Which clinical manifestation would the nurse expect to find in a child with infective endocarditis

Infective endocarditis is an infection of the lining of the heart (endocardium) and usually also of the heart valves.

• Infective endocarditis occurs when bacteria enter the bloodstream and travel to and attach to previously injured heart valves.

• Acute bacterial endocarditis usually begins suddenly with a high fever, fast heart rate, fatigue, and rapid and extensive heart valve damage.

• Subacute bacterial endocarditis gradually causes such symptoms as fatigue, mild fever, a moderately fast heart rate, weight loss, sweating, and a low red blood cell count.

• Echocardiography is used to detect the damaged heart valves, and blood cultures are used to identify the microorganism causing infective endocarditis.

• People with artificial heart valves or certain birth defects of the heart need to take antibiotics to prevent endocarditis before they undergo certain dental or surgical procedures.

• High doses of antibiotics are given intravenously, but sometimes surgery is needed to repair or replace damaged heart valves.

Infective endocarditis affects twice as many men as women at all ages. It is more common among older people. People who use illicit intravenous drugs, who have a weakened immune system, who have a prosthetic heart valve, or have a device that is placed within the heart (such as a pacemaker or implantable cardioverter-defibrillator) are at highest risk.

• Acute infective endocarditis develops suddenly and may become life threatening within days.

• Subacute infective endocarditis (also called subacute bacterial endocarditis) develops gradually and subtly over a period of weeks to several months but also can be life threatening.

Bacteria (or, less often, fungi) that are introduced into the bloodstream can sometimes lodge on heart valves and infect the endocardium. Abnormal, damaged, or replacement (prosthetic) valves are more susceptible to infection than normal valves. The bacteria that cause subacute bacterial endocarditis nearly always infect abnormal, damaged, or replacement valves. However, normal valves can be infected by some aggressive bacteria, especially if many bacteria are present.

Certain surgical, dental, and medical procedures may also introduce bacteria into the bloodstream. Rarely, bacteria are introduced into the heart during open-heart surgery Revascularization Procedures Angina is temporary chest pain or a sensation of pressure that occurs while the heart muscle is not receiving enough oxygen. A person with angina usually has discomfort or pressure beneath the... read more or heart valve replacement surgery Repairing or replacing a heart valve Heart valves regulate the flow of blood through the heart's four chambers—two small, round upper chambers (atria) and two larger, cone-shaped lower chambers (ventricles). Each ventricle has... read more

White Blood Cells The main components of blood include Plasma Red blood cells White blood cells Platelets read more

If the cause of infective endocarditis is injection of illicit drugs or prolonged use of intravenous lines (sometimes used by doctors to deliver long-term intravenous therapies for people who have serious medical conditions), the tricuspid valve (which opens from the right atrium into the right ventricle) is most often infected. In most other cases of endocarditis, the mitral valve or the aortic valve is infected.

An Inside View of Infective Endocarditis

This cross-sectional view shows vegetations (accumulations of bacteria and blood clots) on the four valves of the heart.

The highest risk of endocarditis is in people who

• Inject illicit drugs

• Have a weakened immune system

People who inject illicit drugs are at high risk of endocarditis because they are likely to inject bacteria directly into their bloodstream through dirty needles, syringes, or drug solutions.

People who have a replacement heart valve are also at high risk. For them, the risk of infective endocarditis is greatest during the first year after heart valve surgery. After the first year, the risk decreases but remains slightly higher than normal.

Other risk factors for infective endocarditis are

• Degeneration of the heart valves that occurs with aging

Birth defects are risk factors for children and young adults.

In both acute and subacute bacterial endocarditis, arteries may become blocked if accumulations of bacteria and blood clots on the valves (called vegetations) break loose (becoming emboli), travel through the bloodstream to other parts of the body, and lodge in an artery, blocking it. Sometimes blockage can have serious consequences. Blockage of an artery to the brain can cause a stroke Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction) and symptoms that... read more , and blockage of an artery to the heart can cause a heart attack Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) Acute coronary syndromes result from a sudden blockage in a coronary artery. This blockage causes unstable angina or a heart attack (myocardial infarction), depending on the location and amount... read more

Other symptoms of acute and subacute bacterial endocarditis may include

• Chills

• Joint pain

• Paleness (pallor)

• Painful nodules under the skin

• Confusion

• Echocardiography

• Blood cultures

Because many of the symptoms are vague and general, doctors may have difficulty making a diagnosis. Usually, people suspected of having acute or subacute infective endocarditis are hospitalized promptly for diagnosis as well as treatment.

Doctors may suspect endocarditis in people with a fever and no obvious source of infection, especially if they have

• Characteristic symptoms such as reddish spots on fingers or the whites of the eyes

• A heart valve disorder

• A replacement heart valve

• Recently had certain surgical, dental, or medical procedures

• Injected illicit drugs

Computed tomography (CT) is used occasionally when transesophageal echocardiography does not provide enough information. Positron emission tomography (PET) is sometimes used for the diagnosis of infective endocarditis of prosthetic heart valves and other devices placed in the heart.

If untreated, infective endocarditis is always fatal. When treatment is given, the risk of death depends on factors such as 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. Nonetheless, with aggressive antibiotic treatment, most people survive.

As a preventive measure, people at high risk of infective endocarditis are given antibiotics before certain surgical, dental, and medical procedures. People at high risk include those with

• Replacement valves

• Some birth defects of the heart

• A transplanted heart that has an abnormal valve

• A previous episode of infective endocarditis

Consequently, surgeons, dentists, and other health care practitioners need to know if a person has such risk factors. People who simply have an abnormal heart valve alone do not require antibiotics.

• Antibiotics given by vein (intravenously)

• Sometimes heart surgery

Treatment usually consists of at least 2 weeks and often up to 8 weeks of antibiotics given by vein (intravenously) in high doses. Antibiotic therapy is almost always started in the hospital but may be finished at home with the help of a home nurse. Some people with certain types of infection may be able to switch to antibiotics taken by mouth after a period of intravenous treatment.

Antibiotics alone do not always cure an infection, particularly if the valve is one that has been replaced. One reason is that the bacteria that cause endocarditis in a person with a replacement valve are often resistant to antibiotics. Because antibiotics are given before heart valve replacement surgery to prevent infection, any bacteria that survive this treatment to cause infection are probably resistant. Another reason is that it is generally harder to cure infection on artificial, implanted material than in human tissue.

Heart surgery may be needed to repair or replace damaged valves, remove vegetations, or drain abscesses if antibiotics do not work, a valve leaks significantly, or a birth defect connects one chamber to another.

Dental treatment to eliminate any sources of infection due to mouth or gum disease is usually needed. Doctors usually also remove any devices (such as catheters) that may be a source of infection.

Doctors may use a series of echocardiography examinations to ensure that the infected area is decreasing. They may also do echocardiography at the end of treatment to have a record of the appearance of heart valves because infective endocarditis may recur. Because of the risk of recurrence, ongoing dental care and good skin hygiene (to prevent any bacteria from entering the body through sores or wounds) is needed.

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