocarditis of prosthetic heart valves and other devices placed in the heart.

TREATMENT OF INFECTIVE ENDOCARDITIS

If untreated, endocarditis is always fatal. When treatment is given, the risk of death depends on many factors like the person’s age, duration of the infection, the presence of a replacement heart valve, the type of infecting organism, and the amount of damage done to the heart valves. Most often, most people survive with aggressive antibiotic treatment.

Antibiotics

Treatment usually consists of 2 – 8 weeks of high dose antibiotics given intravenously.  Antibiotic therapy is started in the hospital but may be finished at the correctional facility if it has the heathcare staff trained to administer it and they are able to appropriately monitor the patient.  Some patients may be able to start with intravenous medication and then switch to oral antibiotics, depending on the infecting organism.

Heart Surgery

If the infected valve has been replaced in the past, then antibiotics may not be totally effective.  This is because antibiotics are administered prior to valve replacement surgery, so any bacteria that survive to cause the infection are most likely resistant.  In addition, it is more difficult to kill the bacteria vegetation on an artificial, implanted material than on human tissue.  Thus, heart surgery may be required to repair or replace damaged valves, remove vegetation, or drain abscesses.  

Eliminate the underlying cause

If the infection is from the mouth or related to gum disease, dental treatment to eliminate any sources of infection may be required. If it is from a device implanted in the chest, like a pacemaker or internal defibrillator, they are usually removed as well. 

 It is notable that there is a high risk of recurrence of endocarditis. 

In our next post, we will discuss Non-Infective Endocarditis. All posts are from The Correctional Nurse Educator class entitled Endocarditis for the Correctional Nurse.

Have you had a patient with endocarditis in your Correctional Nursing practice? Share your experiences in the comments section of this post.