Comparing right- and left sided injection-drug related infective endocarditis

Left-sided infective endocarditis presenting with pulmonary involvement and liver abscess: A case report

Key Clinical Message

Infective endocarditis is an important differential diagnosis in patients with persistent fever and chills not responding to antibiotics and involvement of multiple organs. It can present without any specific signs such as valvular murmurs and no growth on blood cultures. Therefore, considering an echocardiography can be crucial and helpful in establishing the diagnosis.

Abstract

Infective endocarditis (IE), a rare disease with high mortality, arises from microbial infection affecting the heart valves and endocardium. It exhibits diverse symptoms and can involve various organs, including the brain, lungs, spleen, and liver. Diagnosis is often intricate due to its polymorphic nature, and negative blood cultures can add complexity to the diagnostic process. In this report, we present an unusual case of IE in a 53-year-old male farmer with multi-organ involvement, including liver abscesses and pulmonary infiltration with cavities. Echocardiography showed a nodular mass attached to his bicuspid aortic valve, thus, playing a crucial role in confirming the diagnosis. This atypical manifestation highlights the necessity for increased clinical vigilance and further research to improve diagnostic approaches for uncommon IE cases.

Comparison of Medical Therapy, Valve Surgery, and Percutaneous Mechanical Aspiration for Tricuspid Valve Infective Endocarditis

BACKGROUND

The opioid pandemic, and particularly injection drug use, has led to an increase in cases of tricuspid valve infective endocarditis. Indications for valve surgery in right-sided infective endocarditis are not well-defined. Percutaneous mechanical aspiration is considered an alternative in patients at high risk for re-infection of a prosthetic valve but lacks robust outcomes data. This retrospective analysis compares the primary outcome of death within 1 year for patients with isolated tricuspid valve infective endocarditis treated with medical therapy alone vs percutaneous mechanical aspiration or valve surgery.

METHODS

The authors performed a retrospective cohort study of patients with isolated tricuspid valve infective endocarditis over a 10-year period. Medical record review was performed to collect demographic-and outcomes-related data. The association between treatment group and outcomes was assessed using Cox proportional hazard regression with inverse probability of treatment weighting.

RESULTS

Between January 1, 2009, and December 31, 2018, 215 patients with isolated tricuspid valve infective endocarditis and surgical indications were identified. One hundred patients (46.5%) were managed medically, 49 (22.8%) were managed surgically, and 66 (30.7%) underwent percutaneous mechanical aspiration. There was no significant difference in 1-year mortality between the 3 treatment groups (P = .15). Vegetation size > 2.0 cm was associated with increased 1-year mortality (hazard ratio 3.01; P = .03). Addiction medicine consultation was associated with decreased 1-year mortality (hazard ratio 0.117; P = .0008).

CONCLUSION

The study highlights that surgery or percutaneous mechanical aspiration in addition to medical therapy does not improve 1-year mortality in patients with isolated tricuspid valve infective endocarditis. Addiction medicine consultation was associated with decreased 1-year mortality in patients with injection drug use-associated isolated tricuspid valve infective endocarditis.

Acute drug-use-related native tricuspid valve infective endocarditis: a non-surgical disease

As a result of the ongoing opioid epidemic, physicians have encountered increasing rates of drug-use-related native tricuspid valve infective endocarditis (DU-TVIE), a complex multi-faceted disease that is best managed by interdisciplinary teams. Despite the large number of patients with DU-TVIE, there is little data to support the optimal treatment strategy with respect to medical and surgical therapy. The recent introduction of percutaneous mechanical aspiration of tricuspid valve vegetations has added another treatment modality that is also of uncertain benefit. Here we review the literature on the management of DU-TVIE and highlight the multi-step treatment approach developed by the multidisciplinary endocarditis team at the University of Kentucky.

A rare Serratia marcescens-associated acute endocarditis of a tricuspid valve in an intravenous drug user : A case report and literature review

Serratia marcescens is a gram-negative bacillus that is an opportunistic agent in respiratory tract infections, urinary tract infections, and septicemia. It is rarely also a cause of infective endocarditis which follows a rapid and devastating course, typically in persons with history of intravenous drug use (IDU). This article reports a fatal case of a 27-year-old patient with a known history of IDU, who presented with clinical symptoms concerning right-sided endocarditis as well as signs of acute respiratory distress syndrome. Finally, a detailed review of the literature is provided concerning the acute endocarditis of a tricuspid valve, especially associated with Serratia marcescens infection.

