Cardiac surgery for infective endocarditis in patients with intravenous drug use

Infective Endocarditis in Patients Addicted to Injected Opioid Drugs

BACKGROUND

Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death.

OBJECTIVES

The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors.

METHODS

From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE).

RESULTS

Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse.

CONCLUSIONS

Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.

Scoping review of percutaneous mechanical aspiration for valvular and cardiac implantable electronic device infective endocarditis

BACKGROUND

Percutaneous mechanical aspiration (PMA) of intravascular vegetations is a novel strategy for management of patients with infective endocarditis (IE) who are at high risk of poor outcomes with conventional cardiac surgery. However, clear indications for its use as well as patient outcomes are largely unknown.

OBJECTIVES

To conduct a scoping review of the literature to summarize patient characteristics and outcomes of those undergoing PMA for management of IE.

METHODS

Two independent reviewers screened abstracts and full text for inclusion and independently extracted data.

DATA SOURCES

MEDLINE, Embase, and Web of Science.

STUDY ELIGIBILITY CRITERIA

Studies published until February 21, 2023, describing the use of PMA for management of patients with cardiac implantable electronic device (CIED) or valvular IE were included.

ASSESSMENT OF RISK OF BIAS

As this was a scoping review, risk of bias assessment was not performed.

METHODS OF DATA SYNTHESIS

Descriptive data was reported.

RESULTS

We identified 2252 titles, of which 1442 abstracts were screened, and 125 full text articles were reviewed for inclusion. Fifty-one studies, describing a total of 294 patients who underwent PMA for IE were included in our review. Over 50% (152/294) of patients underwent PMA to debulk cardiac implantable electronic device lead vegetations prior to extraction (152/294), and 38.8% (114/294) of patients had a history of drug use. Patient outcomes were inconsistently reported, but few had procedural complications, and all-cause in-hospital mortality was 6.5% (19/294).

CONCLUSIONS

While PMA is a promising advance in the care of patients with IE, higher quality data regarding patient outcomes are needed to better inform the use of this procedure.

Characterization of patients receiving surgical versus non-surgical treatment for infective endocarditis in West Virginia

BACKGROUND

Infective endocarditis (IE) has increased in rural states such as West Virginia (WV) with high injection drug use. IE is medically managed with antimicrobial treatment alone or combined with surgical treatment. This study aimed to characterize the predictors associated with surgical treatment and rates of inpatient mortality and readmission among IE patients in WV's rural centers.

METHODS

This retrospective review of electronic health records includes all adults hospitalized for IE at major rural tertiary cardiovascular centers in WV during 2014-2018. Descriptive statistics were presented on demographics, history of injection drug use, clinical characteristics, and hospital utilization by surgery status, and multivariable logistic regression examined the association of surgery with key predictor variables, generating odds ratios (OR).

RESULTS

Of the 780 patients with IE, 38% had surgery, with a 26-fold increase in patients undergoing surgery between 2014-2018. Comparing surgery and non-surgery patients revealed significant differences. Surgery patients were significantly younger (median age 35.6 vs. 40.5 years; p<0.001); had higher rates of drug use history (80% vs. 65%; p<0.001), psychiatric disorders (57% vs. 31%; p<0.001), and readmissions (18% vs.12%; p = 0.015). Surgery patients had lower rates of discharge against medical advice (11% vs.17%; p = 0.028) and in-hospital mortality (5% vs.12%; p<0.001). In the multivariable logistic regression, surgery was associated with injection drug use (OR: 1.9; 95% CI:1.09-3. 3), indications for surgery (OR: 1.68; 95% CI:1.48-1.91), left-sided IE (OR: 2.14; 95%CI:1.43-3.19) and later years (OR:3.75; 95%CI:2.5-5.72).

CONCLUSION

This study characterizes the predictors associated with surgical treatment and rates of inpatient mortality and readmission among IE patients across rural WV. The decision to perform cardiac surgery on IE patients is complex. Results with increased injection drug use-associated IE emphasize the importance of comprehensive care by a multidisciplinary team for optimal management of patients with IE.

The Evolving Trends in Infective Endocarditis and Determinants of Mortality: a 10-year Experience From a Tertiary Care Epicenter

The epidemiology of infective endocarditis (IE) continues to evolve in areas affected by the opioid epidemic. Understanding the demographics of the disease allows us to better tailor therapy towards this at-risk population. This was an observational study of adults (age ≥ 18) admitted to the University of Kentucky hospital with IE between January 2009 and December 2018. 1,255 patients were included in the final analysis. The mean age was 42 years, 45% were female and injection drug use was seen in 66% of patients. On multivariable analysis, higher Charlson comorbidity indices, left sided, and multivalve involvement were associated with increased mortality, whereas surgical intervention demonstrated a trend towards lower mortality. Our results highlight the alarming increase in injection drug use related IE and the high mortality rates despite therapeutic advances. Patients with left sided IE, multivalve involvement and a higher Charlson comorbidity index had decreased survival.

Medical Complications of Injection Drug Use - Part I

Medical Complications of Injection Drug Use - Part IDuring the past 2 decades, the risk of death and the prevalence of hospitalizations in the United States have increased substantially among people who inject drugs, in large part because of the opioid epidemic. This article reviews the complications observed in people who inject drugs as well as strategies to reduce harm.

Outcomes after Surgery for Endocarditis among Intravenous Drug Users and Nonusers

BACKGROUND

The optimal treatment strategy for intravenous drug users (IVDU) with infective endocarditis (IE) is controversial. We therefore sought to investigate outcomes among IVDUs after surgery for IE.

METHODS

We retrospectively reviewed all 192 consecutive patients who underwent an operation for IE between 2005 and 2016 in the Helsinki University Hospital. Forty-seven patients (24.5%) were IVDUs and 145 (75.5%) were non-IVDUs. Mortality and reinfection and reoperation rates were evaluated.

RESULTS

IVDUs were younger (29.9 vs. 63.8 years, p < 0.001) and had less cardiovascular risk factors and lower EuroSCORE II (4.3 vs. 7.3%, p < 0.001), but Staphylococcus aureus infection (66.0 vs. 23.4%, p < 0.001), tricuspid valve endocarditis (34.0 vs. 2.8%, p < 0.001), and liver disease (63.8 vs. 2.8%, p < 0.001) occurred more often in IVDUs than in non-IVDUs. Thirty-day mortality of IVDUs was 8.5% and that of non-IVDUs was 6.9% (p = 0.711). Survival of IVDUs at 5 years was 70.8 ± 7.4% and survival of non-IVDUs was 67.9 ± 4.7% (p = 0.678). Relative to an age- and sex-matched general population, IVDUs had 58.6 (95% confidence interval [CI]: 33.7-101.9; p < 0.001) and non-IVUD 4.4 (95% CI: 3.1-6.2; p < 0.001) standardized mortality ratio. IVDUs had a higher reinfection rate at 5 years (25.8 ± 7.7% vs. 3.0 ± 1.7%, p < 0.001) and a higher early reoperation rate than non-IVDUs (10.6 vs. 1.4%, p = 0.003).

CONCLUSIONS

IVDUs and non-IVDUs had comparable survival at 5 years, but IVDUs had a very significantly increased risk of death in comparison to an age- and sex-matched general population. IVDUs had higher reinfection and early reoperation rates. Survival was poor after medically treated reinfection.

Evolving mortality rates in people who inject drugs: An Australian tertiary hospital observational study on infective endocarditis

Background

Injection drug use (IDU) associated infective endocarditis (IE) is clinically challenging due to social issues this population endures. Rates of IDU are rising globally, however, there is a lack of clear guidelines for IDU associated IE. The aim of this study is to assess the epidemiology of the IDU and non-IDU populations and compare their long-term outcomes to help guide future management.

