Endocarditis & Drug Use

is a serious cardiac condition that can often become life-threatening. The condition occurs when the endocardium, which is the inner lining of the heart, becomes inflamed. Both bacteria and infection can lead to the development of this disease, and it can be either short term or chronic. In cases where the illness is caused by an infection, physicians refer to it as infective endocarditis.

Generally, symptoms of this disease develop when bacteria or infection enters the bloodstream and attaches to the heart valves, triggering inflammation.

What Are the Risk Factors for This Condition?

This condition is relatively rare in healthy individuals. Patients who have heart defects, artificial heart valves or urinary catheters are at an increased risk. Individuals with gum disease, inflammatory bowel disease and any other disease where dangerous bacteria can potentially enter the bloodstream are also at an elevated risk. Certain dental procedures that involve cutting the gums may pose a risk, too.

In addition, individuals who inject illegal drugs face a higher risk. Typically, people who use illegal drugs have difficulty obtaining sterile needles and injection materials. They may share needles with others or use injection practices that are unsafe. For example, they may not be able to find an alcohol swab to disinfect the injection site prior to doing the injection. These practices increase the risk that harmful bacteria will enter the bloodstream. Illegal drugs such as cocaine cause heart damage and this can further elevate the risk in people with substance use issues.

What Are Some Symptoms of Endocarditis?

This illness generally begins with flu-like symptoms. For example, people often present with a fever, chills, fatigue and aching joints or muscles. Swelling of the abdomen, legs or feet may occur, and this is often accompanied by shortness of breath and chest pain during breathing. Less commonly, individuals may have night sweats, unintended weight loss, blood in the urine and pain in the spleen, which is an organ that fights infection. Rarely, people may observe skin changes with this condition. They may develop painful red spots under the skin of the fingers and toes, known as Osler’s nodes, and they may also have red spots on the palms of the hands or soles of the feet, known as Janeway lesions. Tiny red or purple bumps called petechiae may form inside the mouth or on the whites of the eyes, and they can also develop on the skin.

In individuals with substance use issues that involve the injection of illicit drugs, inflammation from endocarditis usually affects the tricuspid valve of the heart. The tricuspid valve is also impacted in cases of long-term intravenous drug use. In cases of substance use involving opioids, the mitral and aortic valves may also be impacted.

How Do Doctors Diagnose This Condition?

Evaluation begins with a health history and a physical examination. The doctor will ask the patient about any personal or family history of cardiovascular disease and substance use, and he or she will also need to have a complete list of all medications that the patient is taking. The clinician will ask the patient if he or she has recently had any procedure that may have allowed bacteria to enter the bloodstream. These procedures include teeth cleanings, dental surgery on the gums, colonoscopies, and bronchoscopies.

At this point, the doctor will begin the physical examination. Cardiac infections can cause bumps on the skin, mouth, and whites of the eyes, so the doctor will shine a light into the patient’s eyes and mouth to check for these. He or she will also visually inspect the patient’s feet and hands to look for signs of Osler’s nodes or other nodules.

One of the key parts of the exam will be the cardiovascular exam. During this portion, the doctor will use a stethoscope to listen to the patient’s heart. To help make it easier for the doctor to detect the types of murmurs and abnormal sounds that are indicative of an infected endocardium, the doctor may listen first with the patient sitting up and a second time with the patient lying down. The doctor may also need to listen to specific heart valves with the patient lying on his or her left side. As part of the cardiac exam, the doctor will check the patient’s blood pressure in both arms, and he or she will check the patient’s pulse at the wrist and at other areas of the body. The doctor will be checking to see whether the patient’s heart rate and rhythm are normal, and special attention will be paid to any signs of potential arrhythmias. The clinician will also listen to the patient’s breathing to check for any signs of a cough or shortness of breath.

During the physical, the doctor will also check the patient’s abdomen and lower limbs. With the patient lying down, the clinician will gently touch several areas of the patient’s abdomen to check for any tenderness, swelling or lumps. Since an infected endocardium can cause pain in the spleen, the doctor will lightly touch this area to check for both pain and potential enlargement of the organ. The doctor may also touch the patient’s lower limbs and ankles to check for the presence of pitting edema or swelling, in this area. The patient will also have his or her temperature measured to see if any fever is present.

If the physical exam results cause the doctor to suspect that the patient may have an infected endocardium, additional tests will be ordered to confirm this. Patients will first have an electrocardiogram, which is a test that records the electrical activity of the heart, and a chest X-ray to rule out any lung infections. For a more detailed look at the potential damage to the heart, patients may need to have an echocardiogram. This test is an ultrasound of the heart that uses sound waves to create an image. Where possible, it is done with the probe placed lightly on the skin over the heart. Known as a transthoracic echocardiogram, this form is completely noninvasive and painless.