Prevalence of Right- and Left-Sided Endocarditis Among Intravenous Drug Use Patients at a Large Academic Medical Center

Background

Left-sided infective endocarditis (IE) is increasingly being recognized among intravenous drug use (IVDU) patients. We sought to assess the trends and risk factors that contribute to left-sided IE in this high-risk population at University of Kentucky.

Methods

A retrospective chart review of patients with the diagnosis of both IE and IVDU admitted at University of Kentucky was carried out from January 1, 2015 to December 31, 2019. Baseline characteristics, trends of endocarditis and clinical outcomes (mortality and in-hospital interventions) were recorded.

Results

A total of 197 patients were admitted for management of endocarditis. One hundred and fourteen (57.9%) had right-sided endocarditis, 25 (12.7%) had combined left-sided and right-sided endocarditis, and 58 (29.4%) had left-sided endocarditis. Staphylococcus aureus was the most common pathogen. Mortality and inpatient surgical interventions were higher among patients with left-sided endocarditis. Patent foramen ovale (PFO) was the most common shunt found (3.1%), followed by atrial septal defect (ASD, 2.4%) with PFO being significantly more common among patients with left-sided endocarditis.

Conclusion

Right-sided endocarditis continues to be predominant among IVDU patients and Staphylococcus aureus was the most common organism involved. Patients with evidence of left-sided disease were found to have significantly more PFO, needed more inpatient valvular surgeries, and had higher all-cause mortality. Further studies are needed to assess if PFO or ASD can increase the risk of acquiring left-sided endocarditis in IVDU.

Characteristics and outcomes of angiovac-assisted debulking of intracardiac masses, thrombi, and endocarditis

BACKGROUND

Traditional management for right-sided infective endocarditis and other adherent masses centers around balancing the risks and benefits of open surgical removal against medical therapy.

METHODS

Single-center study analysis of 19 patients who underwent vacuum-assisted debulking and/or en bloc removal of right-sided infective endocarditis and other adherent masses between September 2017 and November 2021. Clinical outcomes during the perioperative period, postoperative period, hospital course, and post-discharge were analyzed.

RESULTS

We included 12 male and 7 female patients with an average age 47.4 ± 16.8. Relevant risk factors included 47.4% of patients with active intravenous drug use (IVDU), 21.1% of patients with a history of permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD), and 5.3% of prior malignancy with mediastinal radiation. 31.6% of patients had documented right-sided masses from a non-infectious etiology, while 68.4% of patients were noted to have right-sided infective endocarditis (RSIE). All patients were found to have large, mobile masses or vegetations at high risk for embolization to the pulmonary vasculature. Average in-hospital length of stay was 17.8 ± 12.2 days, blood cultures cleared postoperatively in 8.9 ± 7.3 days, periprocedural mortality was 0%, subsequent open surgical valvular repair during the same admission was 5.3%, and in-hospital mortality was 5.3%. Within 6 weeks of follow-up, 15.8% of patients were readmitted for recurrence of bacteremia, 10.5% of patients were found to have new pulmonary embolism, and 15.8% of patients underwent open surgical valvular repair. Total death after 1-year and 2-years was 15.8% and 5.3%, respectively. Recurrence of bacteremia was 21.1% within 1-year.

CONCLUSION

AngioVac is a viable therapeutic strategy for select patients with intravascular and intracardiac right-sided masses including thrombi, emboli, or infective masses such as endocarditis.

Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association

BACKGROUND

The American Heart Association has sponsored both guidelines and scientific statements that address the diagnosis, management, and prevention of infective endocarditis. As a result of the unprecedented and increasing incidence of infective endocarditis cases among people who inject drugs, the American Heart Association sponsored this original scientific statement. It provides a more in-depth focus on the management of infective endocarditis among this unique population than what has been provided in prior American Heart Association infective endocarditis-related documents.

METHODS

A writing group was named and consisted of recognized experts in the fields of infectious diseases, cardiology, addiction medicine, and cardiovascular surgery in October 2021. A literature search was conducted in Embase on November 19, 2021, and multiple terms were used, with 1345 English-language articles identified after removal of duplicates.

CONCLUSIONS

Management of infective endocarditis in people who inject drugs is complex and requires a unique approach in all aspects of care. Clinicians must appreciate that it requires involvement of a variety of specialists and that consultation by addiction-trained clinicians is as important as that of more traditional members of the endocarditis team to improve infective endocarditis outcomes. Preventive measures are critical in people who inject drugs and are cured of an initial bout of infective endocarditis because they remain at extremely high risk for subsequent bouts of infective endocarditis, regardless of whether injection drug use is continued.