Methods

An observational cohort study was conducted on all 350 patients treated for IE at St Vincent’s Hospital Melbourne between 1999 and 2015. Follow up was performed until death or January 2021. Primary outcome was all-cause mortality.

Results

IDU patients are younger (p<0.001), more likely to have concurrent infections (p<0.001), and other addiction disorders (p<0.001), while non-IDU patients are older with a higher level of comorbid illnesses (p<0.001). IDU and non-IDU patients received similar management during their admissions and experienced similar levels of in-hospital outcomes, except for non-IDU patient being more likely to develop pneumonia post-surgery (p = 0.03). IDU patients are more likely to become reinfected (p = 0.034) but have better long-term survival, with survival estimates at 15-years being 64.98% (95%CI: 50.94–75.92%) for IDU patients compared to 26.67% (95%CI: 19.76–34.05%) for non-IDU patients (p<0.001).

Conclusion

Despite having higher levels of reinfection, IDU patients have better long-term survival compared to non-IDU patients. Therefore, we suggest IDU patients should not have blanket restrictions on the management they are offered unless at the individual level there is a contraindication to therapy.

Infective Endocarditis in People Who Inject Drugs: Report from the Italian Registry of Infective Endocarditis

Intravenous drug use is a predisposing condition for infective endocarditis (IE). We report the clinical features of IE, taken from the Italian Registry of IE, in people who inject drugs (PWIDs). The registry prospectively collected epidemiological, clinical, in-hospital, and follow-up data on patients with IE from 17 Italian centers. A total of 677 patients were enrolled, and 61 (9%) were intravenous drug users (IDUs). Most PWIDs were male (78.6%), and aged between 41 and 50 years old (50%). The most frequent comorbidities were HIV (34.4%) and chronic liver disease (32%). Predisposing factors for IE were present in 6.5% of the patients, and 10% had minor valvular abnormalities. IE had occurred previously in 16.4% of the patients, and 50% of them had undergone heart surgery. Overall mortality was 9.8% in IDUs and 20% in patients with recurrent IE. IE in PWIDs mostly affected the native valves (90%). The echocardiographic diagnosis of IE was based on the detection of vegetation in 91.82% of cases. Staphylococcus aureus was the main microorganism isolated (70%) from blood cultures. Thirty patients (49%) underwent heart surgery: thirteen had aortic valves, eleven had mitral valves, and six had tricuspid valve interventions. IE in PWIDs was relatively common, and patients with native valve right-sided IE had a better prognosis, with a low rate of surgical interventions.

Multivalve infective endocarditis in intravenous drug using patients: an epidemiological study

BACKGROUND

Infective endocarditis (IE) remains a life-threatening condition. Intravenous drug use (IVDU) adds to the clinical challenge associated with IE due to clinical aberrations caused by the social issues associated with this population.

AIM

To improve survival, this study aimed to characterize the contemporary IVDU-associated IE population seen at our tertiary hospital, determine their long-term outcomes and find risk factors associated with mortality.

DESIGN

Retrospective observational cohort study.

METHODS

A total of 79 patients accounting for 89 presentations were treated for IVDU-associated IE at St Vincent's Hospital Melbourne (SVHM) between 1999 and 2015. Patients were followed-up until death or January 2021. The primary outcome was all-cause mortality and Kaplan-Meier survival analysis was used to calculate long-term survival estimates. Cox proportional hazards analysis was used to examine risk factors for mortality.

RESULTS

The IVDU population treated at SVHM had a high rate of multivalvular IE, at 18.98%. Multivariate analysis revealed that multivalvular IE is significantly associated with an increased risk of mortality in a dose-dependent relationship (two valves affected: HR = 4.73, P = 0.006, three valves affected: HR = 14.19, P = 0.014). The IVDU population has survival estimates of 83.78% (95%CI: 73.21-90.45%) at 1-year and 64.98% (95%CI: 50.94-75.92%) at 15-years.

CONCLUSION

IVDU patients have high rates of multivalvular endocarditis, which is associated with increased risk of mortality and difficult to identify on echocardiography. Clinicians should be suspicious of multivalve involvement in the IVDU population and decisions related to medical management/intervention should be made with the understanding that these patients are at a higher risk of death.

Diagnosis and Management of Infective Endocarditis in People Who Inject Drugs: JACC State-of-the-Art Review

The incidence of injection drug use-associated infective endocarditis has been increasing rapidly over the last decade. Patients with drug use-associated infective endocarditis present an increasingly common clinical challenge with poor long-term outcomes and high reinfection and readmission rates. Their care raises issues unique to this population, including antibiotic selection and administration, indications for and ethical issues surrounding surgical intervention, and importantly management of the underlying substance use disorder to minimize the risk of reinfection. Successful treatment of these patients requires a broad understanding of these concerns. A multidisciplinary, collaborative approach providing a holistic approach to treating both the acute infection along with effectively addressing substance use disorder is needed to improve short-term and longer-term outcomes.

Multidisciplinary team approach to confront the challenge of drug use-associated infective endocarditis

OBJECTIVES

Drug use-associated infective endocarditis is a rapidly growing clinical problem. Although operative outcomes are generally satisfactory, reinfection secondary to recurrent substance use is distressingly common, negatively affects long-term survival, generates practical and ethical challenges, and creates potential conflict among care team members. We established a Drug Use Endocarditis Treatment team including surgeons, infectious disease, and addiction medicine experts specifically focused on the unique complexities of drug use-associated infective endocarditis.

METHODS

We reviewed the impact of Drug Use Endocarditis Treatment team involvement on quantitative measures of quality of care, including length of stay, time to addiction medicine consultation, time to surgery, and discharge on appropriate medications for opioid use disorder, as well as operative mortality. Standard statistical tests were used, including the Fisher exact test, t test, and Wilcoxon rank-sum test. Qualitative assessment was made of the impact on clinicians, including communication and mutual understanding.

RESULTS

Comparing the pre-Drug Use Endocarditis Treatment cohort with the post-Drug Use Endocarditis Treatment cohort, patients in the post-Drug Use Endocarditis Treatment cohort who underwent surgery had a significantly lower time from admission to addiction medicine consultation (3.8 vs 1.0 days P < .001) and clinically relevant increase in discharge on medications for opioid use disorder (48% vs 67% P = .35). Additionally, involved members of the team thought communication was improved.

CONCLUSIONS

The Drug Use Endocarditis Treatment team improved engagement with addiction medicine consultation and appropriate discharge care. Given the impact of relapse of injection drug use on long-term outcomes, interventions such as this offer potentially powerful tools for the treatment of this complex patient population.

Surgeons' re-operative valve replacement practices in patients with endocarditis due to drug use

Background:

This study discerns surgeons' attitudes and practices in the determination of heart valve replacement for patients with infectious endocarditis (IE) due to intravenous drug use (IVDU). We aimed to identify the factors contributing to surgeons' decision-making process for initial and recurrent surgical heart valves and the availability of institutional guidance.

Methods:

An IRB-approved, anonymous mixed-methods, open survey instrument was designed and validated with 24 questions. A convenience sample of cardiothoracic surgeons in the United States and globally resulted in a total of 220 study participants with 176 completing every question on the survey.

Results:

A cluster analysis revealed that although surgeons can be divided into subgroups based on their previous experience with valve replacements, these groups are not perfectly homogenous, and the number of identified clusters is dependent on technique used. Analysis of variance revealed the variables that most clearly divided the surgeons into subgroups were, in order of importance, years of practice, number of valve replacements, and geography.

