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

Long-term Risk of Serious Infections and Mortality Among Patients Surviving Drug Use-Associated Infective Endocarditis

Among a statewide cohort of 1874 patients surviving hospitalization for drug use-associated endocarditis during 2017-2020, the 3-year risk of death or future hospitalization was 38% (16% for death before later infection, 14% for recurrent endocarditis, 14% for soft tissue, 9% for bacteremia, 5% for bone/joint, and 4% for spinal infections).

Changing the High-Risk Behaviors of Injecting Drug Users in Iran: Application Theory of Planned Behavior

Background

Injection risk behavior is a major predictor of HIV infection. The present study was conducted to survey the effect of educational intervention based on the theory of planned behavior on changing high-risk behaviors (the high-risk behaviors of injecting and behaviors of transmitting blood diseases to others) of injecting drug users under the coverage of addiction harm reduction centers.

Methods

This study is an experimental research on 120 drug addicts in 2021-2022. Two addiction harm reduction centers in Fasa City, Iran, were chosen randomly (one as the test group and the other as the control group). The data collection tool is made up of two parts. The first part is a questionnaire on demographics. The second part is a questionnaire based on the theory of planned behavior, which was made using information from different sources and studies. The training program was set up based on the pretest results and the theory of planned behavior for the test group. Before and six months after the educational intervention, the experimental and control groups filled out the questionnaire. With a significance level of 0.05, the independent t, chi-square, and paired t statistical tests were used to examine the data using the SPSS 22 program.

Results

In the test group, the average age of addicts was 37.42 ± 10.55 years, while in the control group, the average age was 38.36 ± 10.09 years (p=0.244). Six months after the educational intervention, all TPB theory's constructs (knowledge, attitude, subjective norms and perceived behavioral control, behavioral intention, and behavior of injecting drug users) were higher in the test group than in the control group (p=0.001).

Conclusion

The results show the effect of this educational intervention in reducing high-risk behaviors related to injection in injection drug addicts, so it is suggested as a useful method to reduce high-risk injection behaviors in these people.

Clinical characteristics and risk factors for right-sided infective endocarditis in Korea: a 12-year retrospective cohort study

Right-sided infective endocarditis (RSIE) is less common than left-sided infective endocarditis (LSIE) and exhibits distinct epidemiological, clinical, and microbiological characteristics. Previous studies have focused primarily on RSIE in patients with intravenous drug use. We investigated the characteristics and risk factors for RSIE in an area where intravenous drug use is uncommon. A retrospective cohort study was conducted at a tertiary hospital in South Korea. Patients diagnosed with infective endocarditis between November 2005 and August 2017 were categorized into LSIE and RSIE groups. Of the 406 patients, 365 (89.9%) had LSIE and 41 (10.1%) had RSIE. The mortality rates were 31.7% in the RSIE group and 31.5% in the LSIE group (P = 0.860). Patients with RSIE had a higher prevalence of infection with Staphylococcus aureus (29.3% vs. 13.7%, P = 0.016), coagulase-negative staphylococci (17.1% vs. 6.0%, P = 0.022), and gram-negative bacilli other than HACEK (12.2% vs. 2.2%, P = 0.003). Younger age (adjusted odds ratio [aOR] 0.97, 95% confidence interval [CI] 0.95-0.99, P = 0.006), implanted cardiac devices (aOR 37.75, 95% CI 11.63-141.64, P ≤ 0.001), and central venous catheterization  (aOR 4.25, 95%  CI 1.14-15.55, P = 0.029) were independent risk factors for RSIE. Treatment strategies that consider the epidemiologic and microbiologic characteristics of RSIE are warranted.

Evidence of "Repeated Admission Bias" Among Those Who Use Injection Drugs Across 2 Decades of US Treatment Admissions: 2000-2020

OBJECTIVES

Encounter-based datasets like the Treatment Episode Dataset-Admissions (TEDS-A) are used for substance use-related research. Although TEDS-A reports the number of previous treatment admissions, a limitation is this reflects encounters, not people. We sought to quantify the methodologic bias incorporated by using all encounters versus initial encounters and assess if this risk is evenly distributed across all routes of drug administration.

