Echocardiographic findings suggestive of infective endocarditis in asymptomatic Danish injection drug users attending urban injection facilities

Patient characteristics, treatment patterns, and prognosis in drug-use-associated infective endocarditis in Denmark from 1999 to 2018

BACKGROUND

While the proportion of drug-use-associated infective endocarditis (DU-IE) has been increasing during the opioid crisis in the United States, it is unknown whether this is seen in Denmark, where several preventive means have been implemented. We aimed to assess the temporal proportion of DU-IE and examine the rate of IE recurrence and mortality.

METHODS

This nationwide cohort study identified all patients with first-time infective endocarditis in 1999-2018. Drug use was defined using ICD-8/10 codes or prescription filling of medication for opioid use disorder. Long-term mortality was examined with a Kaplan-Meier estimator and a multivariate Cox model. The recurrence of IE was examined with the Aalen-Johansen method and a multivariate cause-specific hazard model.

RESULTS

We included 8,843 patients with IE: 407 with DU-IE (60.7% male, median age 43.8 years) and 8,436 with non-DU-IE (65.8% male, median age 71.5 years). The proportion of DU-IE decreased from 5.9% to 3.8% during our study period. The one-year cumulative incidence of all-cause mortality was 16.9% (CI 12.9%-20.8%) for patients with DU-IE and 17.3% (CI 16.4%-18.2%) for patients with non-DU-IE. Drug use was associated with higher one-year mortality (adjusted HR 1.64 (CI 1.23%-2.21%)). The 1-year cumulative incidence of IE recurrence was 12.8% (CI 9.3%-16.3%) in patients with DU-IE and 4.3% (CI 3.8%-4.8%) in patients with non-DU-IE. Drug use was associated with a higher 1-year recurrence of IE (adjusted HR 3.39 (CI 2.35-4.88)).

CONCLUSION

In Denmark, the proportion of patients with DU-IE fell by one-third from 1999 to 2018. DU-IE was associated with higher mortality and recurrence rates than non-DU-IE.

Dealing with the epidemic of endocarditis in people who inject drugs

North America is facing an opioid epidemic and growing illicit drug supply, contributing to growing numbers of injection drug use-related infective endocarditis (IDU-IE). Patients with IDU-IE have high early and late mortality. Patients with IDU-IE more commonly present with right-sided IE compared to those with non-IDU-IE and a majority are a result of S. aureus. While most patients can be successfully managed with intravenous antibiotic treatment, surgery is often required in part related to high relapse rates, potential treatment biases, and more aggressive pathophysiology in some. Multidisciplinary management as endocarditis teams, including not only cardiologists and cardiac surgeons but also infectious disease specialists, drug addiction experts, social workers, neurologists and/or neurosurgeons, is essential to best manage substance use disorder and facilitate safe discharge to home and society. Structural and population-level interventions, such as harm reduction programs, are necessary to reduce IDU-IE relapse rates in the community and other IDU-related health concerns such as overdoses. In this review, we describe the pathophysiological, clinical, surgical, social, and ethical characteristics of IDU-IE and the management thereof. We present the most recent clinical guidelines for this condition and discuss existing gaps in knowledge to guide future research, practice changes, and policy interventions.

The epidemiology of infective endocarditis with focus on non-device related right-sided infective endocarditis: A retrospective register-based study in the region of Southern Denmark

AIMS

Non-device related right-sided infective endocarditis (ND-RSIE) is not well characterized. We aimed to characterize patients with infective endocarditis (IE) with emphasis on the epidemiology, clinical characteristics and complications of ND-RSIE.

METHODS

In this population-based cohort study, we identified patients with IE using ICD-10 codes from the Danish National Hospital Register in the Region of Southern Denmark between January 2007 and May 2017. Hospital records were reviewed, and characteristics and outcomes recorded.

RESULTS

We included 1243 confirmed IE episodes of which 82% were left-sided IE, 11% were cardiac device right sided infective endocarditis (RSIE) and 7% were ND-RSIE. Patients with ND-RSIE were considerably younger, had less comorbidity and had a lower 30-day mortality (6%) compared with patients with device RSIE (24%) and left-sided IE (26%) (p<0.01). ND-RSIE was associated with underlying heart disease, involvement of the tricuspid valve (57%), Staphylococcus species (53%) and complications (61%). Forty percent of ND-RSIE occurred among people who inject drugs (PWID) for whom significant differences were observed compared with non-PWID with regards to tricuspid valve involvement (96% vs. 32%), causative microorganisms (Staphylococcus aureus 79% vs. 27%), complications (86% vs. 45%), recurrence (29% vs. 11%) and 30-day mortality (0% vs. 7%).