Conclusions:

Our analysis showed heterogeneity among cardiothoracic surgeons regarding how they make clinical decisions regarding re-operative valve replacement related to IE-IVDU. Therefore, an opportunity exists for interprofessional teams to develop comprehensive guidelines to decrease variability in surgical decision-making regarding valve replacement associated with IE-IVDU.

Contemporary Trends and Outcomes of Prosthetic Valve Infective Endocarditis in the United States: Insights from the Nationwide Inpatient Sample

BACKGROUND

Prosthetic valve endocarditis (PVE) carries high mortality and morbidity as compared to native valve endocarditis (NVE). Contemporary data on PVE are lacking, we aimed to study contemporary trends, outcomes, and burden of PVE using nationally representative data.

METHODS

We used the National Inpatient Sample from 2000 to 2017 to identify patients admitted with PVE using ICD-9-CM and ICD-10 codes. Risk-adjusted rates were calculated using an Analysis of Covariance (ANCOVA) with the Generalized Linear Model (GLM). Trends were assessed with linear regression and Pearson's Chi-square when appropriate. Binomial logistic regression was used to assess predictors of in-hospital mortality.

RESULTS

We identified 43,602 hospitalizations for PVE. PVE hospitalizations increased from 1803 in 2000 to 3450 in 2017. Risk-adjusted mortality decreased from 10.7% in 2002 to 7.3% in 2017 (P<0.01). Logistic regression analysis on mortality showed increase association with age (OR, 1.021, 95%CI [1.017-1.024], p<0.01), Hispanics (OR, 1.493, 95%CI [1.296-1.719], p<0.01) and patients with drug abuse(OR, 1.233, 95%CI [1.05-1.449], p=0.01). Co-morbid conditions like congestive heart failure (OR, 1.511, 95%CI [1.366-1.673], p<0.01), renal failure (OR, 1.572, 95%CI [1.427-1.732], p<0.01) and weight loss (OR, 1.425, 95%CI [1.093-1.419], p<0.01) were also associated with higher mortality.

CONCLUSIONS

Over the years the adjusted in-hospital mortality in PVE has trended down but the average cost of stay has increased despite decrease in length of stay.

Long-term Outcomes Are Poor in Intravenous Drug Users Following Infective Endocarditis, Even After Surgery

BACKGROUND

Previous studies of outcomes in people who inject drugs (PWID) with infective endocarditis (IE) have often been retrospective, have had small sample sizes, and the duration of follow-up has been short and limited to patients who were operated on.

METHODS

PWID treated for IE between 1 January 2006 and 31 December 2016 were identified from a prospectively collected database. PWID hospitalized with other infections acted as a novel comparison group. Outcomes were all-cause mortality, cause of death, relapse, recurrence, and reoperation.

RESULTS

There were 105 episodes of IE in 92 PWID and 112 episodes of other infections in 107 PWID in whom IE was suspected but rejected. Survival at 30 days for the IE group was 85%, and 30-day survival following surgery was 96%. The most common pathogens were Staphylococcus species (60%) and Streptococcus species (30%). The surgical intervention rate was 47%. Survival for the IE group at 1, 3, 5, and 10 years was 74%, 63%, 58%, and 44%, respectively. This was significantly lower compared with the comparator group of other infections in PWID (P = .0002). Mortality was higher in patients who required surgery compared with those who did not (hazard ratio, 1.8 [95% confidence interval, .95-3.3]). The commonest cause of death was infection (66%), usually a further episode of IE (55%).

CONCLUSIONS

Although early survival was good, long-term life expectancy was low. This was attributable to ongoing infection risk, rather than other factors known to affect prognosis in PWID. Surgery conferred no long-term survival advantage. More efforts are needed to reduce reinfection risk following an episode of IE in PWID.While early survival for people who inject drugs (PWID) with infective endocarditis is good, long-term survival is poor due to ongoing infection risk. Surgery conferred no long-term survival advantage, so more efforts are needed to reduce reinfection risks for PWID.

Burden of infective endocarditis in an Australian cohort of people who inject drugs

BACKGROUND

Infective endocarditis (IE) results in substantial morbidity and mortality in people who inject drugs (PWID).

AIMS

To describe the burden of IE and its outcomes in PWID.

METHODS

Retrospective cohort study of adults admitted to a tertiary referral centre in Melbourne, Australia, with IE due to injection drug use from 1997 to 2015.

RESULTS

Ninety-seven PWID with 127 episodes of IE were identified with a median acute inpatient stay of 37 days (1-84). Admission to an intensive care unit was required in 67/127 (53%) episodes. Twenty-seven percent (34/127) of episodes occurred in patients with a previous episode of endocarditis. One third (43/127, 34%) of episodes involved left-sided cardiac valves. Antimicrobial treatment was completed in 88 (70%) episodes. Valve surgery was performed in 25/127 (20%) episodes. Predictors of surgery in univariable analysis were left-sided cardiac involvement (risk ratio (RR) 6.0), severe valvular regurgitation (RR 2.6) and cardiac failure (RR 2.2) (all P < 0.005). Twenty (16%) episodes resulted in death. Predictors of mortality on univariable analysis were left-sided cardiac involvement (RR 6.4), and not completing treatment (RR 0.12; both P < 0.001). The average estimated cost per episode was AU$74 168.

CONCLUSIONS

IE causes a considerable burden of disease in PWID, with significant healthcare utilisation and cost. Surgery and death are not infrequent complications. In addition to ensuring completion of antimicrobial therapy, strategies such as opioid maintenance programmes may be useful in improving health outcomes for PWID.

A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery

BACKGROUND Intravenous drug use is an epidemic in the United States. One of the complications of intravenous drug use can be infective endocarditis. The treatment for this disease is a combination of intravenous antibiotics, cardiac surgery consultation, and multidisciplinary psychiatric care. Despite surgical intervention, recurrence of disease is common. In the setting of recurrent infective endocarditis in the setting of intravenous drug use, the ethics of redo cardiac surgery has not been well-established. CASE REPORT A 34-year-old man with history of intravenous drug use presented on 3 separate occasions with infective endocarditis resulting in 3 tricuspid valve surgeries within fewer than 7 months. He said he had not injected drugs since before his first operation, he was considered to have a strong social support system, and he completed his postoperative antibiotic regimens each time. However, prior to his last operation, the patient had a urine drug screen positive for opiates without recorded prescribed opioids. Pathology reports from the 3 intraoperative specimens showed different pathogens each time. An extensive interprofessional discussion ensued. CONCLUSIONS Infective endocarditis in the setting of intravenous drug use and its treatments continue to be a point of ethical and medical discussion for all professionals involved with the care of these patients. This case could be used as an example of individualized decision-making, with rigorous ethical and medical discussion factoring into each decision for cardiac surgery. The ongoing treatment for patients with recurrent endocarditis in the setting of intravenous drug use requires more research and guidelines to help medical professionals better care for this patient population.

Tricuspid valve vegetation debulking using the AngioVac system

Tricuspid valve endocarditis with recurrent septic pulmonary emboli is an indication for surgery. We present the case of a 36-year old man with tricuspid valve endocarditis and septic pulmonary emboli with percutaneous extraction of the vegetation. We discuss the nuances of such an approach and the need for more evidence in the management of these complex patients.

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

BACKGROUND

Injection drug use-associated infective endocarditis (IDU-IE) is a growing epidemic. The objective of this survey was to identify the beliefs and practice patterns of Canadian cardiac surgeons regarding surgical management of IDU-IE.

