Lecture Notes: Infective Endocarditis (IE)

1. Definition

Endocarditis — also called Infective Endocarditis (IE) — is an infection of the inner lining
of the heart (endocardium), usually involving the heart valves.

It occurs when bacteria, fungi, or other infectious agents enter the bloodstream and adhere to
damaged endocardial surfaces, leading to inflammation and formation of vegetations (masses
of platelets, fibrin, microorganisms, and inflammatory cells) on valves or endocardial tissue.

Types:

 Acute Infective Endocarditis (AIE):

o Rapid onset and severe infection (days to weeks)
o Commonly caused by Staphylococcus aureus
o Affects normal or abnormal valves
 Subacute Infective Endocarditis (SIE):
o Slower progression (weeks to months)
o Often caused by Streptococcus viridans
o Usually affects previously damaged or prosthetic valves

Predisposing Conditions:

 Rheumatic Heart Disease (RHD)

 Congenital heart defects
 Prosthetic heart valves
 Intravenous (IV) drug use
 Indwelling catheters
 Dental or surgical procedures causing bacteremia

2. Signs and Symptoms

The manifestations of endocarditis are variable, depending on the causative organism, route of
infection, and degree of cardiac involvement.

A. General (Systemic) Manifestations

 Fever and chills (most common early symptom)

 Fatigue and malaise
 Anorexia and weight loss
  Night sweats
 Arthralgia or myalgia (joint/muscle pain)

B. Cardiac Manifestations

 New or changing heart murmur (due to valve destruction)

 Tachycardia
 Heart failure signs: dyspnea, orthopnea, peripheral edema
 Chest pain (if coronary emboli or myocarditis occurs)

C. Peripheral (Embolic and Immunologic) Signs

Sign Description / Significance

Petechiae Small, red or purple spots on skin, conjunctiva, or mucosa
Splinter hemorrhages Thin, red streaks under fingernails/toenails
Osler’s nodes Painful, raised nodules on fingers or toes (immunologic)
Janeway lesions Painless red spots on palms and soles (microemboli)
Roth’s spots Retinal hemorrhages with pale centers (seen in fundoscopic exam)
Clubbing of fingers Seen in chronic cases
Splenomegaly From immune response
Signs of embolization Stroke (brain), hematuria (kidneys), gangrene (limbs)

3. Laboratory and Diagnostic Tests

Test / Procedure Purpose / Findings

Blood Cultures (3 sets, 30 mins apart) Confirms bacteremia; identifies causative organism
CBC (Complete Blood Count) ↑ WBC count (infection); mild anemia (chronic IE)
ESR / CRP Elevated — indicates ongoing inflammation
Echocardiogram (2D or TEE) Detects vegetations, abscesses, valve dysfunction
Electrocardiogram (ECG) May show conduction abnormalities or arrhythmias
Chest X-ray Detects cardiomegaly, pulmonary congestion
Urinalysis Hematuria or proteinuria (embolic kidney involvement)
Blood chemistry (renal & hepatic Checks organ function, especially before antibiotic
tests) therapy

Modified Duke Criteria

Used to diagnose Infective Endocarditis:

 Major Criteria: Positive blood cultures, evidence of endocardial involvement on echo

 Minor Criteria: Fever, vascular phenomena (emboli), immunologic phenomena,
predisposing heart condition
Diagnosis:
→ 2 major, or 1 major + 3 minor, or 5 minor criteria

4. Pathophysiology

Step-by-Step Mechanism:

1. Entry of Pathogen into Bloodstream:

o Bacteria enter via dental work, IV lines, surgery, or infection elsewhere.
2. Adherence to Endocardium:
o Microorganisms attach to rough or damaged heart surfaces or prosthetic material.
3. Formation of Vegetations:
o Fibrin and platelets accumulate over bacteria → vegetation formation.
o These vegetations protect bacteria from host defenses and antibiotics.
4. Valve Destruction and Dysfunction:
o Vegetations cause scarring, ulceration, and perforation → regurgitation or
stenosis → decreased cardiac output.
5. Embolization:
o Fragments of vegetations may break off → travel via bloodstream → block
arteries in brain, lungs, kidneys, or limbs → infarctions.
6. Immune Response:
o Antigen–antibody complexes form → deposit in tissues → cause
glomerulonephritis, vasculitis, and Osler’s nodes.