CONCLUSION

ND-RSIE is relatively rare and differs with regards to epidemiology, clinical characteristics and complications compared with left-sided IE and cardiac device RSIE, but has a favourable prognosis. Forty percent of ND-RSIE occurs among PWID, which is associated with frequent complications but a very low mortality.

Drug consumption rooms: A systematic review of evaluation methodologies

ISSUES

Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.

APPROACH

Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded.

KEY FINDINGS

Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'.

IMPLICATIONS

Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities.

CONCLUSIONS

Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.

Seroprevalence of Bartonella spp., Coxiella burnetii, and Hantavirus among people who inject drugs in Rio de Janeiro, Brazil: a retrospective assessment of a biobank

The increasing use of illicit drugs imposes a public health challenge worldwide. People who inject drugs (PWID) are more susceptible to health complications due to immunosuppression associated with drug use and non-hygienic self-administration of substances, contaminants, and liquids. PWID are subjected to increased risk of acquiring and transmitting different pathogens (frequently functioning as sentinel cases for (re)emerging pathogens), including those transmitted by arthropods and vertebrate reservoirs in unhealthy environments. A clear association between injection drug use and HIV, HBV, and HCV infections has been described; however, other infectious viral and bacterial agents have been seldomly assessed. In this study, we investigated the seroprevalence of Bartonella spp., Coxiella burnetii, and Hantavirus among 300 randomly selected PWIDs from Rio de Janeiro, as part of a multi-city cross-sectional study carried out in the 1990s. Point seroprevalences and respective 95% CIs are as follows: 9.3% for C. burnetii (95% CI: 6.0%-13.0%), 1.0% for Bartonella spp. (95% CI: 0.0%-3.0%), and 4.0% for Hantavirus (95% CI: 2.0%-7.0%). In addition to the blood-borne pathogens, the results of this study increase our knowledge on other transmissible infectious agents in PWID. The high seroprevalence of C. burnetii and Hantavirus found among PWID is intriguing and suggests the need to carry out prospective studies, including molecular analyses, to confirm these findings and allow a better understanding of the putative relevance of these zoonotic infectious agents among PWID.

Both-sided native valve infective endocarditis in a drug addict with incidental pneumoconiosis

Involvement of both right and left heart chambers with infective endocarditis is extremely rare. In this case report, we aimed to present a rare case of Infective endocarditis (IE) in an intravenous & inhalational drug misuse involving both cardiac chambers with incidental pneumoconiosis.

Clinical - microbiological characterization and risk factors of mortality in infective endocarditis from a tertiary care academic hospital in Southern India

Aims

To dissect the clinical-microbiological profile of Infective endocarditis (IE) population and to determine the risk factors for IE related mortality.

Methods

A cohort study was conducted using relevant data from clinical records of patients (≥12 years) with definite/possible IE from December 2007 to December 2013 and was analyzed using appropriate statistical tests.

Results

In the cohort of 139 IE patients, mean age was 47.9 ± 15.8 years, with male preponderance (68.3%). Rheumatic heart disease was the commonest (30.9%) underlying cardiac lesion followed by mitral valve prolapse with mitral regurgitation (23.7%), degenerative valvular disease (23%), congenital heart disease (15.8%) and prosthetic valves (3.6%). Vegetations were detected in 94.2% cases. Blood cultures were positive in 69.8% cases, commonest organism isolated was α – hemolytic streptococci (30.9%) followed by Enterococcus (12.9%) and methicillin sensitive Staphylococcus aureus (10.8%). Complications observed were congestive cardiac failure (31.2%), acute kidney injury (25.9%), stroke (21.6%), septic shock (16.5%), embolic phenomenon non-stroke (8.6%), atrial fibrillation (5%) and ring abscess (2.9%). Mortality rate was 17.3%. Congestive cardiac failure, increase in the peak leucocyte count and stroke were the independent predictors of mortality.

Conclusions

This study reiterates the persistent dominance of rheumatic heart disease in the population studied and α – hemolytic Streptococci as the commonest responsible microorganism.

A systematic review of injecting-related injury and disease among people who inject drugs

BACKGROUND

Non-viral injecting-related injuries and diseases (IRID), such as abscesses and vascular damage, can result in significant morbidity and mortality if untreated. There has been no systematic assessment of the prevalence of non-viral IRID among people who inject drugs; this review aimed to address this gap, as well as identify risk factors for experience of specific IRID.

