Stimulated by Zhang and Yi 2026.[1]
SAE – serious adverse event
IF – impact factor
SBE – subacute bacterial endocarditis
IE – infective endocarditis
PID – prolapsed intervertebral disc
IV – intravenous
MRSA – methicillin-resistant Staphylococus aureus
MSSA – methicillin-sensitive Staphylococus aureus– key to acronyms
This is a SAE report from Beijing, China, published in the American Journal of Case Reports (IF 0.7).
It is a familiar topic and often discussed in medical acupuncture circles, but it is a rather rare event. As acupuncturists we want to know when we should avoid or be more cautious of needling certain patients.
When I was a medical student and junior doctor this was always called SBE, but now the more usual term in infective endocarditis (IE), and it can be acute or subacute. This report is of an acute case, in a 62-year-old man with no predisposing factors – normal cardiac valves and no prior IE.
The report focusses the blame on ‘long needle’ acupuncture, which immediately led me to imagine 150mm needles placed through abdominal viscera; however, the acupuncture treatment was for back pain and involved the use of just 60mm needles (hardly long when treating the lumbar spine and hip girdles).
From the time-line in the case report it looks as if the initial focus of infection was lumbar discitis and osteomyelitis, which of course would be derived from bloodborne spread rather than inoculation. Whether or not acupuncture was the cause of sufficient Staphylococus aureus bacteraemia to seed infection in the lumbar spine is hard to say. The patient received 3 sessions of acupuncture, the last of which was 3 days prior to the onset of symptoms. It is quite possible that he had already developed discitis following a PID prior to seeking acupuncture treatment, but equally it is possible that bacteriaemia with a high virulence organism such as Staphylococus aureus following skin puncture could result in discitis within 3 days.
Septic shock was the initial problem followed by more delayed development of tricuspid valve vegetations and multiple abscesses, including bilateral psoas and erector spinae abscesses. The latter may be supporting evidence for acupuncture as the causal mechanism.
Tricuspid valve IE is less common that left-sided IE and is often associated with intravenous drug use, so presumably Staphylococus aureus from dirty skin over an injection site or a dirty needle finds its way first to the right side of the heart via peripheral veins. At risk individuals have pre-existing valvular heart disease, which is more likely to affect the valves on the left side, where the pressure is greater.
A case of tricuspid valve IE was reported in the Czech Republic in 2006 following an ear piercing in a 15-year-old boy with no prior valvular heart disease. Staphylococus aureus was grown from blood cultures, and the same strain was grown from a tiny purulent focus at the site of the ear piercing.[2]
By contrast, the first case report of IE I have in my records was from 1983 and also attributed IE to piercing the ear, this time with indwelling acupuncture needles for smoking cessation; however, the responsible organism (Pseudomonas aeruginosa) was not grown from an ear swab, despite the patient reporting irritation and discharge from the needle site.[3] This 57-year-old woman had a prosthetic mitral valve, so was at increased risk of IE, and this is one of the cases that resulted in the BMAS starting to advise that valvular heart disease should be a contraindication to the use of indwelling needles.
The second reported case came in 1985, and again involved the use of an indwelling needle in the ear for smoking cessation.[4] The patient was a 56-year-old woman with known rheumatic heart disease and the indwelling needle caused a local infection within 5 days of placement. The infection was treated with oral antibiotics but ultimately required minor surgical treatment. The patient became unwell 3 days following the surgical debridement and 1 of 8 blood cultures subsequently grew Staphylococus aureus. There were no absolutely definitive signs of IE and antibiotic treatment was successful. The authors raised the topic of antibiotic prophylaxis for acupuncture, but a subsequent comment by a professor of medicine from Washington in the same journal argued cogently against such a strategy.[5]
The third case report of IE following use of an indwelling needle in the ear was published in JAMA in 1992.[6] In this case the patient was a 59-year-old women with multiple prosthetic heart valves due to rheumatic heart disease. The same strain of Proprionobacterium acnes was grown from separate blood cultures over a week or so, but there is no mention of growing the same strain from the ear. The patient also received a number of injections at the same time as the indwelling needle was placed.
The following year the first case of IE following body acupuncture was reported, although this particular case dated back to 1986.[7] It was one of a series of 4 cases from the same centre in Australia and involved a 61-year-old woman with diabetes, rheumatoid arthritis, and hypothyroidism. She was the only one not known to have valvular heart disease, but she was on a low dose of prednisolone to control her rheumatoid arthritis. She developed an acute illness 2 days following acupuncture to her left thigh, knee, and ankle. Blood cultures subsequently grew Staphylococus aureus. She had received acupuncture treatment 2 years earlier without any complication.
In 2001 a case of IE following body acupuncture was reported in the UK.[8] The patient concerned was a 42-year-old woman with Marfan’s syndrome and prosthetic aortic valve. She had a session of acupuncture for back pain and became unwell 6 days later with Staphylococus aureus IE. She required further surgery to replace the valve.
The next case in the literature is from California in 2002 and involved a 33-year-old man with a hip pain following a hockey game. He was diagnosed with a muscle strain at a local urgent care facility and prescribed an NSAID. The urgent care physician recorded a fever on the patient’s chart but did not discuss this with the patient. The patient’s pain did not improve, and he sought acupuncture treatment following the advice of a friend. This did not help either and he eventually became more acutely unwell and was admitted to hospital. The clinical trajectory was not straightforward, but eventually IE was diagnosed after 4 blood cultures grew Staphylococus aureus, and trans-oesophageal echocardiography showed a large aortic valve vegetation. He recovered after 6 weeks of IV oxacillin. He subsequently attempted to sue the acupuncturist but was defeated by the medical record from the urgent care facility that had recorded a fever prior to him seeking the acupuncture.