Simplified Flow:

Bacteremia → Endocardial infection → Vegetation formation → Valve damage + Embolization

→ Heart failure or systemic complications

5. Medical and Surgical Management

A. Medical Management

Goal Treatment / Intervention Rationale

Long duration needed to
High-dose IV antibiotics (4–6
Eradicate infection penetrate vegetations and kill
weeks) based on culture results
organisms
Empiric antibiotic therapy Penicillin + Gentamicin or Broad coverage against common
(before culture results): Vancomycin + Ceftriaxone organisms
Reduces metabolic demand and
Manage fever and pain Antipyretics, rest
discomfort
 Goal Treatment / Intervention Rationale
Prevent embolic Reduces risk of vegetation
Bed rest during acute stage
complications dislodgment
Diuretics, ACE inhibitors, Improves cardiac function if HF
Manage heart failure
oxygen therapy develops
Used cautiously (only in Prevents clot formation in
Anticoagulants
selected cases) prosthetic valves

B. Surgical Management

Procedure Indication / Purpose

Valve Repair or Replacement (prosthetic or Severe valve damage, heart failure, uncontrolled
biologic) infection
Vegetation Removal / Debridement Removes infected tissue and prevents emboli
Drainage of abscess If infection spreads into myocardial tissue
Cardiac device removal In pacemaker or catheter-related infections

C. Prevention (Prophylaxis)

 Prophylactic antibiotics before dental, respiratory, or genitourinary procedures for

high-risk patients (with prosthetic valves, prior IE, or RHD).
Example: Amoxicillin 2 g PO 30–60 min before procedure

6. Nursing Management

A. Nursing Assessment

 Assess for risk factors: history of valve disease, IV drug use, prior IE, dental procedures.
 Monitor vital signs, especially temperature (fever spikes) and heart sounds (new
murmurs).
 Observe for peripheral manifestations (petechiae, splinter hemorrhages, Osler’s nodes,
Janeway lesions).
 Monitor for signs of embolization:
o Brain (stroke signs)
o Lungs (dyspnea, chest pain)
o Kidneys (flank pain, hematuria)
 Assess for signs of heart failure (dyspnea, edema, weight gain).
 Review laboratory results and antibiotic response.

B. Nursing Diagnoses
  Decreased cardiac output related to valvular dysfunction
 Risk for infection spread related to bacterial colonization
 Impaired tissue perfusion related to embolic phenomena
 Activity intolerance related to weakness and fatigue
 Knowledge deficit related to disease process and prevention

C. Nursing Interventions and Rationales

Nursing Action Rationale

Monitor vital signs (especially temperature
Detects early signs of persistent infection
trends)
Auscultate heart sounds for new or changing
Indicates worsening valve damage
murmurs
Administer antibiotics as ordered (IV route, full Ensures eradication of organism and
course) prevents relapse
Assess for adverse drug reactions (esp.
Prevents toxicity (renal, ototoxicity)
aminoglycosides, vancomycin)
Decreases cardiac workload and embolic
Encourage bed rest during acute phase
risk
Monitor for signs of embolic events (neurologic Detects life-threatening complications
changes, hematuria, limb pain) early
Monitor intake and output; assess for edema Detects heart failure and renal impairment
Maintain aseptic technique for IV lines and
Prevents secondary infections
invasive devices
Educate patient about oral hygiene and regular
Reduces bacterial entry from oral flora
dental care
Teach importance of antibiotic prophylaxis Prevents recurrence of infective
before dental/surgical procedures endocarditis
Provide emotional support and explain treatment Promotes cooperation and reduces anxiety
duration during prolonged therapy

D. Evaluation / Expected Outcomes

 Afebrile and free from signs of infection

 Stable vital signs and heart sounds without new murmurs
 No evidence of embolic events or heart failure
 Patient demonstrates understanding of medication regimen and preventive care
 Patient maintains good oral hygiene and avoids high-risk behaviors (e.g., IV drug use)

Summary Table: Endocarditis at a Glance

 Aspect Key Points
Definition Infection of heart’s inner lining and valves
Common Causes Staphylococcus aureus, Streptococcus viridans, fungi
Risk Factors RHD, prosthetic valves, IV drug use, dental procedures
Major Signs Fever, new murmur, Osler’s nodes, Janeway lesions, petechiae
Complications Valve destruction, embolization, heart failure
Diagnosis Blood cultures, echocardiogram, Duke criteria
Treatment IV antibiotics 4–6 weeks ± valve surgery
Nursing Focus Infection control, cardiac monitoring, patient education, prevention