Vegetation on tricuspid valve by echocardiogra...

Vegetation on tricuspid valve where arrow points.

From Beginning to Endo…

(Updated Dec 2015)

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.

Video of the Heart’s Function

A short video neatly describing the work of the heart as it pumps blood and nutrients around the body -and collects waste at the same time! Understand the work of the heart valves and where they are located as well as why they are so important.

Watch the heart pump blood through to the lungs, become full of oxygen, thread back into heart, where it gets squeezed into the aorta, which then pumps lovely oxygenated blood, now full of nutrients,out to the entire body, right out to the capillaries, feeding every cell with nutrients. Brilliant stuff! NOTE: The Bicuspid valve is more commonly called the Mitral valve because it has two flaps (cusps) and looks like a bishop’s miter or headdress.


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

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.

Chronic IE

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 HIV/AIDS.

If you inject drugs intravenously, 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.

Video explaining how endocarditis affects the heart

This video explains how bacteria, namely staphlococcus aureus, manages to take hold in our bodies and becomes able to form a growing vegetation around the heart valve, when the circumstances are ‘just right’. So what makes us vulnerable to endocarditis? See how it can take hold in the heart valve.


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.


Crucial tips to remember and pass on to your mates

* Never EVER lick touch or blow on your spike or works before a hit (staph lives on your skin naturally (especially of you haven’t washed for a while) and strep is often found in the throat. Just the bacterium that endo needs to thrive!

* 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

Leave a comment


  1. Jack

     /  January 23, 2017

    URGENT: I’m a journalist working on a story about endocarditis among IV drug users. I’m trying to find someone to interview who’s lived through this. Can you reach out to let me know if this is something you can help with? Email: jrodolico [at] nhpr [dot] org

  2. Chris Cross

     /  January 3, 2017

    Urgent I just recently had endocarditis surgery and Was wondering what would happen if I didn’t do the 6 weeks of IV ANTIBIOTICS are there any oral antibiotics I could take instead?

  3. Layla west

     /  December 26, 2016


  4. Lizzi

     /  November 30, 2016

    If someone has endocarditis and has had multiple heart surgery’s (not exactly sure for what), and they continue to use IV drugs while they are in and out of the hospital for endocarditis as it is. Will continuing to use IV increase there chances of death? My friend of childhood passed this morning. I don’t want to ask anyone because it just happened. What are the main causes of death with Endo?

  5. nanette warr

     /  November 13, 2016

    My daughter died from Bacteremia, staph – causing damage to the heart valves, lungs and adrenal glands. She was an iv heroin user – very short term – less than a year. She was also involved in a serious car accident 6 months before death, with the steering wheel crushing her sternum and ribs – her spleen had to be removed. How can a coroner determine if the damage from staph was from the drug use and not from catching it in the hospital?

    • Dear Nanette,
      We are very, very sorry to hear of your daughters death, I cannot think of anything in life more painful than losing a child. As you know we are not Drs here, but what I think we can say is that Endocarditis (which it sounds like what your daughter had at some stage -staph infection of the heart valve) could have become worse – reaching other areas of her system – due to the trauma of the car accident. It is also very possible that she received the staph infection from hospital after the trauma of the car accident, which could have created the conditions for endocarditis to manifest. I really don’t know if a coroner could tell these things apart, it is worth trying to find out -it is amazing what they can find out after death now, and it is also worrying just what can happen in hospital when one is very vulnerable and having surgeries. I am so sorry we cannot be of any more help. There are some excellent videos on you tube for medical students and coroners that could be worth looking at or contacting the drs involved with your question. Again, our deepest sympathies for your terrible tragedy: 21st July every year is International Remembrance Day -the day we pay tribute to all of our friends and loved ones who have died as a result of the war on drugs (through overdose, discrimination, violence, neglect etc). Perhaps you may want to connect with a group in your area who is commemorating the event. International Overdose Day is 31st August every year also. All the very best, BP xx

  6. Thank you for this very informative explanation – I hope it saves someone, anyone.
    RIP Brittany, 26 is too young to die.

