Attitudes and Approaches Towards Repeat Valve Surgery in Recurrent Injection Drug Use-associated Infective Endocarditis: A Qualitative Study

"They Just Assume That We're All Going to Do the Wrong Thing With It. It's Just Not True": Stakeholder Perspectives About Peripherally Inserted Central Catheters in People Who Inject Drugs

Background

In the absence of adequate harm reduction opportunities, people who inject drugs (PWID) are at increased risk for serious infections. Infectious diseases guidelines recommend extended periods of intravenous antibiotic treatment through peripherally inserted central catheters (PICCs), but PWID are often deemed unsuitable for this treatment. We conducted semi-structured interviews and focus groups to understand the perspectives and opinions of patients and clinicians on the use of PICCs for PWID.

Methods

We approached patients and clinicians (doctors, nurses, PICC nurses, social workers, and case workers) involved in patient care at Tufts Medical Center (Boston, Massachusetts) between August 2019 and April 2020 for semi-structured interviews and focus groups.

Results

Eleven of 14 (79%) patients agreed to participate in an in-depth interview, and 5 role-specific clinician focus groups (1 group consisting of infectious diseases, internal medicine, and addiction psychiatry doctors, 2 separate groups of floor nurses, 1 group of PICC nurses, and 1 group of social workers) were completed. Emergent themes included the overall agreement that PICCs improve healthcare, patients' feelings that their stage of recovery from addiction was not taken into consideration, and clinicians' anecdotal negative experiences driving decisions on PICCs.

Conclusions

When analyzed together, the experiences of PWID and clinicians shed light on ways the healthcare system can improve the quality of care for PWID hospitalized for infections. Further research is needed to develop a system of person-centered care for PWID that meets the specific needs of patients and improves the relationship between them and the healthcare system.

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.

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.

Health care workers' perspectives on care for patients with injection drug use associated infective endocarditis (IDU-IE)

Background

Despite high morbidity and mortality, patients with injection drug use associated infective endocarditis (IDU-IE) lack standardized care, and experience prolonged hospitalization and variable substance use disorder (SUD) management.

Our study’s objective was to elicit perspectives of health care workers (HCWs) who deliver care to this population by understanding their perceived patient, provider, and system-level resources and barriers.

Methods

This qualitative study included interviews of HCWs providing care to patients with IDU-IE from January 2017 to December 2019 at a single Midwest academic center. Based on electronic medical record queries to determine high and low rates of referral to SUD treatment, HCWs were selected using stratified random sampling followed by convenience sampling of non-physician HCWs and a patient. Study participants were recruited via email and verbal consent was obtained. The final sample included 11 hospitalists, 3 specialists (including 2 cardiovascular surgery providers), 3 case managers, 2 social workers, 1 nurse, and 1 patient. Qualitative semi-structured interviews explored challenges and resources related to caring for this population. Qualitative Data Analysis (QDA) Minor Lite was used for thematic data using an inductive approach.

Results

Three major thematic categories emerged relative to patient-level barriers (e.g., pain control, difficult patient interactions, social determinants of health), provider-level barriers (e.g., inequity, expectations for recovery, varying levels of hope, communication style, prescribing medication for SUD), and system-level barriers (e.g., repeat surgery, placement, resources for SUD and mental health). The need to address underlying SUD was a prominent theme.

Conclusion

Practical steps we can take to improve treatment for this population include training and coaching HCWs on a more person-centered approach to communication and transparent decision-making around pain management, surgery decisions, and expectations for SUD treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08121-z.

Creation of a Multidisciplinary Drug Use Endocarditis Treatment (DUET) Team: Initial Patient Characteristics, Outcomes, and Future Directions

Background

Consensus guidelines recommend multidisciplinary models to manage infective endocarditis, yet often do not address the unique challenges of treating people with drug use–associated infective endocarditis (DUA-IE). Our center is among the first to convene a Drug Use Endocarditis Treatment (DUET) team composed of specialists from Infectious Disease, Cardiothoracic Surgery, Cardiology, and Addiction Medicine.

Methods

The objective of this study was to describe the demographics, infectious characteristics, and clinical outcomes of the first cohort of patients cared for by the DUET team. This was a retrospective chart review of patients referred to the DUET team between August 2018 and May 2020 with DUA-IE.

Results

Fifty-seven patients were presented to the DUET team between August 2018 and May 2020. The cohort was young, with a median age of 35, and injected primarily opioids (82.5% heroin/fentanyl), cocaine (52.6%), and methamphetamine (15.8%). Overall, 14 individuals (24.6%) received cardiac surgery, and the remainder (75.4%) were managed with antimicrobial therapy alone. Nearly 65% of individuals were discharged on medication for opioid use disorder, though less than half (36.8%) were discharged with naloxone and only 1 patient was initiated on HIV pre-exposure prophylaxis. Overall, the cohort had a high rate of readmission (42.1%) within 90 days of discharge.

Conclusions

Multidisciplinary care models such as the DUET team can help integrate nuanced decision-making from numerous subspecialties. They can also increase the uptake of addiction medicine and harm reduction tools, but further efforts are needed to integrate harm reduction strategies and improve follow-up in future iterations of the DUET team model.

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

BACKGROUND AND AIM OF STUDY

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Candida spp. infective endocarditis: Characteristics and outcomes of twenty patients with a focus on injection drug use as a predisposing risk factor

BACKGROUND

Candida spp. infective endocarditis (CIE) although rare is associated with high morbidity and mortality. Risk factors include prosthetic heart valves and injection drug use (IDU). We reviewed all cases of CIE at our institution to describe the microbiology, treatment and outcomes of patients focusing on IDU as a predisposing factor.

METHODS

Retrospective cohort of patients with definite CIE between 2013 and 2019 at a university hospital was analysed. Demographic data collected included IDU, microbiologic, treatment and mortality. The primary outcome of interest was 12-month, all-cause mortality.

RESULTS

Twenty patients were included (one had two separate episodes of CIE); CIE accounted for 4% of total infective endocarditis (IE) cases during the study period. The median (IQR) age was 38 (30-58) years, 10 (50%) had a previous history of IE, and 4 (20%) patients had prosthetic heart valves or an implanted cardiac device. Thirteen (65%) patients were IDU. The tricuspid valve was the primary valve involved (8/18, 44%), and C albicans was the most frequently isolated organism (8, 36%). Echinocandin was the most common treatment strategy (8, 40%). Only three (15%) patients underwent valve replacement during hospitalisation. There were no in-hospital fatalities, and 5 (25%) patients died at one year; all were IDU (39% to 0%, p = .11).

CONCLUSION

CIE is a rare infectious disease seen more commonly in the IDU population. Cardiac surgery was rarely performed, and long-term mortality was 25%. Additional data are needed to identify ideal management strategies in this population.

Infective Endocarditis in Persons Who Use Drugs: Epidemiology, Current Management, and Emerging Treatments

Infective endocarditis associated with injection drug use (IDU-IE) is markedly increasing in the United States and Canada. Long-term outcomes are dismal and stem from insufficient substance use disorder treatment. In this review, we summarize the principles of antimicrobial and surgical management for infective endocarditis associated with injection drug use. We discuss approaches to opioid use disorder care and harm reduction in the inpatient setting and review opportunities to address preventable infections among persons injecting drugs. We highlight barriers to implementing optimal treatment and consider novel approaches that may reshape infective endocarditis associated with injection drug use treatment in coming years.