METHODS

TEDS-A 2000-2020 dataset with nonmissing primary substance data was used. Of the data, 3.17% were missing the usual administration route, and 11.9% were missing prior admission data. Prior admissions are documented as 0 through 4, then binned for 5 or greater (5+). Risk of admission bias was defined as odds ratio (OR RAB ): odds of total admissions relative to the odds of the first admission. Bootstrap confidence intervals were generated (5000 iterations) across administration routes and demographics; however, their widths were <0.0055 and not reported.

RESULTS

There were 38,238,586 admissions over the 21 years, with 13,865,517 (41.2%) first admissions. Of all admissions, 15.7% indicated injection drug use (IDU); 26.3% of encounters reporting IDU were in the 5+ group. This resulted in an OR RAB of 1.77. White enrollees had an elevated OR RAB (1.05), whereas among Latinos, OR RAB was low (0.74).

CONCLUSIONS

Using encounter-based datasets can introduce bias when including all admissions versus exclusively initial treatment episodes. This report is the first to quantify this bias and shows that individuals with IDU are at highest risk for returning to treatment, thereby over-representing this method of use when all encounters are used.

New Ways to Help Patients Worst Off

AbstractThis introduction to The Journal of Clinical Ethics highlights and expands four articles within this issue that propose somewhat new and radical innovations to help and further the interests of patients and families worst off. One article urges us to enable historically marginalized groups to participate more than they have in research; a second urges us to allocate limited resources that can be divided, such as vaccines and even ventilators, in a different way; a third urges us to help families find greater meaning when their loved ones are dying; and a fourth urges us to treat patients who illegally use drugs as caringly as is possible, though there may be limits to what providers can do. This piece also addresses the importance of providers bonding with patients, recognizing that some providers may be better at eliciting patients' trust than others, and thus the importance of connecting these patients with these providers since this may be the sole way these patients can optimally respond and do well. Finally, providers taking time away from their patients to oppose and reduce social stigma is considered.

Epidemiology of acute infections in people who inject drugs in Australia

ISSUES

People who inject drugs are at risk of acute infections, such as skin and soft tissue infections, infective endocarditis, bone and joint infections and bloodstream infections. There has been an increase in these infections in people who inject drugs internationally over the past 10 years. However, the local data regarding acute infections in Australia has not been well described.

APPROACH

We review the epidemiology of acute infections and associated morbidity and mortality amongst people who inject drugs in Australia. We summarise risk factors for these infections, including the concurrent social and psychological determinants of health.

KEY FINDINGS

The proportion of people who report having injected drugs in the prior 12 months in Australia has decreased over the past 18 years. However, there has been an increase in the burden of acute infections in this population. This increase is driven largely by skin and soft tissue infections. People who inject drugs often have multiple conflicting priorities that can delay engagement in care.

IMPLICATIONS

Acute infections in people who inject drugs are associated with significant morbidity and mortality. Acute infections contribute to significant bed days, surgical requirements and health-care costs in Australia. The increase in these infections is likely due to a complex interplay of microbiological, individual, social and environmental factors.

CONCLUSION

Acute infections in people who inject drugs in Australia represent a significant burden to both patients and health-care systems. Flexible health-care models, such as low-threshold wound clinics, would help directly target, and address early interventions, for these infections.

Evidence of telescoping in females across two decades of US treatment admissions for injection drug use: 2000-2020

Background

People who inject drugs (PWID) have an increased risk of soft tissue infection, drug overdose and death. Females may be particularly vulnerable due to barriers to substance use disorder (SUD) treatment entry, stigma, and telescoping, or the greater severity in substance use-related comorbidity and consequences despite a shorter history of use. We set out to identify sex differences in United States injection drug use (IDU).

Methods

The Treatment Episode Dataset-Admission (2000-2020) provided data to identify PWID undergoing their initial SUD treatment admission. Mann-Whitney U test, chi-square, and Spearman correlations were used for ordinal variables, categorical variables, and to assess similarity of male/female trends over the 21 years, respectively. The probabilistic index (PI) and Cramer's V provided effect sizes for Mann-Whitney U tests and chi-square tests, respectively.

Results

A total of 13,612,978 records existed for cases entering their initial treatment. Mapping to a history of IDU left 1,458,695 (561,793 females). Females had a higher prevalence among PWID across all 21 years; IDU trends were essentially identical between males and females (r = 0.97). Females endorsed beginning their primary substance later in life (PI = 0.47, p < 0.0001) and entered treatment after a shorter period of substance use (PI = 0.57, p < 0.0001).