  7. allen

     /  May 26, 2014

    Thery nothing u can .do besides seek help even if u can’t afford it that or just sit back in pure .agonizing. mental and physical, emotional. Pain and. Confusion. That just gets worse and .worst.. I have one of the worst types of ie I sat in the hospital for 8 weeks. But they healed me but my infection is coming bac and k worse than ever it’s an t totally uneplainable. Pain that nobody else could ever phathom .except other ie patients. And all .I can do is sit and watch it happen and .beg his to end it or just take my life .now .and end the pain

  8. donald thor

     /  April 30, 2014

    just got out of the hospital for endocaditus. REALLY struggling to stay off heroin because this hospital swtay really hurt, but as usual it’s a losing battle. I want to use bad (30 years using – over 20 heroin). If I stop injecting will that keep me from hurting my heart? i.e. it’s not the heroin, but the dirty rigs that’s causing this right?

    • Hey, im so sorry i didnt see this properly till now. Thats a good question -in a way, it IS bacteria entering through an injection site that causes endo, but…if you have had it once and damaged your heart valve, it will be easier for bacteria to set up home there, so where the bacteria might have just sailed by before, this time, cause you have some damage there, it could stick, and multiply, causing you trouble, again. People DO get endo 2 even 3 times. Re using, god, I dont know what to say except – if you are really desperate, can you smoke it instead? That is a very good harm reduction option and if you get brown heroin – well that is just made for smoking and im SURE sometimes some brown heroin and works better smoked than hit up. If you keep all your works and everything clean when cooking up, obviously that helps a lot and can be all the difference but, we dont always know what is in the heroin itself, where it has been etc. And cooking or boiling it -doesn’t really kill bacteria (you need to boil for like 2 or 3 min for that!). But good luck, if you must use, be SUPER sterile -but we would recommend to switch to smoking. it is a habit that is hard to change but it can be done, you have to force yourself, but youll be saving your life in the process and once smoking, youll wonder why you waited so long to switch. Good luck Donald.

  9. Betz

     /  April 6, 2014

    @Rebirth. I am a nursing student studying endocarditis. The likely reason most people (including those who inject their own drugs) don’t know about endocarditis is that the numbers of people who experience it are relatively low compared to other conditions: 3-10/100,000 people a year according to most cardiology journals. The symptoms can be much like other infections–like bad flu–until something really bad happens, e.g. a stroke.

  10. daniel i

     /  August 3, 2013

    Pis i have that problem and i do not have money to treat my self what will i do so that i will live long

    • Wow – are you sure it is endocarditis?? What country do you live in? What city? Maybe we can refer to to somewhere to get help? How did you get a diagnosis? Is it Acute endocarditis or Chronic endocarditis? Either way you will need treatment urgently. Let us know and we will see if we can help. This is terrible! BPx

  11. Jeffery Adside

     /  January 31, 2013

    heart murmurs may not be deadly but it could indicate some other health problems.^

    Visit our new online site too

  12. Rebirth

     /  August 24, 2012

    Great read and great info. I had an old friend die due to endocarditis last year…this is after years of laying off the point, (and the drugs). I am a nursing/midwifery student currently, a user in the past. I thought I was up on harm reduction, I study for my mommas who need the education with out judgement, well as my own interest. I had never came across this till I found out he died and did a little digging into his “heart problem” that had never existed before. It really bothered me. Why did I not know about this? Why is this not common drug knowledge- at least in my part of the States? Our maddening drug war tactics prevent it’s own supposed goals of actually helping people and preventing harm. Why aren’t our rehabs and “centers” pointing All IV drug users to their docs for a heart scan? Cheap…way cheaper than a 6 week stay on round the clock ABX or taking care of complications. The person is served well and we can prevent needless death and treat early. Friend is not the word for this dude to me. We got along horribly, but I have love for him and I have mad love for all my brothers and sisters and aunties and uncles out there, using or not. We wouldn’t dream of not testing for or leaving type 2 diabetes untreated. We try and we educate, right? This could be discribed as a disease of excess too. It can even be reversed in the right conditions. These people are stigmatized but not to the point of refusing Heath education and treatment in favor of spending money on raid and imprisonment of potatoe chip factory managers.

  13. Email from reader:
    Good piece on endocarditis in bp. I’d like to add that the risk is increased if you have a congenital heart murmur. I had to have valve replacement surgery after injecting dry diamorphine amps but using tap water as i didn’t have any sterile. Caught a nasty bug and after surgery was in hospital for over 6 months on some extremely unpleasant antibiotics.
    (thanks for that info! Scary stuff!)

  14. a brilliant piece of Information!

    great read!

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