From Beginning to Endo…
BP takes a long hard look at INFECTIVE ENDOCARDITIS, a potentially life-threatening infection of the heart valve. Mainly caused by bacteria entering the skin through injecting, IE can be extremely unpleasant and has a nasty habit of ironing you out completely if left untreated. Know the signs & symptoms.
AIthough relatively uncommon in comparison to most health problems intravenous drug users encounter, it is extremely important for us to be aware of infective endocarditis (IE) for several reasons:
First of all, Infective Endocarditis has a high mortality rate, and almost always kills the patient if left untreated;
Secondly, it is often preventable. Knowledge of the symptoms of IE, early diagnosis and correct management are what makes all the difference to your recovery.
And thirdly, a hygienic injecting regime is crucial when avoiding the types of bacteria that cause endocarditis.
In most cases, these organisms are streptococci (“strep”), staphylococci (“staph”) or members of other species of bacteria that normally live on body surfaces, entering the bloodstream through a break in the skin, as happens through injecting,
What is it?
Explaining what endocarditis is requires a little translation of the name; endo- means inside, -card- refers to the heart (like ‘cardiac’) and the -itis bit signifies a process of inflammation. Combining all three gives you an inflammation of the inside of the heart, usually caused by an infection, but occasionally by a fungus.
What happens to your heart?
In a nutshell, what happens is that the bacteria or fungus involved can collect on one of the four valves inside the heart which normally keep the blood (flowing in the right direction (BP no.6). The bacteria grow to form ‘vegetations’ which then damage the valve and interfere with the normal flow of blood.
To give a little more detail, blood that flows across a heart valve abnormallv will create an increased pressure gradient or slant. This causes the flow to become more turbulent allowing fibrin (an insoluble protein found in blood) and platelets (blood particles) to deposit on the surface of the valve; This will begin as a sterile vegetation but if an opportunity occurs for a bacterium to enter your bloodstream, (through unhygienic injecting practices for example), a single organism can be deposited in the fibrin and platelet mass, providing a perfect site for infection. As the bacteria multiply they cause inflammation that promotes even more fibrin and platelet deposition. The resulting infected thrombus is termed a vegetation. The infected vegetation will send intermittent showers of bacteria into the circulation which results in fever in many people and occasionally a piece of the vegetation may break off and enter the circulation causing systemic emboli (clots). The growth eventually destroys the heart valve.
The bacteria are able to maintain their presence in the bloodstream because the heart valves are an especially difficult place for the body’s immune system to reach in order to fight off the infection.
Symptoms of Endocarditis Include:
”Acute’ IE can comes on extremely quickly with rapid onset of symptoms over 1-2 days: high fever, chest pain, shortness of breath, cough, and small hemorrhages on the palms and soles of the feet, delerium. If very severe, heart damage can cause shock, the patient may suddenly collapse, have a rapid pulse and have pale, cool, clammy skin.
The more ‘chronic’ variety can build up over weeks, sometimes months & symptoms can be more vague. A low-grade fever (less than 39.4 degrees C). chills; night sweats_ pain in muscles and joints; a persistent tired feeling; headache; shortness of breath; poor appetite: weight loss; small, tender nodules an the fingers or toes; and tiny hemorrhages (broken blood vessels) on the whites of the eyes, the palate, inside the cheeks, on the chest, on the fingers and toes odd chest pains.
Acute endocarditis can appear extremely fast, must often occurring when an aggressive species of skin bacteria- especially a staphylococcus (which normally live quite happily on the skins surface) enters the bloodstream and attacks e normal, undamaged heart valve. Once staph bacteria begin to multiply inside the heart they may send small clumps of bacteria called septic emboli (dots or bits of vegetation) into the bloodstream to spread the infect-on to other organs, especially to the kidneys, Iungs and brain.
Unfortunately IV drug users are at rather high risk for acute endocarditis since injecting allows aggressive staph bacteria many opportunities to enter the blood through broken skin and unhygienic drug paraphernalia. If untreated, this form of endocarditis can be fatal m less than 2 months.
Endocarditis can also occur more slowly. This chronic form of Infective Endocarditis (IE), is most often caused by one of the viridans group of streptococci (Streptococcus sanguis mutans, mitts. or milleri that normally five in the mouth and throat A slow and insidious progression that occurs over weeks/months and !f left untreated it can progress for weeks/ months even as long as a year before it too, is fatal
Risks for IV Drug Users
The chances of getting endocarditis are mainly determined by how easily the bacteria can gain entry to the body and haw easy it is for them to grow on the heart valves. Obviously, consistent care must be taken to avoid bacterium entering into your injecting routine .