Conclusions

We saw evidence of telescoping among PWID with a SUD entering their initial episode of treatment. Interventions should be implemented prior to the transition to IDU, and this window of opportunity is shortened in females. Utilizing gender-responsive treatment options may be a way to increase treatment-seeking earlier in the disease course.

HIV and HCV testing at clinical encounters among people who inject drugs, 2013-2018-Opportunities for increased testing and prevention

People who inject drugs (PWID) with unsafe injection practices have substantial risk for HIV and hepatitis C virus (HCV) infections. We describe frequency of, and factors associated with, HIV and HCV testing during clinical encounters with PWID. Inpatient and Emergency Department clinical encounters at an Atlanta hospital were abstracted from medical records spanning January 2013-December 2018. We estimated frequency of HIV and HCV testing during injection drug use (IDU)-related encounters among PWID without previous diagnoses. We assessed associations between patient factors and testing using generalized estimating equations models. HIV testing occurred in 39.3% and HCV testing occurred in 17.1% of eligible IDU-related encounters. Testing was more likely in IDU-related encounters during 2017-2018 than in encounters during 2013-2014; (HIV, AOR = 2.14, 95% CI, 1.32-3.49, p < .01). Testing was less likely among Black/African American patients compared to White patients (adjusted odds ratio [AOR]: HIV, AOR = 0.48, 95% confidence interval [CI], 0.33-0.72, p < .01); HCV, AOR = 0.41, 95% CI, 0.24-0.70, p < .01). This difference may be attributable to recent testing among Black patients in non-IDU related encounters. HIV and HCV testing improved over time; however, missed opportunities for testing still existed. Strategies should aim to improve equitable HIV and HCV testing among PWID.

Safe Prescribing Practices: Clinicians' Views on Prescribing Opioids to Patients With Early-Stage Cancer

PURPOSE

Opioids are often necessary for patients experiencing high-intensity pain. However, side effects exist and some patients may misuse opioids. To better understand how opioids are prescribed to patients with early-stage cancer and how to enhance opioid safety, clinicians' views of opioid prescribing were explored.

METHODS

This was a qualitative inquiry including any Alberta clinician prescribing opioids to patients with early-stage cancer. Semistructured interviews were conducted with nurse practitioners (NP), medical oncologists (MO), radiation oncologists (RO), surgeons (S), primary care physicians (PCP), and palliative care physicians (PC) between June 2021 and March 2022. Interpretive description was used to analyze the data using two coders (C.C. and T.W.). Debriefing sessions were used to resolve and discrepancies.

RESULTS

Twenty-four clinicians were interviewed (NP [n = 5], MO [n = 4], RO [n = 4], S [n = 5], PCP [n = 3], and PC [n = 3]). The majority had been in practice at least 10 years. Prescribing practices were related to disciplinary perspective, goals of care, patient condition, and resource availability. Most clinicians did not see opioid misuse as a problem but were aware that specific patient risk factors are present and that long-term use can be problematic. Most clinicians undertake safe prescribing approaches tacitly (eg, screening for past opioid misuse and reviewing number of prescribers) and not all agreed they should be universally applied. Barriers (eg, procedural and time) and facilitators (eg, education) to safe prescribing approaches were identified.

CONCLUSION

To enhance uptake and cross-disciplinary consistency of safe prescribing approaches, clinician education regarding opioid misuse and benefits of safe prescribing practices, and addressing procedural barriers are necessary.

Missed opportunities for prevention: prevalence and incidence of human immunodeficiency virus and hepatitis C virus diagnoses among a cohort of individuals discharged from an urban hospital with injection drug-related diagnoses, 2012-2019

PURPOSE

Risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections has increased due to the ongoing opioid epidemic and unsafe injection practices. We estimated the prevalence and incidence of HIV and HCV diagnoses among people who inject drugs from hospital-based clinical encounters.

METHODS

We linked clinical encounters at an Atlanta hospital during 2012-2018 with state HIV and HCV surveillance records to examine the prevalence of infections at discharge and incidence of infections post clinical encounter.