METHODS

A 30-question survey was developed by a working group and distributed to all practicing adult cardiac surgeons in Canada. Data were analyzed using descriptive statistics.

RESULTS

Of 146 surgeons, 94 completed the survey (64%). Half of surgeons (49%) would be less likely to operate on patients with IE if associated with IDU. In the case of prosthetic valve IE owing to continued IDU, 36% were willing to reoperate once and 14% were willing to reoperate twice or more. Most surgeons required commitments from patients before surgery (73%), and most referred patients to addiction services (81%). Some surgeons would offer a Ross procedure (10%) or homograft (8%) for aortic valve IE, and 47% would consider temporary mechanical circulatory support. Whereas only 17% of surgeons worked at an institution with an endocarditis team, 71% agreed that there was a need for one at each institution. Most surgeons supported the development of IDU-IE-specific guidelines (80%).

CONCLUSIONS

Practice patterns and surgical management of IDU-IE vary considerably across Canada. Areas of clinical unmet needs include the development of a formal addiction services referral protocol for patients, the development of an interdisciplinary endocarditis team, as well as the creation of IDU-IE clinical practice guidelines.

Staphylococcal Enterotoxins and Toxic Shock Syndrome Toxin-1 and Their Association among Bacteremic and Infective Endocarditis Patients in Egypt

Purpose

Infective endocarditis (IE) is a major complication in patients with bacteremia of Staphylococcus (S.) aureus infection. Our aim was to determine the association of the major Staphylococcal superantigens (SAgs), including Staphylococcal enterotoxins (SEs) and toxic shock syndrome toxin-1 (TSST-1), among hospitalized patients diagnosed with bacteremia and those with IE.

Methods

This study was conducted on 88 patients; of these, 84 (95.5%) had two positive blood cultures. Eighteen out of the 84 patients (21.4%) were diagnosed based on the modified Duke criteria by a cardiologist to have IE. The recovered isolates were screened phenotypically using ELISA followed by molecular analysis of sea, seb, sec, sed, see, and tsst-1, the major SAg coding genes, and the obtained findings were statistically analyzed.

Results

Phenotypic screening for SE production of 26 selected Staphylococci (15 isolated from the IE patients (10 S. aureus and 5 coagulase negative staphylococci (CoNS)) and 11 from bacteremic patients (10 S. aureus and 1 CoNS)) using ELISA revealed that 12/26 (46%) isolates were SE producers. PCR analysis showed that 19 (73%) isolates were PCR positive for SAg genes with the highest prevalence of the sea gene (79%), followed by seb (63%) and tsst-1 (21%). The least frequent gene was sed (5.3%). Statistical correlations between bacteremic and IE isolates with respect to prevalence of SAgs showed no significant difference (P value = 0.139, effect size = 0.572) indicating no specific association between any of the detected SAgs and IE.

Conclusion

There is high prevalence of SEs among clinical isolates of Staphylococci recovered from patients suffering bacteremia and those with IE. No significant difference was found among Staphylococcal isolates recovered from patients with bacteremia or IE regarding both phenotypic and genotypic detection of the tested SAgs.

Surgery for Endocarditis in Intravenous Drug Users

BACKGROUND

Few studies have analyzed outcomes after surgery for endocarditis in intravenous drug users (IVDUs). The aim of this study was to compare survival after surgery for endocarditis in IVDUs versus non-IVDUs. Secondary outcomes were the rates of reoperation, reinfection, and relapse to drug use.

METHODS

This population-based, observational cohort study included all patients who had undergone surgery for endocarditis at Karolinska University Hospital between 2002 and 2019. Patient data were collected from the institutional surgical database and medical charts. We used multivariable Cox regression to analyze associations between intravenous drug use and long-term survival.

RESULTS

Of the 510 study patients, 55 were IVDUs (11%) and 455 were not (89%). During a mean follow-up of 5.3 years (maximum, 17.1 years), 30 IVDUs (55%) and 133 non-IVDUs (29%) died. The 30-day mortality was 10.9% and 8.5%, respectively, for IVDUs and non-IVDUs (P = .53). Survival in IVDUs versus non-IVDUs at 1, 5, and 8 years was 76% versus 86%, 49% versus 76%, and 35% versus 68%, respectively (adjusted hazard ratio = 4.12; 95% confidence interval, 2.54-6.68; P < .001). The risk for reoperation was higher in IVDUs (adjusted hazard ratio = 3.47; 95% confidence interval, 1.74-6.89; P < .001). Forty-two IVDUs died or were reinfected (76%) and 49 died or returned to drug use (89%).

CONCLUSIONS

After surgery for endocarditis, IVDUs had substantially higher mortality and reoperation rates than did non-IVDUs. However, postoperative survival was comparable between groups, indicating that IVDUs manage surgery well. Prevention of relapse to drug use is of utmost importance in these patients.

Percutaneous Mechanical Aspiration vs Valve Surgery for Tricuspid Valve Endocarditis in People Who Inject Drugs

BACKGROUND

Valve surgery in tricuspid valve infective endocarditis (TVIE) is controversial in people who inject drugs (PWID) due to perceived risks of reinfection because of recidivism. The study objective was to compare outcomes of percutaneous mechanical aspiration (PMA) using the Penumbra Indigo system to valve surgery in PWID with TVIE.

METHODS

Retrospective cohort of adult PWID hospitalized with definite TVIE and received PMA or valve surgery from January 2014 to April 2019. Primary endpoint was all-cause 12-month mortality; secondary endpoints included in-hospital mortality and all-cause 12-month readmission.

RESULTS

In total, 85 patients were included: 42 undergoing PMA and 43 undergoing valve surgery. Baseline patient demographics were similar between groups; 62 (73%) patients were women, and the median age was 31 (interquartile range, 27-41) years. Seventy-four (86%) patients had a previous history of infective endocarditis and received long-term antibiotic therapy before surgical intervention; 33 (38%) patients presented with septic shock on admission. The most commonly organism was methicillin-resistant Staphylococcus aureus (n = 32 of 84, 38%). Five (12%) PMA patients died in hospital compared with 1 (2%) patient who received valve surgery (P = .11). All-cause 12-month mortality was 24% and 19% for the PMA and surgery groups, respectively (P = .57). When considering confounders, there was no difference in all-cause 12-month mortality between the PMA and valve surgery groups (adjusted odds ratio, 1.5; 95% confidence interval, 0.48-4.8); no significant differences in secondary outcomes were identified.

CONCLUSIONS

PMA was associated with similar outcomes to valve surgery for management of TVIE in PWID. PMA may be an alternative to valve surgery as a treatment or bridging strategy to surgery while PWID undergo addiction treatment.

New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use

Hospitalists are increasingly responsible for the management of infectious consequences of opioid use disorder (OUD), including increasing rates of hospitalization for injection drug use (IDU)-associated infective endocarditis, osteomyelitis, and soft tissue infections. Management of IDU-associated infections poses unique challenges: symptoms of the underlying addiction can interfere with care plans, patients often have difficult psychosocial circumstances in addition to their addiction, and they are often stigmatized by the healthcare system. Although there are few randomized trial data to support one particular approach to management, the literature suggests that successful treatment of IDU-associated infections requires appropriate antimicrobial and surgical interventions in addition to acknowledgment and treatment of the underlying OUD. In this narrative review, the best available evidence is used to answer several of the most commonly encountered questions in the management of IDU-associated infections. These data are used to develop a framework for hospitalists to approach the care of patients with IDU-associated infections.