Five-Year Cardiovascular Outcomes after Infective Endocarditis in Patients with versus without Drug Use History

Background: Disparities in treatment and outcomes of infective endocarditis (IE) between people who use drugs (PWUD) and non-PWUD have been reported, but long-term data on cardiovascular and cerebrovascular outcomes are limited. We aim to compare 5-year rates of mortality, cardiovascular and cerebrovascular events after IE between PWUD and non-PWUD. Methods: Using data from the TriNetX Research Network, we examined 5-year cumulative incidence of mortality, myocardial infarction, heart failure, atrial fibrillation/flutter, ventricular tachyarrhythmias, ischemic stroke, and intracranial hemorrhage in 7132 PWUD and 7132 propensity score-matched non-PWUD patients after a first episode of IE. We used the Kaplan−Meier estimate for incidence and Cox proportional hazards models to estimate relative risk. Results: Matched PWUD were 41 ± 12 years old; 52.2% men; 70.4% White, 19.8% Black, and 8.0% Hispanic. PWUD had higher mortality vs. non-PWUD after 1 year (1−3 year: 9.2% vs. 7.5%, p = 0.032; and 3−5-year: 7.3% vs. 5.1%, p = 0.020), which was largely driven by higher mortality among female patients. PWUD also had higher rates of myocardial infarction (10.0% vs. 7.0%, p < 0.001), heart failure (19.3% vs. 15.2%, p = 0.002), ischemic stroke (8.3% vs. 6.3%, p = 0.001), and intracranial hemorrhage (4.1% vs. 2.8%, p = 0.009) compared to non-PWUD. Among surgically treated PWUD, interventions on the tricuspid valve were more common; however, rates of all outcomes were comparable to non-PWUD. Conclusions: PWUD had higher 5-year incidence of cardiovascular and cerebrovascular events after IE compared to non-PWUD patients. Prospective investigation into the causes of these disparities and potential harm reduction efforts are needed.

Serratia Marcescens, a Rare and Devastating Cause of Endocarditis: A Case Report and Review of the Literature

Serratia marcescens is a gram-negative bacillus that is an opportunistic agent in respiratory tract infections, urinary tract infections, and septicemia. It is rarely a cause of infective endocarditis, but in cases of endocarditis, it follows a rapid and devastating course.

A previously healthy female in her mid-50s presented with fever, abdominal pain, right lower extremity pain, and diarrhea. Blood cultures were positive for S. marcescens, and additional evaluation revealed infarction in the spleen and kidneys, raising concern for endocarditis with associated embolic phenomena. The patient was subsequently found to have an embolus in the right popliteal artery and underwent a right popliteal thromboembolectomy. Antimicrobial therapy with cefepime and gentamicin was begun. A transesophageal echocardiogram revealed a large, mobile mitral valve vegetation. Care was complicated by intracranial hemorrhage, and the decision was made to withdraw care.

A review of the databases Embase and PubMed revealed 63 additional cases of S. marcescens endocarditis. Analysis of these cases demonstrated a preponderance of aortic and mitral valve involvement, not tricuspid valve involvement, despite a risk factor of intravenous drug use in over 60% of cases. Mortality was 50%, and sequelae such as congestive heart failure and renal insufficiency occurred in the majority of survivors. In conclusion, S. marcescens is a rare but devastating cause of endocarditis with a primary risk factor of intravenous drug use but with a predilection for left-sided valvular lesions, not right-sided lesions.

Effect of Socioeconomic Distress on Risk-Adjusted Mortality After Valve Surgery for Infective Endocarditis

Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI > 75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P = 0.016). High socioeconomic distress (DCI > 75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P < 0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis.

Rupture of Both Left-Sided Valves Following Endocarditis Causing One Trouble After Another: A Case Report

Despite the advances in managing left-sided infective endocarditis, complications are still not uncommon. Both aortic and mitral insufficiency can occur from infective endocarditis. In addition, valvular insufficiency due to rupture of valves presents acutely with cardiac decompensation and requires early surgical intervention. Here, we report a case of a 38-year-old intravenous drug user male with Group A Streptococcus-associated left-sided native valve infective endocarditis who presented with acute heart failure three months after his treatment of infective endocarditis. Infective endocarditis complications can lead to severe valve damage, causing acute heart failure, and may require immediate surgical intervention.

Surgery Is Underused in Elderly Patients With Left-Sided Infective Endocarditis: A Nationwide Registry Study

Background

Infective endocarditis is associated with higher mortality in elderly patients, but the role of surgery in this group has not been fully evaluated. The aim of this study was to assess outcomes of left‐sided infective endocarditis in elderly patients and to determine the influence of surgery on mortality in the elderly.