RESULTS

At discharge, 32.9% and 28.6% of patients with injection drug use-related clinical encounters had an HIV or HCV diagnosis, respectively. HIV and HCV diagnoses at the time of discharge were mostly among 40-64 years old patients, males, and Black/African Americans. Post clinical encounter, 3.8% of patients were later diagnosed with HIV, and 16.5% were later diagnosed with HCV, translating to incidence rates of 9.3 per 1000 person-years and 41.5 per 1000 person-years, respectively. The majority of HIV and HCV diagnoses post clinical encounter occurred among Black/African Americans and males. Of patients with HIV and HCV diagnoses post clinical encounter, 27.3% and 11.9% had been tested during their clinical encounter, respectively.

CONCLUSIONS

Targeted interventions for HIV/HCV prevention, screening, diagnosis, and linkage to treatment are needed to reduce the incidence of new infections among people who inject drugs.

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.

Estimated Number of People Who Inject Drugs in the United States

BACKGROUND

Public health data signal increases in the number of people who inject drugs (PWID) in the United States during the past decade. An updated PWID population size estimate is critical for informing interventions and policies aiming to reduce injection-associated infections and overdose, as well as to provide a baseline for assessments of pandemic-related changes in injection drug use.

METHODS

We used a modified multiplier approach to estimate the number of adults who injected drugs in the United States in 2018. We deduced the estimated number of nonfatal overdose events among PWID from 2 of our previously published estimates: the number of injection-involved overdose deaths and the meta-analyzed ratio of nonfatal to fatal overdose. The number of nonfatal overdose events was divided by prevalence of nonfatal overdose among current PWID for a population size estimate.

RESULTS

There were an estimated 3 694 500 (95% confidence interval [CI], 1 872 700-7 273 300) PWID in the United States in 2018, representing 1.46% (95% CI, .74-2.87) of the adult population. The estimated prevalence of injection drug use was highest among males (2.1%; 95% CI, 1.1-4.2), non-Hispanic Whites (1.8%; 95% CI, .9-3.6), and adults aged 18-39 years (1.8%; 95% CI, .9-3.6).

CONCLUSIONS

Using transparent, replicable methods and largely publicly available data, we provide the first update to the number of people who inject drugs in the United States in nearly 10 years. Findings suggest the population size of PWID has substantially grown in the past decade and that prevention services for PWID should be proportionally increased.

Support, don't punish: Drug decriminalization is harm reduction

Despite large investments in and policy support for harm reduction including naloxone, syringes, and medications for opioid use disorder, people who use drugs continue to experience unprecedented rates of mortality from overdose and morbidity from infectious diseases. The criminalization of drug use has disproportionately exacerbated these drug-related harms and imposed short- and long-term burdens on already marginalized and vulnerable populations. Pharmacy professionals and students are not immune to the effects of drug criminalization, where one conviction can lead to the loss of their license, employment, or educational progress. Communities become less healthy and stagnate in punitive criminalization systems, further reducing opportunities for growth. Decriminalization of drug use and possession is an urgently needed and effective approach to drug use that shifts resources from punishment to public health, thereby reducing the negative impacts of drug use and keeping communities safe and healthy. Pharmacists play essential roles in the prevention and management of drug misuse and use disorders. As policy makers consider and implement drug decriminalization, pharmacists must actively advocate for these policies and educate community and organizational partners on the individual, professional, and community benefits of this harm reduction strategy.

Improving care for individuals with serious infections who inject drugs

Background

Hospitalizations for serious infections requiring long-term intravenous (IV) antimicrobials related to injection drug use have risen sharply over the last decade. At our rural tertiary care center, opportunities for treatment of underlying substance use disorders were often missed during these hospital admissions. Once medically stable, home IV antimicrobial therapy has not traditionally been offered to this patient population due to theoretical concerns about misuse of long-term IV catheters, leading to discharges with suboptimal treatment regimens, lengthy hospital stays, or care that is incongruent with patient goals and preferences.

Methods

A multidisciplinary group of clinicians and patients set out to redesign and improve care for this patient population through a health care innovation process, with a focus on increasing the proportion of patients who may be discharged on home IV therapy. Baseline assessment of current experience was established through retrospective chart review and extensive stakeholder analysis. The innovation process was based in design thinking and facilitated by a health care delivery improvement incubator.