Epidemiology, Microbiology, and Clinical Outcomes Among Patients With Intravenous Drug Use-Associated Infective Endocarditis in New Brunswick

BACKGROUND

Within the context of Canada's opioid crisis, medical complications associated with intravenous drug use (IVDU) are increasing. Infective endocarditis (IE) is a serious complication of IVDU, and understanding the characteristics of these patients could aid health systems, clinicians, and patients in the optimization of treatment and prevention of IVDU-IE.

METHODS

At a tertiary care hospital in southern New Brunswick, we conducted a retrospective chart review to identify patients with IVDU-IE admitted between January 1, 2013, and December 31, 2017. We collected data related to the epidemiology, microbiology, clinical manifestations, echocardiography, complications during hospital admission, and outcomes.

RESULTS

Forty-two cases of IVDU-IE met inclusion criteria. The rate of IVDU-IE increased from 2.28 per 100,000 population in 2014 to 4.00 in 2017, which, although not statistically significant, reflects patterns in other jurisdictions. Most patients (72.4%) were male, and the mean age was 38.3 (±11.5) years. Most patients (79.3%) injected opioids. The most common clinical sign was fever (90.5%), and Staphylococcus aureus (61.9%) was the most common microorganism. The tricuspid valve was most commonly infected (58.5%), 50% of cases had heart failure as a complication during admission, and 45.2% of cases required valve replacement or repair. The 2-year survival rate after admission for initial IVDU-IE episode was 62.0% (95% confidence interval: 36.5-79.7).

CONCLUSION

IVDU-IE is common in New Brunswick and may be increasing. Despite the relatively young age of this patient population, IVDU-IE is associated with significant morbidity and mortality. Expanding effective harm reduction and addiction treatment strategies for this cohort is recommended.

Unmasking Severe Tricuspid Valve Regurgitation After Percutaneous Debulking of Large Tricuspid Vegetation

A 27-year-old man admitted with tricuspid valve endocarditis with a large vegetation, persistent bacteremia, and pulmonary and systemic septic embolization was deemed not a suitable surgical candidate. He underwent percutaneous vegetation debulking using the AngioVac system. The patient defervesced post-operatively with clinical improvement but with abruptly worsened tricuspid regurgitation. (Level of Difficulty: Beginner.).

A Multidisciplinary Pathway for the Diagnosis and Treatment of Infectious Endocarditis

Supplemental Digital Content is available in the text.

Clinical pathways can be useful when disparate clinical-pathologic groups converge on a common diagnostic and therapeutic trajectory. The progressive increase in the incidence of endocarditis in the US has included higher-risk subjects whose candidacy for aggressive cardiac surgical intervention may be highly resource-intensive, prohibitively high risk, or delayed and possibly deferred by comorbidities. We sought to define the sequence, application, and resolution of multidisciplinary endocarditis team decision-making in 4 distinct clinical groups.

Ethical Dilemma: Should Continuous Intravenous Drug Use Affect Appropriate Management in Prosthetic Valve Endocarditis?

Drug use is a major challenge that negatively impacts many aspects of health. The issue of drug use is growing with every passing day. Efforts to mitigate its use are countered by even more people succumbing to the intravenous drug use due to their relatively easy availability and patients' poor insight into their medical condition. Infective endocarditis (IE) is a condition with high mortality and morbidity. It requires prolonged treatment with antibiotics, and, under some special circumstances, surgical management is also necessitated. Intravenous drug users who get valve replacement after index IE episode may continue to use drugs despite our utmost efforts to prevent it. They can subsequently develop prosthetic valve endocarditis (PVE), which is one of the indications for surgical valve replacement, hence requiring a redo surgery. However, their irregular behavior can create reservations while considering a repeat valvular surgery and delay the appropriate treatment. This can increase morbidity and mortality from PVE in intravenous drug users with otherwise no or few comorbidities.

Epidemiology and outcomes of non-HACEK infective endocarditis in the southeast United States

Objectives

Infective endocarditis (IE) with non-HACEK Gram-negative (GN) organisms is rare, but associated with poor outcomes. The purpose of this study was to quantify the microbiology, treatment strategies, and frequency of poor outcomes in patients with non-HACEK GN IE.

Materials

Retrospective cohort of adults with definite non-HACEK GN IE from 1/11-1/19. The primary endpoint was poor patient outcome, defined as a composite of all-cause death or infection-related readmission within 90-days of index infection.

Results

43 patients were included: 51% patients were men, and the median (IQR) age was 40 (31–50) years. Forty patients reported injection drug use. The most common organisms were Pseudomonas aeruginosa (68%) and Serratia marcescens (9%). Seventy-six percent of patients received definitive combination therapy; the most common antibiotics used in combination with a β-lactam were aminoglycosides (50%) and fluoroquinolones (34%). Three patients discontinued combination therapy due to toxicity. Twelve-month, all-cause mortality and readmission was 30% and 54%, respectively. In multivariable logistic regression, variables independently associated with composite poor outcome were receipt of fluoroquinolone-based IE combination therapy and septic shock.

Conclusions

Long-term mortality and readmission rates were high. Patients who received fluoroquinolone-based IE combination therapy more frequently developed poor outcomes than those who did not.

Clinical Outcomes of Infective Endocarditis in Injection Drug Users

BACKGROUND

Rising rates of hospitalization for infective endocarditis (IE) have been increasingly tied to rising injection drug use (IDU) associated with the opioid epidemic.

OBJECTIVES

This study analyzed recent trends in IDU-IE hospitalization and characterized outcomes and readmissions for IDU-IE patients.

METHODS

The authors evaluated the National Readmissions Database (NRD) for IE cases between January 2010 and September 2015. Patients were stratified by IDU status and surgical versus medical management. Primary outcome was 30-day readmission and cause, with secondary outcomes including mortality, length of stay (LOS), adjusted costs, and 180-day readmission. The Kruskal-Wallis and chi-square tests were used to analyze baseline differences by IDU status. Multivariable regressions were used to analyze mortality, readmissions, LOS, and adjusted costs.

RESULTS

The survey-weighted sample contained 96,344 (77.8%) non-IDU-IE and 27,432 (22.2%) IDU-IE cases. IDU-IE increased from 15.3% to 29.1% of IE cases between 2010 and 2015 (p < 0.001). At index hospitalization, IDU-IE was associated with reduced mortality (6.8% vs. 9.6%; p < 0.001) but not 30-day readmission (23.8% vs. 22.9%; p = 0.077) relative to non-IDU-IE. Medically managed IDU-IE patients had higher LOS (β = 1.36 days; 95% confidence interval [CI]: 0.71 to 2.01), reduced costs (β = -$4,427; 95% CI: -$7,093 to -$1,761), and increased readmission for endocarditis (18.1% vs. 5.6%; p < 0.001), septicemia (14.0% vs. 7.3%; p < 0.001), and drug abuse (4.3% vs. 0.7%; p < 0.001) compared with medically managed non-IDU-IE. Surgically managed IDU-IE patients had increased LOS (β = 4.26 days; 95% CI: 2.73 to 5.80) and readmission for septicemia (15.6% vs. 5.2%; p < 0.001) and drug abuse (7.3% vs. 0.9%; p < 0.001) compared with non-IDU-IE.

CONCLUSIONS

The incidence of IDU-IE continues to rise nationally. Given the increased readmission for endocarditis, septicemia, and drug abuse, IDU-IE presents a serious challenge to current management of IE.

Cost-Effectiveness of Postoperative Drug Rehabilitation for Injection Drug Users

BACKGROUND

With the opioid crisis showing no sign of abating, strategies are needed to facilitate postoperative care for endocarditis related to injection drug use (IDU). The current standard, 6 weeks of intravenous antibiotics, yields frequent reoperation and IDU relapse. We examined the cost-effectiveness of inpatient drug rehabilitation (DR) postoperatively to optimize outcomes and costs.