The primary bacteria which affects drug users is called staphylococcus aureus (often shortened to s. aureus) This is the very same bug that can cause things like septicemia, cellulitis and abscesses This is why, if you have an infected sore on your skin, you must take extreme care to avoid spreading the bactetria to your injecting site. allowing potential entry into your bloodstream or deeper skin tissue. There’s also a long list of other bugs but they are relatively rare and tend only to cause problems in people with a compromised immune system, such as with AIDS.
As an IV drug user, your risks increase even further if you: drink heavily: have had endocarditis in the past have HIV/AIDS. or any other disease that affects the immune system: a malformation of the heart or heart valve present from birth; an implanted device in the heart (pacemaker wire or artificial heart valve), cancer with chemotherapy-, a history of chronic illness If any of these affect you, you should be offered preventative antibiotics whenever you have things like dental surgery done which might introduce infection.
Any IV user with a compromised immune system should insist upon taking antibiotics both before and after any dental or medical procedure to reduce the risk of contracting endocarditis or, at the very least ensure you have a full discussion with your doctor or dentist about the risks.
Prevention, for IV drug users, comes with hygienic injecting practises. To prevent endocarditis, your doctor and dentist may prescribe antibiotics before you undergo any medical or dental procedure in which bacteria have a chance of entering your blood. Antibiotics are usually administered to patients who have had endocarditis in the past and patients with other highrisk conditions (see Risks for IV Users). In general, antibiotics are given one to two hours before a high-risk procedure and up to eight hours afterward.
Before a dental procedure, an antiseptic mouth rinse also can be used, espcially one containing chlorhexidine or povidone-iodine. Our hygiene article this issue covers more preventative practices to avoid exposing yourself to IE. Endocarditis is not preventable by avoiding needle sharing as it is not transmitted directly from person to person.
Remember, since the bacteria that causes IE is found on the skin or in soft tissue infections like abscesses or cellulitis. if you have infections such as these, you need to pay particular care to ensure that your injection site and injecting paraphrenalia, are as hygienic and/or sterile as possible. This will help to prevent the bacteria entering your bloodstream. Licking your spike (or your injection site before or after a fix) is another way of transferring streptococci bacteria that could be living inside your mouth or throat – due to absesses or throat infections. (see BP’s article on hygiene & vein care this issue
Whether your heart valves are normal, damaged or artificial, you can help prevent endocarditis by avoiding taking your drugs IV. If you want to continue fixing, ALWAYS BE AS STERILE AND/OR HYGIENIC AS POSSIBLE WHEN BOTH MIXING UP YOUR GEAR & INJECTING
Your doctor may suspect endocarditis based on your medical history, risk factors and symptoms, gathering additional evidence from a physical examination (see symptoms) and drawing blood samples . Other tests include an Echocardiography (ECG), where sound waves are used to outline the structure of the heart, heart chambers and valves. The first line of defence is a combination of antibiotics given intravenously, m a course which normally lasts for six weeks and it also requires a fairly long hospital admission of 6 weeks or more.
Drug users are usually affected on the right side of the heart – which pumps blood to the lungs – in contrast to the other forms of endocarditis, which normally affect the valves on the left side. This can make little difference to the complications that can be encountered. The difference comes in terms of treatment. Left-sided valves can be relatively easily replaced surgically, but replacing a right-sided valve is a more difficult operation with lower success rates, and because of this, does not tend to be attempted. This means that the affected person, even if treated successfully with antibiotics, can still be left with a permanently damaged valve and will be more prone to heart problems, including further attacks of endocarditis, in later life.
Despite all of these serious problems with the condition, endocarditis is still very treatable as long as it is recognised early.
Tips to Remember
* Never EVER lick touch or blow on your spike or works before a hit
* Never inject near any skin infection or wound, no matter how small. (see vein-care)
* If you have a heart condition, HIV/AIDs (or a compromised Immune system) or have had Endocarditis in the past – tell your GP and dentist before surgery to receive preventative antibiotics
* Never cough, sneeze on/near your gear.
* Never pick or squeeze pimples or sores inbetween hits (as you might do on the coke). If you can’t help yourself then ensure you seriously wash your hands & fingers well afterwards
* Always wash your hands well before & after a hit.
Black poppy mag Issue 7
- What Is Endocarditis? (everydayhealth.com)