Results

The components of the resulting intervention included early identification of hospitalized people who inject drugs with serious infections, a proactive psychiatry consultation service for addiction management for all patients, a multidisciplinary care conference to support decision making around treatment options for infection and substance use, and care coordination/navigation in the outpatient setting with a substance use peer recovery coach and infectious disease nurse for patients discharged on home IV antimicrobials. Patients discharged on home IV therapy followed routine outpatient parenteral antimicrobial therapy (OPAT) protocols and treatment protocols for addiction with their chosen provider.

Conclusion

An intervention developed through a design-thinking-based health care redesign process improved patient-centered care for people with serious infections who inject drugs.

β-Lactamase Suppression as a Strategy to Target Methicillin-Resistant Staphylococcus aureus: Proof of Concept

β-Lactamase (penicillinase) renders early, natural β-lactams like penicillin G useless against methicillin-resistant Staphylococcus aureus (MRSA), which also expresses PBP2a, responsible for resistance to semisynthetic, penicillinase-insensitive β-lactams like oxacillin. Antimicrobial discovery is difficult, and resistance exists against most treatment options. Enhancing β-lactams against MRSA would revive its clinical utility. Most research on antimicrobial enhancement against MRSA focuses on oxacillin due to β-lactamase expression. Yet, Moreillon and others have demonstrated that penicillin G is as potent against a β-lactamase gene knockout strain, as vancomycin is against wild-type MRSA. Penicillin G overcame PBP2a because β-lactamase activity was blocked. Additionally, animals treated with a combination of direct β-lactamase inhibitors like sulbactam and clavulanate with penicillin G developed resistant infections, clearly demonstrating that direct inhibition of β-lactamase is not a good strategy. Here, we show that 50 μM pyrimidine-2-amines (P2As) reduce the minimum inhibitory concentration (MIC) of penicillin G against MRSA strains by up to 16-fold by reducing β-lactamase activity but not by direct inhibition of the enzyme. Oxacillin was not enhanced due to PBP2a expression, demonstrating the advantage of penicillin G over penicillinase-insensitive β-lactams. P2As modulate an unknown global regulator but not established antimicrobial-enhancement targets Stk1 and VraS. P2As are a practical implementation of Moreillon's principle of suppressing β-lactamase activity to make penicillin G useful against MRSA, without employing direct enzyme inhibitors.

Application of machine learning algorithms for localized syringe services program policy implementation - Florida, 2017

BACKGROUND

People who inject drugs (PWID) are at an amplified vulnerability for experiencing a multitude of harms related to their substance use, including viral (e.g. HIV, Hepatitis C) and bacterial infections (e.g. endocarditis). Implementation of evidence-based interventions, such as syringe services programs (SSPs), remains imperative, particularly in locations at an increased risk of HIV outbreaks. This study aims to identify communities in Florida that are high-priority locations for SSP implementation by examining state-level data related to the substance use and overdose crises.

METHODS

State-level surveillance data were aggregated at the ZIP Code Tabulation Area (ZCTA) (n = 983) for 2017. We used confirmed cases of acute HCV infection as a proxy of injection drug use. Least Absolute Selection and Shrinkage Operator (LASSO) regression was used to develop a machine learning model to identify significant indicators of acute HCV infection and high-priority areas for SSP implementation due to their increased vulnerability to an HIV outbreak.

RESULTS

The final model retained three variables of importance: (1) the number of drug-associated skin and soft tissue infection hospitalizations, (2) the number of chronic HCV infections in people aged 18-39, and 3) the number of drug-associated endocarditis hospitalizations. High-priority SSP implementation locations were identified in both urban and rural communities outside of current Ending the HIV Epidemic counties.

CONCLUSION

SSPs are long researched, safe, and effective evidence-based programs that offer a variety of services that reduce disease transmission and assist with combating the overdose crisis. Opportunities to increase services in needed regions across the state now exist in Florida as supported by the expansion of the Infectious Disease Elimination Act of 2019. This study provides details where potential areas of concern may be and highlights regions where future evidence-based harm reduction programs, such as SSPs, would be useful to reduce opioid overdoses and disease transmission among PWID.Key messagesThe rate of acute HCV in Florida in 2017 was 1.9 per 100,000, nearly twice the national average.Serious injection related infections among PWID are significant indicators of acute HCV infection.High-priority SSP implementation locations in Florida were identified in both urban and rural communities, including those outside of current Ending the HIV Epidemic counties.