METHODS

Two postoperative strategies were assessed: hospital-only care (HC) vs HC plus inpatient DR. Monte Carlo simulation evaluated effectiveness in quality-adjusted life-years (QALY) and cost per patient calculated over a 20-year time horizon in 100,000 iterations. Willingness to pay was set to $100,000/QALY. To determine probabilities of continued postoperative IDU, recurrent infection, and death, best available evidence was combined with institutional data from IDU patients. Baseline probability of postoperative IDU was set to 35% after DR vs 60% after HC, and the cost of inpatient rehabilitation to $30,000.

RESULTS

Addition of inpatient DR to standard HC is the favorable strategy, with incremental per-patient cost of $36,920 and 0.93 QALYs gained over 20 years. Sensitivity analysis demonstrates DR is within our willingness-to-pay of $100,000/QALY if postoperative IDU is reduced by at least 7% (from 60% to 53%).

CONCLUSIONS

Addition of postoperative inpatient DR for IDU-related endocarditis is cost-effective even if only a modest reduction in IDU is achieved. Collaboration between hospitals and payors to launch pilot programs that provide postoperative addiction treatment and intravenous antibiotics after cardiac operations could dramatically improve endocarditis care.

Trends and Outcomes of Cardiovascular Surgery in Patients With Opioid Use Disorders

Importance

Persistent opioid use is currently a major health care crisis. There is a lack of knowledge regarding its prevalence and effect among patients undergoing cardiac surgery.

Objective

To characterize the national population of cardiac surgery patients with opioid use disorder (OUD) and compare outcomes with the cardiac surgery population without OUD.

Design, Setting, and Participants

In this retrospective population-based cohort study, more than 5.7 million adult patients who underwent cardiac surgery (ie, coronary artery bypass graft, valve surgery, or aortic surgery) in the United States were included. Pregnant patients were excluded. Propensity matching was performed to compare outcomes between cardiac surgery patients with OUD (n = 11 359) and without OUD (n = 5 707 193). The Nationwide Inpatient Sample database was queried from January 1998 to December 2013. Data were analyzed in January 2018.

Exposures

Persistent opioid use and/or dependence.

Main Outcomes and Measures

In-hospital mortality, complications, length of stay, costs, and discharge disposition.

Results

Among the 5 718 552 included patients, 3 887 097 (68.0%) were male; the mean (SD) age of patients with OUD was 47.67 (13.03) years and of patients without OUD was 65.53 (26.14) years. The prevalence of OUD among cardiac surgery patients was 0.2% (n = 11 359), with an 8-fold increase over 15 years (0.06% [262 of 437 641] in 1998 vs 0.54% [1425 of 263 930] in 2013; difference, 0.48%; 95% CI of difference, 0.45-0.51; P < .001). Compared with patients without OUD, patients with OUD were younger (mean [SD] age, 48 [0.30] years vs 66 [0.05] years; P < .001) and more often male (70.8% vs 68.0%; P < .001), black (13.7% vs 4.8%), or Hispanic (9.1% vs 4.8%). Patients with OUD more commonly fell in the first quartile of median income (30.7% vs 17.1%; P < .001) and were more likely to be uninsured or Medicaid beneficiaries (48.6% vs 7.7%; P < .001). Valve and aortic operations were more commonly performed among patients with OUD (49.8% vs 16.4%; P < .001). Among propensity-matched pairs, the mortality was similar between patients with vs without OUD (3.1% vs 4.0%; P = .12), but cardiac surgery patients with OUD had an overall higher incidence of major complications (67.6% vs 59.2%; P < .001). Specifically, the risks of blood transfusion (30.4% vs 25.9%; P = .002), pulmonary embolism (7.3% vs 3.8%; P < .001), mechanical ventilation (18.4% vs 15.7%; P = .02), and prolonged postoperative pain (2.0% vs 1.2%; P = .048) were significantly higher. Patients with OUD also had a significantly longer length of stay (median [SE], 11 [0.30] vs 10 [0.22] days; P < .001) and cost significantly more per patient (median [SE], $49 790 [1059] vs $45 216 [732]; P < .001).

Conclusions and Relevance

The population of patients with persistent opioid use or opioid dependency undergoing cardiac surgery has increased over the past decade. Cardiac surgery in patients with OUD is safe but is associated with higher complications and cost. Patients should not be denied surgery because of OUD status but should be carefully monitored postoperatively for complications.

Long term surgical outcomes for infective endocarditis in people who inject drugs: a systematic review and meta-analysis

Background

In recent years, the number of infective endocarditis (IE) cases associated with injection drug use has increased. Clinical guidelines suggest deferring surgery for IE in people who inject drugs (PWID) due to a concern for worse outcomes in comparison to non-injectors (non-PWID). We performed a systematic review and meta-analysis of long-term outcomes in PWID who underwent cardiac surgery and compared these outcomes to non-PWID.

Methods

We systematically searched for studies reported between 1965 and 2018. We used an algorithm to estimate individual patient data (eIPD) from Kaplan-Meier (KM) curves and combined it with published individual patient data (IPD) to analyze long-term outcomes after cardiac surgery for IE in PWID. Our primary outcome was survival. Secondary outcomes were reoperation and mortality at 30-days, one-, five-, and 10-years. Random effects Cox regression was used for estimating survival.

Results

We included 27 studies in the systematic review and 19 provided data (KM or IPD) for the meta-analysis. PWID were younger and more likely to have S. aureus than non-PWID. Survival at 30-days, one-, five-, and 10-years was 94.3, 81.0, 62.1, and 56.6% in PWID, respectively; and 96.4, 85.0, 70.3, and 63.4% in non-PWID. PWID had 47% greater hazard of death (HR 1.47, 95% CI, 1.05–2.05) and more than twice the hazard of reoperation (HR 2.37, 95% CI, 1.25–4.50) than non-PWID.

Conclusion

PWID had shorter survival that non-PWID. Implementing evidence-based interventions and testing new modalities are urgently needed to improve outcomes in PWID after cardiac surgery.

Recurrent Endocarditis in Persons Who Inject Drugs

BACKGROUND

Infective endocarditis (IE) is increasing among persons who inject drugs (PWID) and has high morbidity and mortality. Recurrent IE in PWID is not well described.

METHODS

This was a retrospective cohort study conducted between February 2007 and March 2016. It included adult inpatients (≥18) at any of 3 tertiary care centers in London, Ontario, with definite IE based on the Modified Duke's Criteria. The objectives were to characterize recurrent IE in PWID, identify risk factors for recurrent IE, identify the frequency of fungal endocarditis, and establish whether fungal infection was associated with higher mortality.

RESULTS

Three hundred ninety patients had endocarditis, with 212/390 in PWID. Sixty-eight of 212 (32%) PWID had a second episode, with 28/212 (12%) having additional recurrences. Second-episode IE was more common in PWID (11/178 [6.2%] vs 68/212 [32.1%]; P < .001). Peripherally inserted central catheter (PICC) line abuse was associated with increased risk of recurrent endocarditis (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.01-3.87; P = .04). In PWID, fungal IE was more common in second episodes than first episodes (1/212 [0.5%] vs 5/68 [7.4%]; P = .004). Additionally, fungal infections were associated with mortality in second-episode IE in PWID with an adjusted OR of 16.49 (95% CI, 1.12-243.17; P = .041). Despite recurrent infection, likely due to continued drug use, there was a low rate of referral to addiction treatment (14/68 [20.6%]).

