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Unraveling the `Mystery` of Endocarditis

Season: 1995

Submitted By: Darlene Buligan

I`ll bet that if you have a congenital heart problem, you`ve heard the mysterious word endocarditis many times. You`ve probably been told to take certain measures to protect yourself from this relatively rare disease. But what exactly is endocarditis? How is it contracted? What happens if you get it? How can you avoid getting it? Recently, I interviewed Dr. Jack Colman, staff cardiologist at the Toronto Congenital Cardiac Centre for Adults. I hope this article gives you a better understanding of endocarditis.

What is endocarditis?

Endocarditis is an infection on the inner lining of the heart or its valves, usually caused by a bacterial germ. Sometimes it can be caused by a fungus or other germ, and thus the term infective endocarditis covers any sort of infection on the lining of the heart. It can also occur on something that a surgeon has put into the heart, like an artificial valve or conduit. Once the infection is present, the germs multiply. These clump together with blood cells called platelets, and material called fibrin - all of which is referred to as a vegetation.

The bacteria that cause endocarditis are usually either streptococcus (strep) or staphylococcus (staph). Staph Is the worst kind of endocarditis, is the most rapidly progressive, causes the most serious damage to the heart, and is often fatal.

Why are people with congenital heart abnormalities more susceptible to endocarditis than people with `normal` hearts?

A healthy heart has smooth surfaces for the blood to flow across; the blood flow itself is also smooth. Bacteria can`t usually gain a foothold in the heart. However, a heart with congenital disease usually has rough areas, and the blood flow is turbulent. This makes it more likely for bacteria to stick to the rough areas.

Colman explains that there are three things that have to come together to give a person endocarditis. "First of all [there`s usually] some abnormality within the heart... The second thing is a source of infection into the blood stream... And the third thing is the type of germ: qualities that allow certain germs to gain a foothold in the abnormal areas of the heart."

What are the symptoms of endocarditis, how is it detected, and if I get it, how is it treated?

The symptoms of endocarditis are usually flu-like, with fever, achy bones and joints, headache, and sweats. This doesn`t mean that if you have congenital heart disease, and you experience flu-like symptoms, you have endocarditis. If you`ve been exposed to someone with a cold or the flu, chances are you have a cold or the flu.

But if - for example - you`ve recently had dental work and haven`t been exposed to anyone with the flu, and you develop a fever and headaches that last more than a few days, it`s wise to ask (insist if you must!) your doctor to do blood cultures.

The ultimate form of detection for endocarditis is blood cultures. Blood samples are taken from the patient; the blood is then grown (cultured) in a lab. If infection is indicated, the patient is alerted and treatment starts right away!

If you have congenital heart disease and your doctor is thinking about giving an antibiotic for a fever, or a possible strep throat, it`s wise to have blood cultures done before taking antibiotics. It is very important to do blood cultures before taking antibiotics - because - if you do have a bacterial infection, antibiotics may suppress the results of the blood cultures. Therefore, the infection won`t get properly treated, and that could prove dangerous.

The usual course of treatment is four weeks in-hospital with intravenous antibiotics. This can vary, depending on the type of germ, and the severity of infection. The severity of your congenital heart defect may also be taken into consideration.

How do I protect myself against endocarditis?

You can never protect yourself 100% against endocarditis, however, you can take some steps to give yourself better protection when it`s needed. Antibiotics are generally recommended to be taken in a high dose one hour prior to any procedure (dental work, some surgeries, etc.) that`s known to be potentially associated with endocarditis. This preventive treatment is called prophylaxis. As Colman explains, `The principle is to have the antibiotic in the blood at a high level at the time of the procedure... at the time when the germs are going to be circulating. And that`s why people are supposed to take a high dose just before the procedure; one more dose is often given six hours later.`

I suggested to Dr. Colman that `better safe than sorry` was the best philosophy. In other words, if you`re at greater risk, why not take antibiotics for low-risk procedures, too? I mean, it can`t hurt, right? Not necessarily. Dr. Colman`s response to my comment was, `...if there`s no benefit, then there`s no reason to do it.` Some people are allergic to antibiotics, and they can also cause stomach upset. Colman goes on to say, `Extra use of antibiotics makes it more likely that germs that are resistant to those antibiotics are going to be around subsequently.`

What can happen if you contract endocarditis?

• Effects endocarditis can include:
• sending infection to other parts of the body
• kidney damage
• creating a hole between one part of the heart and another
• causing an abscess in the heart muscle
• vegetations can break off, block blood vessels within the body, including the brain, and cause a stroke
• infecting a conduit or artificial valve.
• Valve damage is the most common problem. A healthy valve can become leaky, and a mildly leaking valve may leak a lot more. If endocarditis gets well-established surgery may be required to clean out and eradicate the infection.

Because the heart isn`t working as well you can become short of breath, lose energy, build up fluid in the lungs, or retain fluid in general.

How do people contract endocarditis?

As Dr. Colman explains, `... classically dental work. But also other sorts of surgical procedures, like a gall bladder operation... It can be an injury that somebody has, or a bad cut that gets dirty and infected. So usually it`s a procedure or injury where there`s bleeding, either through the skin, or, more often, internally, like in the mouth, the respiratory tract, or in the bowel, or in the bladder. `

You may be aware of protecting yourself against infection with regard to certain dental and surgical procedures. But, as Colman explains, not many people realize that those dangling hangnails and bitten cuticles can be a dangerous source of infection. `Anybody has a hangnail once in a while, and that`s not what we`re talking about. But people who tend to tear at their cuticles and pull at their hangnails often will have little areas of infection in and around their nails, which are potential sources for [staph] endocarditis. Also, people who get skin rashes, and who constantly scratch at the skin problem and get it dirty are at greater risk.` (Acne itself is apparently not a big risk factor.)

I asked Dr. Colman about gynecological and obstetric procedures: do women with congenital heart problems need antibiotic coverage when having a D&C, or a delivery? He suggested that doctors are divided on the issue. Generally, the procedures themselves are not high-risk catalysts for endocarditis, even in women with congenital heart problems. However, depending on how high-risk the patient`s heart condition is, antibiotic prophylaxis may be recommended. It`s important to discuss your potential risk with your cardiologist.

Another mega-risk factor, and not just in people with congenital heart `disease` - is intravenous drug abuse. When drug addicts use dirty needles to inject themselves organisms, typically staph bacteria, can be easily introduced into the blood stream.

I asked Dr. Colman whether getting a tattoo, piercing your ears, or having sex can put a person with congenital heart disease at greater risk. Let`s tackle the sex part first, shall we? He said that a person doesn`t get bacterial germs entering the blood stream via sexual intercourse, and that sex is not a risk factor for endocarditis. As for the ear-piercing and tattooing, as long as the instruments used are sterile, there is no great danger. Should you, however, develop any infection through either tattooing or ear-piercing, and you have a congenital heart problem, you should see your doctor immediately.

In conclusion...

Endocarditis is a serious illness and deserves serious attention. In wrapping up this article I feel you should consider the following:

• Each situation is unique, so what may hold true for someone with a congenital heart problem similar to yours may not apply to you.
• People with congenital cardiac illness need to keep themselves informed and aware. Ask a lot of questions, don`t assume anything, and if you`re concerned about something, consult your doctor.
• Make sure you carry your Endocarditis Prophylaxis Information wallet card at all times!
• People with congenital heart problems can often lead a full and satisfying life, and by taking a few precautions, can experience it `like everybody else`.