Acute injection-related infections requiring hospitalisation among people who inject drugs: Clinical features, microbiology and management

INTRODUCTION

People who inject drugs are at risk of hospitalisation with injection-related infections (IRI). We audited the clinical features, microbiology and management of IRI at a tertiary service in Melbourne to describe the burden and identify quality improvement opportunities.

METHODS

We performed retrospective review of IRI admissions from January 2017 to April 2019. We extracted admissions where ICD-10 codes or triage text suggested injecting drug use, and the diagnosis suggested IRI. We reviewed these for eligibility and extracted data using a standardised form. We performed mixed-effects logistic regression to determine predictors of unplanned discharge.

RESULTS

From 574 extracted candidate admissions, 226 were eligible, representing 178 patients. Median age was 41 years (interquartile range 36-47), 66% (117/178) male and 49% (111/226) had unstable housing. Over 50% (96/178) had a psychiatric diagnosis and 35% (62/178) were on opioid agonist therapy (OAT) on admission. Skin and soft tissue infection was the most common IRI (119/205, 58%), followed by bacteraemia (36/205, 18%) and endocarditis (26/205, 13%). Management included addictions review (143/226, 63%), blood-borne virus screening (115/226, 51%), surgery (77/226, 34%) and OAT commencement (68/226, 30%). Aggression events (54/226, 15%) and unplanned discharge (69/226, 30%) complicated some admissions. Opioid use without OAT was associated with almost 3-fold increased odds of unplanned discharge compared to no opioid use (odds ratio 2.90, 95% confidence interval 1.23, 6.85, p = 0.015).

DISCUSSION AND CONCLUSION

Comorbidities associated with IRI may be amenable to opportunistic intervention during hospitalisation. Further research is needed to develop optimal models of care for this vulnerable patient group.

Caring for behaviorally challenging patients in nonpsychiatric settings

This article discusses a pilot study on the use of a behavior support plan to safely address patients who exhibit disruptive behaviors in the ED and nonpsychiatric medical settings while respecting their autonomy.

Steep rise in drug use-associated infective endocarditis in West Virginia: Characteristics and healthcare utilization

Introduction

Life-threatening infections such as infective endocarditis (IE) are increasing simultaneously with the injection drug use epidemic in West Virginia (WV). We utilized a newly developed, statewide database to describe epidemiologic characteristics and healthcare utilization among patients with (DU-IE) and without (non-DU-IE) drug use-associated IE in WV over five years.

Materials and methods

This retrospective, observational study, incorporating manual review of electronic medical records, included all patients aged 18–90 years who had their first admission for IE in any of the four university-affiliated referral hospitals in WV during 2014–2018. IE was identified using ICD-10-CM codes and confirmed by chart review. Demographics, clinical characteristics, and healthcare utilization were compared between patients with DU-IE and non-DU-IE using Chi-square/Fisher’s exact test or Wilcoxon rank sum test. Multivariable logistic regression analysis was conducted with discharge against medical advice/in-hospital mortality vs. discharge alive as the outcome variable and drug use as the predictor variable.

Results

Overall 780 unique patients had confirmed first IE admission, with a six-fold increase during study period (p = .004). Most patients (70.9%) had used drugs before hospital admission, primarily by injection. Compared to patients with non-DU-IE, patients with DU-IE were significantly younger (median age: 33.9 vs. 64.1 years; p < .001); were hospitalized longer (median: 25.5 vs. 15 days; p < .001); had a higher proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates (42.7% vs. 29.9%; p < .001), psychiatric disorders (51.2% vs. 17.3%; p < .001), cardiac surgeries (42.9% vs. 26.6%; p < .001), and discharges against medical advice (19.9% vs. 1.4%; p < .001). Multivariable regression analysis showed drug use was an independent predictor of the combined outcome of discharge against medical advice/in-hospital mortality (OR: 2.99; 95% CI: 1.67–5.64).

Discussion and conclusion

This multisite study reveals a 681% increase in IE admissions in WV over five years primarily attributable to injection drug use, underscoring the urgent need for both prevention efforts and specialized strategies to improve outcomes.

Dealing with the epidemic of endocarditis in people who inject drugs

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

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.