CONCLUSIONS

PWID have a high risk of recurrent endocarditis, particularly in patients who abuse PICC lines. Fungal endocarditis is more common in second-episode endocarditis and is associated with increased mortality. Consideration of empiric antifungal therapy in PWID with IE history and suspected IE should be considered.

Management of endocarditis among persons who inject drugs: A narrative review of surgical and psychiatric approaches and controversies

BACKGROUND

People who inject drugs (PWID) represent a high-risk subgroup of endocarditis patients. This is highlighted by poorer post-operative outcomes in injection drug use-related infective endocarditis (IDU-IE), which is largely attributable to the increased vulnerability of prosthetic valves to re-infection. Consequently, many centres do not perform valve replacement on these patients. A parallel, but often underrecognized, component of care is the role of multidisciplinary management for individuals with IDU-IE, including perioperative addictions and psychiatric care. Consequently, surgical management options in IDU-IE remain a controversial topic.

OBJECTIVES

To determine the characteristics of optimal surgical and psychiatric care for individuals with IDU-IE.

METHODS

We conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, organizing the findings into several key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions.

RESULTS/CONCLUSIONS

Managing IDU-IE involves the treatment of two comorbidities: the intra-cardiac infection and the underlying substance use disorder. Cardiac surgery represents a high-intensity intervention with appreciable risk, and the benefit it is not always clear. As patients often present acutely, it is not feasible to use drug abstinence as a prerequisite to surgery. Involvement of inpatient psychiatry and addictions teams, however, appears to be an evidence-based approach that can bridge IDU-IE patients with opioid agonist therapy in hospital and adequate outpatient treatment options for their underlying addiction upon their discharge from hospital. It is likely that a majority of these patients are not receiving optimal psychiatric management despite increasing recognition of efficacy. Further interdisciplinary studies are needed to elucidate optimal surgical and multidisciplinary protocols.

BACKGROUND

Infective endocarditis (IE) is an infection of the innermost lining of the heart often affecting the heart valves. Over the last few decades, the epidemiology of IE has shifted in the developed world and while it continues to be a significant cause of morbidity and mortality, there has been a significant increased incidence among persons who inject drugs (PWID). To date, well-conducted epidemiologic studies of IE among PWID have been sparse, which has limited our ability to fully characterize this disease phenomenon. To address this knowledge deficit, we conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, and organized our findings into six key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions.

High Morbidity and Mortality Among Patients With Sentinel Admission for Injection Drug Use-Related Infective Endocarditis

Background

Hospitalizations for individuals with injection drug use-related infective endocarditis (IDU-IE) represent an increasing portion of all patients with endocarditis. This study describes the evolving trends in demographics, clinical characteristics, rates of surgical intervention, and mortality among patients hospitalized with IE, comparing those with and without injection drug use.

Methods

This is a retrospective cohort study of patients admitted between January 1, 2007 to June 30, 2015 at a tertiary care center in Boston, Massachusetts. Endocarditis was defined by International Classification of Diseases, Ninth Revision code and verified by the modified Duke Criteria for IE. The clinical characteristics, microbiology, site of infection, complications of IE, and outcome were all abstracted by chart review. Rates of surgical consultation and surgical intervention within 90 days of admission were obtained, and assessment of surgical risk calculated was by EuroSCORE II (euroscore.org/calc). Subsequent hospitalizations for all causes were also reviewed.

Results

Injection drug use-related infective endocarditis occurred in younger patients with lower rates of diabetes, renal dysfunction, and prior cardiothoracic (CT) surgery than those without IDU. Injection drug use-related infective endocarditis was associated with higher rates of complications, CT surgery consultation, and surgery within 90 days for absolute surgical indication. Readmissions for endocarditis occurred in 20% of IDU-IE patients and 9% of those with non-IDU IE. All-cause 1-year mortality rates were similar (IDU-IE 16%, non-IDU IE 13%; P = .58).

Conclusions

Despite younger age, fewer medical comorbidities, and fewer prior cardiac surgeries, all-cause 1-year mortality was similar for patients after sentinel admission for IDU-IE compared with non-IDU IE. Interventions in the acute hospital setting and after discharge are needed to support patients with IDU-IE, focusing on harm reduction and treatment of addiction to reduce the unexpectedly high mortality of this young population.

Trends in Drug Use-Associated Infective Endocarditis and Heart Valve Surgery, 2007 to 2017: A Study of Statewide Discharge Data

Background

Drug use-associated infective endocarditis (DUA-IE) is increasing as a result of the opioid epidemic. Infective endocarditis may require valve surgery, but surgical treatment of DUA-IE has invoked controversy, and the extent of its use is unknown.

Objective

To examine hospitalization trends for DUA-IE, the proportion of hospitalizations with surgery, patient characteristics, length of stay, and charges.

Design

10-year analysis of a statewide hospital discharge database.

Setting

North Carolina hospitals, 2007 to 2017.

Patients

All patients aged 18 years or older hospitalized for IE.

Measurements

Annual trends in all IE admissions and in IE hospitalizations with valve surgery, stratified by patients' drug use status. Characteristics of DUA-IE surgical hospitalizations, including patient demographic characteristics, length of stay, disposition, and charges.

Results

Of 22 825 IE hospitalizations, 2602 (11%) were for DUA-IE. Valve surgery was performed in 1655 IE hospitalizations (7%), including 285 (17%) for DUA-IE. Annual DUA-IE hospitalizations increased from 0.92 to 10.95 and DUA-IE hospitalizations with surgery from 0.10 to 1.38 per 100 000 persons. In the final year, 42% of IE valve surgeries were performed in patients with DUA-IE. Compared with other surgical patients with IE, those with DUA-IE were younger (median age, 33 vs. 56 years), were more commonly female (47% vs. 33%) and white (89% vs. 63%), and were primarily insured by Medicaid (38%) or uninsured (35%). Hospital stays for DUA-IE were longer (median, 27 vs. 17 days), with higher median charges ($250 994 vs. $198 764). Charges for 282 DUA-IE hospitalizations exceeded $78 million.

Limitation

Reliance on administrative data and billing codes.

Conclusion

DUA-IE hospitalizations and valve surgeries increased more than 12-fold, and nearly half of all IE valve surgeries were performed in patients with DUA-IE. The swell of patients with DUA-IE is reshaping the scope, type, and financing of health care resources needed to effectively treat IE.

Primary Funding Source

National Institutes of Health.

Clinical Characteristics and Factors Associated With Mortality in First-Episode Infective Endocarditis Among Persons Who Inject Drugs

IMPORTANCE

Persons who inject drugs (PWID) represent a distinct demographic of patients with infective endocarditis. Many centers do not perform valvular surgery on these patients owing to concerns about poor outcomes. Addiction services are underused in hospitals.

OBJECTIVES

To compare clinical characteristics in first-episode infective endocarditis in PWID who are surgically vs medically managed and to identify variables associated with mortality.

DESIGN, SETTING, AND PARTICIPANTS

This case series studied PWID treated for a first episode of infective endocarditis between April 1, 2007, and March 30, 2016. Participants were adult patients (aged ≥18 years) admitted to any of 3 hospitals in London, Ontario, Canada. Analysis occurred between July 2016 and November 2017.

MAIN OUTCOMES AND MEASURES

Survival among PWID; the causative organisms, site of infection, and cardiac as well as noncardiac complications; referral to addiction services; and surgical vs medical management.