METHODS

We searched MEDLINE, Embase and CINAHL databases to identify studies on the prevalence of, or risk factors for, IRID directly linked to injecting in samples of people who inject illicit drugs.

RESULTS

We included 33 studies: 29 reported IRID prevalence in people who inject drugs, and 17 provided data on IRID risk factors. Skin and soft tissue infections at injecting sites were the most commonly reported IRID, with wide variation in lifetime prevalence (6-69%). Female sex, more frequent injecting, and intramuscular and subcutaneous injecting appear to be associated with skin and soft tissue infections at injecting sites. Cleaning injecting sites was protective against skin infections. Other IRID included infective endocarditis (lifetime prevalence ranging from 0.5-12%); sepsis (2-10%); bone and joint infections (0.5-2%); and thrombosis and emboli (3-27%).

CONCLUSIONS

There were significant gaps in the data, including a dearth of research on prevalence of IRID in low- and middle-income countries, and potential risk and protective factors for IRID. A consistent approach to measurement, including standardised definitions of IRID, is required for future research.

Increasing Infectious Endocarditis Admissions Among Young People Who Inject Drugs

People who inject drugs (PWID) are at risk for infective endocarditis (IE). Hospitalization rates related to misuse of prescription opioids and heroin have increased in recent years, but there are no recent investigations into rates of hospitalizations from injection drug use-related IE (IDU-IE). Using the Health Care and Utilization Project National Inpatient Sample (HCUP-NIS) dataset, we found that the proportion of IE hospitalizations from IDU-IE increased from 7% to 12.1% between 2000 and 2013. Over this time period, we detected a significant increase in the percentages of IDU-IE hospitalizations among 15- to 34-year-olds (27.1%–42.0%; P < .001) and among whites (40.2%–68.9%; P < .001). Female gender was less common when examining all the IDU-IE (40.9%), but it was more common in the 15- to 34-year-old age group (53%). Our findings suggest that the demographics of inpatients hospitalized with IDU-IE are shifting to reflect younger PWID who are more likely to be white and female than previously reported. Future studies to investigate risk behaviors associated with IDU-IE and targeted harm reduction strategies are needed to avoid further increases in morbidity and mortality in this rapidly growing population of young PWID.

Coxiella burnetii Infection in a Community Operating a Large-Scale Cow and Goat Dairy, Missouri, 2013

Coxiella burnetii is a zoonotic pathogen that causes Q fever in humans and is transmitted primarily from infected goats, sheep, or cows. Q fever typically presents as an acute febrile illness; however, individuals with certain predisposing conditions, including cardiac valvulopathy, are at risk for chronic Q fever, a serious manifestation that may present as endocarditis. In response to a cluster of Q fever cases detected by public health surveillance, we evaluated C. burnetii infection in a community that operates a large-scale cow and goat dairy. A case was defined as an individual linked to the community with a C. burnetii phase II IgG titer ≥ 128. Of 135 participants, 47 (35%) cases were identified. Contact with or close proximity to cows, goats, and their excreta was associated with being a case (relative risk 2.7, 95% confidence interval 1.3-5.3). Cases were also identified among individuals without cow or goat contact and could be related to windborne spread or tracking of C. burnetii on fomites within the community. A history of injection drug use was reported by 26/130 (20%) participants; follow-up for the presence of valvulopathy and monitoring for development of chronic Q fever may be especially important among this population.

The diagnostic ability of echocardiography for infective endocarditis and its associated complications

Echocardiography, transthoracic and transoesophageal, plays a key role in the diagnosis and prognosis assessment of patients with infective endocarditis. It constitutes a major Duke criterion and is pivotal in treatment guiding. Seven echocardiographic findings are major criteria in the diagnosis of infective endocarditis (IE) (vegetation, abscess, pseudoaneurysm, fistulae, new dehiscence of a prosthetic valve, perforation and valve aneurysm). Echocardiography must be performed as soon as endocarditis is suspected. Transoesophageal echocardiography should be done in most cases of left-sided endocarditis to better define the anatomic lesions and to rule out local complications. Transoesophageal echocardiography is not necessary in isolated right-sided native valve IE with good quality transthoracic examination and unequivocal echocardiographic findings. Echocardiography is a very useful tool to assess the prognosis of patients with IE at any time during the course of the disease. Echocardiographic predictors of poor outcome include presence of periannular complications, prosthetic dysfunction, low left ventricular ejection fraction, pulmonary hypertension and very large vegetations.