Methods and Results

A nationwide retrospective study was performed of 2186 patients with left‐sided infective endocarditis recorded in the SRIE (Swedish Registry of Infective Endocarditis), divided into patients aged <65 years (n=864), 65 to 79 years (n=806), and ≥80 years (n=516). Survival analysis was performed using the Swedish National Population Registry, and propensity score matching was applied to assess the effect of surgery on survival among patients of all ages. The rate of surgery decreased with increasing age, from 46% in the <65 group to 6% in the ≥80 group. In‐hospital mortality was 3 times higher in the ≥80 group compared with the <65 group (23% versus 7%) and almost twice that of the 65 to 79 group (12%). In propensity‐matched groups, the mortality rate was significantly lower between the ages of 55 and 82 years in patients who underwent surgery compared with patients who did not undergo surgery. Surgery was also associated with better long‐term survival in matched patients who were ≥75 years (hazard ratio, 0.36; 95% CI, 0.24–0.54 [P<0.001]).

Conclusions

The proportion of elderly patients with infective endocarditis who underwent surgery was low compared with that of younger patients. Surgery was associated with lower mortality irrespective of age. In matched elderly patients, long‐term mortality was higher in patients who did not undergo surgery, suggesting that surgery is underused in elderly patients.

Recent trends in infective endocarditis among patients with and without injection drug use: An eight-year single center study

BACKGROUND

Infective endocarditis (IE) is associated with considerable morbidity and mortality. Given the opioid crisis and emergence of drug-resistant organisms, we sought to examine annual trends in hospitalization rates for IE and potential epidemiologic shift in the causative microorganisms among patients with and without injection drug use (IDU).

METHODS

This was a single-center retrospective cohort study of hospitalized adults with IE. Annual trends in hospitalization rates were calculated (2011-2018), and patient characteristics and clinical outcomes were compared according to IDU status.

RESULTS

Our cohort of 244 hospitalized patients with IE had a subset of 112 with IDU. The annual hospitalization rate for IE increased almost four-fold and was most notable among patients with IDU. The highest increase occurred in patients with Staphylococcus aureus-associated IE. Patients with IDU were younger, and more likely to be women with tricuspid valve vegetations and have IE due to methicillin-sensitive and methicillin-resistant Staphylococcus aureus. Patients without IDU were more likely to have central venous catheters with mitral and aortic valve vegetations and have IE due to Streptococcus and coagulase-negative Staphylococcus species. Patients without IDU had a higher requirement for cardiac surgery and higher 90-day mortality. Age was the only independent variable associated with 90-day mortality.

CONCLUSIONS

The rising incidence of IE in younger and older persons is driven in part by the opioid public health crisis and higher prevalence of indwelling central venous catheters, respectively. Timely treatment of opioid use disorders and stewardship surrounding use of central venous catheters is urgently needed.

Endocarditis and the impact of intravenous drug use: a cohort study

OBJECTIVES

This cohort study is a comparison of infective endocarditis in intravenous drug users (IDUs) and non-IDUs within a single tertiary centre. We aim to quantify and describe the factors that influence prognosis and microbiological characteristics.

METHOD

All consecutive admissions to a tertiary referral hospital in the north of England with a diagnosis of endocarditis from April 2013 to January 2020 were identified. Outcomes were all-cause mortality at 30 days, 12 months and 3 years, length of stay and progression to surgery.

RESULTS

A total of 303 cases were identified via clinical coding of which 287 cases of endocarditis were confirmed. First episode endocarditis was then confirmed in 263 episodes, 44 in IDUs and 219 in non-IDUs. Methicillin sensitive Staphylococcus aureus (MSSA) was the most common organism seen overall, significantly more so in IDU than non-IDU cases (29/44 [65.9%] vs. 51/219 [23.3%], p < .001). Overall progression to valve surgery was similar between the two groups (92/219 [42.0%] vs. 19/44[43.2%], p = .886). In IDUs 30-d survival was 93% (80-98) and 3-year survival 47% (30-63%). In non-IDU 30-d survival was 88% (83-92%) and 60% (53-67%) at 3 years. Of the 19 IDUs who underwent valve surgery 7 (37%) survived to study completion without reinfection and 8 (42%) died following recurrent endocarditis.

CONCLUSIONS

We demonstrate that prognosis in IDUs is worse than previously described, particularly in those undergoing valve surgery. This is despite comparable receipt of inpatient treatment to non-IDUs as demonstrated by equal length of stay and rates of surgery. Clinicians should consider the role of addictions services on discharge to break the cycle of reinfection.