Occasionally, doctors may need to place the ultrasound probe down the throat and into the esophagus for more imaging. This is called a transesophageal echocardiogram. Doctors will typically perform blood culture tests that involve taking multiple blood samples within a 24-hour period. The samples are then placed in culture bottles to see if any bacteria grow.

How Is Endocarditis Treated?

Generally, antibiotics are the first line of treatment for this illness. Amoxicillin, rifampicin, fluoroquinolones, gentamicin, and oxacillin are some of the most commonly prescribed drugs for endocarditis treatment. The patient will typically begin with at least one week of intravenous antibiotics, and he or she will stay in the hospital during this time. Doctors will discontinue the intravenous antibiotics once the inflammation has subsided. After returning home, patients will need to continue taking antibiotics by mouth for up to six weeks. Antibiotics may cause side effects that include nausea, delirium, liver damage, and kidney damage. During hospital treatment, doctors will carefully monitor patients for these and other side effects. While on antibiotics at home, patients should be vigilant for any side effects mentioned in the medication guide and report these to their medical team.

For patients who have chronic or severe cases of an infected endocardium, surgery may be advised. During surgery, doctors will remove any dead tissue, debris or scar tissue that may have formed and damaged the heart valves. If a valve is severely compromised, additional surgery may be needed to try to repair the valve, and surgeons may also be able to replace the valve with an artificial one.

What Are Possible Complications of This Illness?

Even with treatment, there is a risk that this illness may lead to complications. For example, patients who have it may develop pus-filled pockets known as abscesses in the heart, brain or lungs, and the condition can cause a pulmonary embolism or blood clot in the lungs. Other potential complications from the disease include stroke, seizures, damage to the kidneys, heart failure, and heart murmurs.

How Does Substance Use Impact Cardiac Treatment?

Patients who have substance use issues that involve injecting drugs typically have multiple episodes of this condition, especially if they continue having untreated substance use issues. Conservative treatments, including antibiotics, may not work as well in these patients; they may require stronger antibiotics or higher doses. Treatment time with antibiotics may have to be extended for longer than the standard six weeks. In many cases, patients with substance use may have such extensive damage from cardiac infections that surgery is needed.

Depending on how advanced a patient’s heart condition is, simply repairing a valve may not work, and valve replacements may be needed. Sometimes, patients with substance use issues need to have multiple heart valve replacements due to extensive cardiac damage. Additionally, due to the surgical risks that substance use may pose, it is not uncommon for some hospitals and surgery centers to refuse to perform cardiac surgery for patients who have substance use issues.

Studies have shown that substance use substantially increases the risk of death from this illness. In a recent study of patients in London, Ontario, 55 percent of patients who had infected heart valves also had substance use issues that involved injecting drugs. One-third of these patients later died as a result of their infection.

Can It Be Prevented?

One of the most important things people can do to prevent endocarditis is to avoid intravenous drug use. In addition, patients who are having dental surgery or other medical procedures should speak with their health care team about taking a preventative course of antibiotics in advance of their procedure. If prescribed, patients should take the entire course of antibiotics exactly as directed. To further reduce their risk, people should avoid body piercings and tattoos, and they should have regular professional dental checkups and cleanings.

How Can People With Substance Use Issues Reduce Their Risk and Complications?

Canadian research from 2018 suggests that surgery can reduce the risk of death from this heart condition by 56 percent. Patients who had substance use counseling while they were in the hospital were able to reduce their risk of mortality by 72 percent. Experts suggest that the most important thing a person with substance use can do to protect themselves from this dangerous cardiac condition is to have treatment for substance use.

What Substance Use Treatment Options Are Available for Those With Cardiac Conditions?

People who have cardiac conditions can use the same treatment services that are available to anyone else with substance use issues. Since infection of the endocardium is a serious disease, individuals are advised to attend a medically supervised detox program. These programs are held at residential facilities, and people are provided with both medical and psychological support.

As part of the treatment process, patients will go through withdrawal. This process rids the body of all traces of any substances, and it can typically take around one week. During this time, patients will have their vital signs monitored regularly, and they will be given medications to help ease pain, nausea, shaking and other symptoms that may occur during the withdrawal process.

Counseling is provided during treatment, and this typically takes place in both individual and group therapy sessions. Patients may also have family therapy sessions. Cognitive behavioral therapy, contingency management, and motivational enhancement therapy are a few of the psychological techniques often used. These techniques help patients reframe their thoughts, develop healthy coping mechanisms and learn to observe their urges without acting on them.

Individuals with heart conditions and substance use issues may require additional monitoring during and after substance use treatment. People should try to educate themselves about their health conditions, and they should watch for and immediately report any signs of heart issues such as chest pain, palpitations, shortness of breath, shaking or fast heart rate. People should take all medications as prescribed, and they should be completely honest with all medical staff about any health issues they may be experiencing. With the right medical interventions and appropriate substance use treatment and support, many individuals can live full lives in recovery.