Infective Endocarditis Secondary to Injection Drug Use: A Survey of Canadian Cardiac Surgeons

Integrating harm reduction into acute care: A single center's experience

Objective

Injection drug use (IDU) is prevalent in North America and is associated with presentations with infective endocarditis. Supporting patients who present with infective endocarditis related to IDU through harm reduction, a pragmatic approach to reduce secondary harms of a health behavior, helps address the underlying IDU. We share a case exemplar of how one acute care facility integrated harm-reduction practices into daily patient care.

Methods

We took a 3-stage approach to integrate harm-reduction practices into daily patient care. In stage 1, we raised awareness and knowledge of harm reduction through education. In stage 2, we provided explicit support for harm reduction. In stage 3, we provided tangible tools to support harm reduction.

Results

More than 300 staff attended education sessions and reported increased knowledge related to substances, harm reduction, and engaging patients who use substances in conversations. Staff requested the hospital explicitly support harm reduction, which led to stage 2. The creation of a harm-reduction philosophy statement provided permission to engage in harm-reduction practices. Stage 3 included the creation of a harm-reduction supply distribution program and consultations with Addictions Medicine and treatment programs. The implementation of harm-reduction supply distribution was successful and is being spread across the facility.

Conclusions

Engaging in harm-reduction practices within an acute care facility is possible through a multistage process focused on education, explicit support, and tangible tools. Spreading harm-reduction integration and working with patients who used substances to evaluate effectiveness are key next steps.

Surgeons' Perspectives on Valve Surgery in People With Drug Use-Associated Infective Endocarditis

BACKGROUND

Hospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons' perspectives about the process of decision making around operation for people with DUA-IE are largely unknown.

METHODS

This multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University.

RESULTS

Nineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care.

CONCLUSIONS

Cardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

Different drugs, different sides: injection use of opioids alone, and not stimulants alone, predisposes to right-sided endocarditis

Objectives

Many studies suggest that infective endocarditis (IE) in people who inject drugs is predominantly right sided, while other studies suggest left sided disease; few have differentiated by class of drug used. We hypothesised that based on differing physiological mechanisms, opioids but not stimulants would be associated with right sided IE.

Methods

A retrospective case series of 290 adult (age ≥18) patients with self-reported recent injection drug use, admitted for a first episode of IE to one of three hospitals in London Ontario between April 2007 and March 2018, stratified patients by drug class used (opioid, stimulant or both), and by site of endocarditis. Other outcomes captured included demographics, causative organisms, cardiac and non-cardiac complications, referral to addiction services, medical versus surgical management, and survival.

Results

Of those who injected only opioids, 47/71 (69%) developed right-sided IE, 17/71 (25%) developed left-sided IE and 4/71 (6%) had bilateral IE. Of those who injected only stimulants, 11/24 (46%) developed right-sided IE, 11/24 (46%) developed left-sided IE and 2/24 (8%) had bilateral IE. Relative to opioid-only users, stimulant-only users were 1.75 (95% CI 1.05 to 2.93; p=0.031) times more likely to have a left or bilateral IE versus right IE.

Conclusions

While injection use of opioids is associated with a strong predisposition to right-sided IE, stimulants differ in producing a balanced ratio of right and left-sided disease. As the epidemic of crystal methamphetamine injection continues unabated, the rate of left-sided disease, with its attendant higher morbidity and mortality, may also grow.

The impact of opioid agonist treatment on hospitalisations for injecting-related diseases among an opioid dependent population: A retrospective data linkage study

BACKGROUND

Injecting-related bacterial and fungal infections cause substantial illness and disability among people who use illicit drugs. Opioid agonist treatment (OAT) reduces injecting frequency and the transmission of blood borne viruses. We estimated the impact of OAT on hospitalisations for non-viral infections and examine trends in incidence over time.

METHODS

We conducted a retrospective cohort study using linked administrative data. The cohort included 47 163 individuals starting OAT between August 2001 and December 2017 in New South Wales, Australia, with 454 951 person-years of follow-up. The primary outcome was hospitalisation for an injecting-related disease. The primary exposure was OAT status (out of OAT, first four weeks of OAT, and OAT retention [i.e., more than four weeks in treatment]). Covariates included demographic characteristics, year of hospitalisation, and recent clinical treatment.

RESULTS

9122 participants (19.3%) had at least one hospitalisation for any injecting-related disease. Compared to time out of treatment, retention on OAT was associated with a reduced rate of injecting-related diseases (adjusted rate ratio[ARR]=0.92; 95%CI 0.87-0.97). The first four weeks of treatment was associated with an increased rate (ARR 1.53, 95%CI 1.38-1.70), which we believe is explained by referral pathways between hospital and community OAT services. The age-adjusted incidence rates of hospitalisations for any injecting-related disease increased from 34.8 (95% CI =30.2-40.0) per 1000 person-years in 2001 to 54.9 (95%CI=51.3-58.8) in 2017.

INTERPRETATION

Stable OAT is associated with reduced hospitalisations for injecting-related bacterial infections; however, OAT appears insufficient to prevent these harms as the rate of these infections is increasing in Australia.

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.

Cardiac surgeons' perspectives and practices regarding people who use drugs: A scoping review

BACKGROUND AND AIM OF STUDY

The rising rates of drug use and associated cardiovascular complications, particularly infective endocarditis, have led to poorer health outcomes for people who use drugs (PWUD). The objectives of this scoping review were to identify (1) attitudes of cardiac surgeons toward PWUD and (2) challenges faced in the surgical treatment of drug use-related disease.

METHODS

A comprehensive literature search of three databases was performed with this assistance of a medical librarian. Articles were screened and analyzed for common themes by two independent authors. After literature review, a scoping review was conducted according to preferred reporting items for systematic reviews and meta-analyses and Joanna Briggs Institute guidelines, summarizing existing evidence.

RESULTS

Analysis of 35 qualified articles revealed eight themes regarding the perspectives and practices of cardiac surgeons toward PWUD: (1) need for multidisciplinary care teams (45.7%); (2) insufficient resources for treatment of underlying substanceuse disorders (40.0%); (3) stigma toward PWUD (37.1%); (4) willingness of surgeons to operate (31.4%); (5) incomplete guidelines for surgical management of drug-use related infective endocarditis (17.1%); (6) recognizing the importance of psychosocial factors (14.3%); (7) use of drug abstinence contracts (14.3%); and (8) use of stigmatizing language to describe PWUD and/or sterile injection (40.0%).

CONCLUSIONS

Provision of equitable care for PWUD requires effort from multiple disciplines including cardiothoracic surgeons, infectious disease specialists, addiction medicine specialists, and social workers. Additionally, further research is needed to gather sufficient data for evidence-based guidelines in the treatment of cardiac complications in PWUD.