RESULTS

Of 370 total first-episode cases of infective endocarditis, 202 (54.6%) were in PWID. Among PWID, 105 (52%) were male, the median (interquartile range) age was 34 (28-42) years, and patients were predominantly positive for the hepatitis C virus (69.8% [141 of 202]). Right-sided infection was more common (61.4% [124 of 202]), and most infections were caused by Staphylococcus aureus (77.2% [156 of 202]). Surgery occurred in 19.3% of patients (39 of 202). The all-cause mortality rate was 33.7% (68 of 202). Adjusting for age and sex, survival analysis demonstrated that surgery was associated with lower mortality (hazard ratio [HR], 0.44; 95% CI, 0.23-0.84; P = .01), as was referral to addiction treatment (HR, 0.29; 95% CI, 0.12-0.73; P = .008). Higher mortality was associated with left-sided infection (HR, 3.26; 95% CI, 1.82-5.84; P < .001) and bilateral involvement (HR, 4.51; 95% CI, 2.01-10.1; P < .001).

CONCLUSIONS AND RELEVANCE

This study presents the demographic characteristics of first-episode infective endocarditis in PWID. Results highlight the potentially important role of addictions treatment in this population. Further study to optimize selection criteria for surgery in PWID is warranted.

Rising rates of injection drug use associated infective endocarditis in Virginia with missed opportunities for addiction treatment referral: a retrospective cohort study

BACKGROUND

Injection drug use (IDU) is a growing public health threat in Virginia, though there is limited knowledge of related morbidity. The purpose of this study was to describe the temporal, geographic and clinical trends and characteristics of infective endocarditis associated with IDU (IDU-IE) and to identify opportunities for better-quality care of people who inject drugs (PWID).

METHODS

We reviewed charts for all admissions coded for both IE and drug use disorders at the University of Virginia Medical Center (UVA) from January 2000 to July 2016. A random sample of 30 admissions coded for IE per year were reviewed to evaluate temporal trends in the proportion of IDU associated IE cases.

RESULTS

There were a total of 76 patients with IDU-IE during the study period, 7.54-fold increase (prevalence ratio: 8.54, 95% CI 3.70-19.72) from 2000 to 2016. The proportion of IE that was IDU-associated increased by nearly 10% each year (prevalence ratio of IDU per year: 1.09, 95% CI: 1.05-1.14). Patients with IDU-IE had longer hospital stays [median days (interquartile range); IDU-IE, 17 (10-29); non-IDU-IE, 10 (6-18); p-value = 0.001] with almost twice the cost of admission as those without IDU [median (interquartile range); IDU-IE, $47,899 ($24,578-78,144); non-IDU-IE, $26,460 ($10,220-60,059); p-value = 0.001]. In 52% of cases there was no documentation of any discussion regarding addiction treatment.

CONCLUSION

IDU-IE is a severe infection that leads to significant morbidity and healthcare related costs. IDU-IE rates are increasing and will likely continue to do so without targeted interventions to help PWID. The diagnosis and treatment of IDU-IE provides an opportunity for the delivery of addiction treatment, counseling, and harm reduction strategies.

Management Considerations in Infective Endocarditis: A Review

IMPORTANCE

Infective endocarditis occurs in approximately 15 of 100 000 people in the United States and has increased in incidence. Clinicians must make treatment decisions with respect to prophylaxis, surgical management, specific antibiotics, and the length of treatment in the setting of emerging, sometimes inconclusive clinical research findings.

OBSERVATIONS

Community-associated infective endocarditis remains the predominant form of the disease; however, health care accounts for one-third of cases in high-income countries. As medical interventions are increasingly performed on older patients, the disease incidence from cardiac implanted electronic devices is also increasing. In addition, younger patients involved with intravenous drug use has increased in the past decade and with it the proportion of US hospitalization has increased to more than 10%. These epidemiological factors have led to Staphylococcus aureus being the most common cause in high-income countries, accounting for up to 40% of cases. The mainstays of diagnosis are still echocardiography and blood cultures. Adjunctive imaging such as cardiac computed tomographic and nuclear imaging can improve the sensitivity for diagnosis when echocardiography is not conclusive. Serological studies, histopathology, and polymerase chain reaction assays have distinct roles in the diagnosis of infective endocarditis when blood culture have tested negative with the highest yield obtained from serological studies. Increasing antibiotic resistance, particularly to S aureus, has led to a need for different antibiotic treatment options such as newer antibiotics and combination therapy regimens. Surgery can confer a survival benefit to patients with major complications; however, the decision to pursue surgery must balance the risks and benefits of operations in these frequently high-risk patients.

CONCLUSIONS AND RELEVANCE

The epidemiology and management of infective endocarditis are continually changing. Guidelines provide specific recommendations about management; however, careful attention to individual patient characteristics, pathogen, and risk of sequela must be considered when making therapeutic decisions.

Infective endocarditis in Western Norway: a 20-year retrospective survey

BACKGROUND

To investigate epidemiological trends of infective endocarditis (IE) in western Norway a retrospective study was performed.

METHODS

Characteristics of 706 IE admissions from 1996 to 2005 and 2006 to 2015 were analysed and compared using the Chi-square test for categorical variables and the t-test for age. Survival was analysed by multiple Cox regression and reported by the hazard ratio (HR).

RESULTS

Mean annual incidence rates increased from 4.6 to 7.4 per 100,000 inhabitants (rate ratio: 1.97, 95% confidence interval: 1.52-2.56, p < .001). Non-viridans streptococci, enterococci and Staphylococcus aureus (S. aureus), were all independently associated with increased mortality. The frequency of IE caused by enterococci increased from 3.7 to 13.0% (p < .001). The proportion of intravenous drug users (IVDU) increased from 16.5 to 23.5% (p = .015) and had increasing aortic valve involvement (p = .023). Prosthetic valve endocarditis (PVE) constituted 30% of IE cases in both decades with biological PVE increasing from 9.4 to 22.1% (p < .001) and mechanical PVE decreasing from 18.7 to 8.9% (p < .001). In the last decade, valve replacement surgery was performed in 37.6% of the patients, of which 85.5% received a bioprosthesis.

CONCLUSIONS

The incidence of IE increased significantly. Non-viridans streptococci, enterococci and S. aureus were all significantly associated with increased mortality. The increased number of enterococcal IE and the increased number of IVDUs with left-sided IE constituted new challenges. Biological implants were preferred in a majority of patients requiring surgery.

Debating Medical Utility, Not Futility: Ethical Dilemmas in Treating Critically Ill People Who Use Injection Drugs

Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal.

Short-term Outcome of Patients with Infective Endocarditis: A Single-center Prospective Study

Objectives:

To investigate the short-term outcome of patients with infective endocarditis (IE).

Patients and Methods:

We analyzed data from 42 patients with active endocarditis which underwent different cardiac surgeries. An active endocarditis was considered due to urine analysis and/or blood culture and acute inflammation Gram stains of sample tissue and/or blood culture and acute inflammation Gram stains of sample tissue.

Design:

Collecting data of 42 patients prospectively.

Setting:

University hospital single center.

Participants:

Patients with IE from July 2014 to June 2016.

Interventions:

None.

Measurement and Main Results:

We collected data of 42 patients in Imam Hospital which is a university-based 1700-bed center. Twelve patients experienced a redo operation; in which, 2 of them have had the second redo. Five patients underwent an aortic valve replacement operation, 2 mitral valve repair, and only one patient had experienced a subaortic web resection. Seven cases were addict; in which, 5 of them were intravenous abusers. There was 1 porphyric patient which suffered from pethidine reliability. Most of our cases underwent Bentall or tricuspid valve repair operation, and multivalve operation was more scarce.

Conclusions:

We have presented the therapeutic strategies and outcome of patients with IE and evaluated their short-term outcome.