Presumably stimulated by the debate going on in the BMAS regarding the safety of acupuncture in patients with valvular heart disease, and the SAE reports that often (without due consideration) recommended antibiotic prophylaxis for acupuncture in these patients, a GP member who had used acupuncture in his NHS general practice for many years reviewed all his patients with known valvular heart disease.[9] He found 36 who had had acupuncture over a ten-year period. He reviewed these patients to exclude the presence of subacute IE. All underwent a clinical examination and a blood test. 2 went on to have blood cultures and trans-oesophageal echocardiography. No patients were ultimately found to have subacute IE.
Thus far, none of the case reports that implicate acupuncture are entirely convincing, unlike the case of the 15-year-old Czech boy with the infected ear piercing.[2] But when considering the possibility of such a serious condition (as IE) we do need to err on the side of caution. I was pleased, therefore, to find a paper that clearly demonstrated the potential risk of acupuncture. It was published in 2008 in the journal Infection Control and Hospital Epidemiology (IF ~3, both now and in 2008, but there was a surge to 6.5 during the pandemic).[10] This paper did not have endocarditis in the title, but came up on my searches because endocarditis appeared in the abstract. It is an investigation of an outbreak of invasive community-acquired MRSA infections in Perth, Western Australia. There were 8 cases in total, 7 from 2003 and 1 further case from the year before found from retrospective investigation. All patients had received invasive procedures from the same doctor (a singlehanded GP in the Perth Metropolitan area). 2 had joint injections and 6 had acupuncture. 5 patients had septic arthritis, and 3 had pyomyositis. One of the patients had suspected endocarditis as well. The doctor was found to be carrying an almost identical strain of MRSA.
The final paper I want to mention is another case of Staphylococus aureus IE affecting the tricuspid valve in a 15-year-old boy with severe atopic eczema. He had received acupuncture through the affected skin around his knees, and it sounds as though he developed bilateral septic arthritis as the initial focus of infection. He had been found to be a nasal carrier of Staphylococus aureus the previous year.
So, what can we learn from all this? Acupuncture is very low risk of causing IE, but that risk is clearly not zero. The background risk of IE in the population is 3 to 10 cases per 100 000 person years (0.01% or less). This increases to 0.1% to 1% per year in high-risk groups (previous IE or valve disease). IV drug use increases the risk by 10 to 100 times. Catheter-related blood stream infection occurs 1 to 5 times per 1000 catheter-days, and the fraction progressing to IE is ~1% to 10%. The risk of acupuncture is probably less than 1 in a million treatments.
So, what should we do? We should ensure the basics of infection control are always covered. We should wash our hands well before performing acupuncture and avoid touching our faces. If we are nasal carriers of Staphylococus aureus, we should probably try to eradicate it, just as is done routinely in all patients undergoing arthroplasty procedures.
One more thing… In 2008 NICE recommended (CG64) that antibiotic prophylaxis should not be routinely prescribed to patients at risk of IE prior to dental procedures and other non-dental procedures affecting the gastrointestinal, genitourinary, or respiratory tracts. Since then there does not appear to have been a rise in cases of IE.[11]
References
1 Zhang Y, Yi L. A 62-Year-Old Man With Tricuspid Valve Endocarditis, Bacteremia, and Septic Pulmonary Embolism Following Long-Needle Acupuncture. Am J Case Rep. 2026;27:e951333. doi: 10.12659/AJCR.951333
2 Kovarik A, Setina M, Sulda M, et al. Infective endocarditis of the tricuspid valve caused by Staphylococcus aureus after ear piercing. Scand J Infect Dis. 2007;39:266–8. doi: 10.1080/00365540600868396
3 Jefferys DB, Smith S, Brennand-Roper DA, et al. Acupuncture needles as a cause of bacterial endocarditis. Br Med J. 1983;287:326–7. doi: 10.1136/bmj.287.6388.326
4 Lee RJ, McIlwain JC. Subacute bacterial endocarditis following ear acupuncture. Int J Cardiol. 1985;7:62–3. doi: 10.1016/0167-5273(85)90175-5
5 Cheng TO, Lee RJ, McIlwain JC. Subacute bacterial endocarditis following ear acupuncture. Int J Cardiol. 1985;8:97. doi: 10.1016/0167-5273(85)90270-0
6 Scheel O, Sundsfjord A, Lunde P, et al. Endocarditis after acupuncture and injection–treatment by a natural healer. JAMA. 1992;267:56. doi: 10.1001/jama.267.1.56b
7 Spelman DW, Weinmann A, Spicer WJ. Endocarditis following skin procedures. J Infect. 1993;26:185–9. doi: 10.1016/0163-4453(93)92923-k
8 Nambiar P, Ratnatunga C. Prosthetic valve endocarditis in a patient with Marfan’s syndrome following acupuncture. J Heart Valve Dis. 2001;10:689–90.
9 Stellon A. Acupuncture in patients with valvular heart disease and prosthetic valves. Acupunct Med. 2003;21:87–91. doi: 10.1136/aim.21.3.87
10 Murray RJ, Pearson JC, Coombs GW, et al. Outbreak of invasive methicillin-resistant Staphylococcus aureus infection associated with acupuncture and joint injection. Infect Control Hosp Epidemiol. 2008;29:859–65. doi: 10.1086/590260
11 Thornhill MH, Dayer MJ, Forde JM, et al. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. BMJ. 2011;342:d2392. doi: 10.1136/bmj.d2392
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