Cancer Screening among Rural People Who Use Drugs: Colliding Risks and Barriers

Rural cancer disparities are associated with lesser healthcare access and screening adherence. The opioid epidemic may increase disparities as people who use drugs (PWUD) frequently experience healthcare-associated stigmatizing experiences which discourage seeking routine care. Rural PWUD were recruited to complete surveys and interviews exploring cancer (cervical, breast, colorectal, lung) risk, screening history, and healthcare experiences. From July 2020–July 2021 we collected 37 surveys and 8 interviews. Participants were 24.3% male, 86.5% White race, and had a mean age of 44.8 years. Females were less likely to report seeing a primary care provider on a regular basis, and more likely to report stigmatizing healthcare experiences. A majority of females reporting receiving recommendations and screens for cervical and breast cancer, but only a minority were adherent. Similarly, only a minority of males and females reported receiving screening tests for colorectal and lung cancer. Screening rates for all cancers were substantially below those for the US generally and rural areas specifically. Interviews confirmed stigmatizing healthcare experiences and suggested screening barriers and possible solutions. The opioid epidemic involves millions of individuals and is disproportionately experienced in rural communities. To avoid exacerbating existing rural cancer disparities, methods to engage PWUD in cancer screening need to be developed.

Expanding the Team: Optimizing the Multidisciplinary Management of Drug Use-Associated Infective Endocarditis

Amidst a substance use epidemic, hospitalizations and valve surgeries related to drug use-associated infective endocarditis (DU-IE) rose substantially in the last decade. Rates of reoperation and mortality remain high, yet in many hospitals patients are not offered valve surgery or evidence-based addiction treatment. A multidisciplinary team approach can improve outcomes in patients with infective endocarditis; however, the breadth of expertise that should be incorporated into this team is inadequately conceptualized. It is our opinion that incorporating addiction medicine services into the team may improve outcomes in DU-IE. Here, we describe our experience incorporating addiction medicine services into the multidisciplinary management of DU-IE and share implications for other hospitals and health systems looking to improve care for people with DU-IE.

Epidemiology of infective endocarditis: novel aspects in the twenty-first century

INTRODUCTION

The epidemiology of infective endocarditis (IE) in this millennium has changed with emergence of new risk factors and reemergence of others. This, coupled with modifications in national guidelines in the setting of a pandemic, prompted an address of the topic.

AREAS COVERED

Our goal is to provide a contemporary review of IE epidemiology considering changing incidence of rheumatic heart disease (RHD), cardiac device implantation, and injection drug use (IDU), with SARS-CoV-2 pandemic as the backdrop.

METHODS

PubMed and Google Scholar were used to identify studies of interest.

EXPERT OPINION

Our experience over the past two decades verifies the notion that there is not one 'textbook' profile of IE. Multiple factors have dramatically impacted IE epidemiology, and these factors differ, based, in part on geography. RHD has declined in many areas of the world, whereas implanted cardiovascular devices-related IE has grown exponentially. Perhaps the most influential, at least in areas of the United States, is injection drug use complicating the opioid epidemic. Healthy younger individuals contracting a potentially life-threatening infection has been tragic. In the past year, epidemiological changes due to the COVID-19 pandemic have also occurred. No doubt, changes will characterize IE in the future and serial review of the topic is warranted.

International Classification of Diseases (ICD) Codes Fail to Accurately Identify Injection Drug Use Associated Endocarditis Cases

OBJECTIVES

Infective endocarditis (IE) secondary to injection drug use (IDU-IE) is a disease with high morbidity, cost, and rapid demographic evolution. Studies frequently utilize combinations of International Statistical Classification of Diseases (ICD) codes to identify IDU-IE cases in electronic medical records. This is a validation of this identification strategy in a US cohort.

METHODS

Records from January 1, 2004 to September 31, 2015 for those aged ≥18yo with any ICD-coded IE encounter (inpatient or outpatient) were retrieved from the electronic medical record and then manually reviewed and classified as IDU-IE by strict and inclusive criteria. This registry was then used to assess the diagnostic accuracy of 10 identification algorithms that combined substance use, hepatitis C, and IE ICD codes.

RESULTS

IE was present in 629 of the 2055 manually reviewed records; 109 reported IDU within 3 months of IE diagnosis and an additional 32 during their lifetime (141 cases). In contrast, no algorithm identified more than 46 (33%) of these cases. Algorithms assessing encounters with both an IE and substance use code had specificities >99% but sensitivities ≤11% with negative predictive values of 83% to 84% and positive predictive values ranging from 75% to 91%. Use of a hepatitis C OR substance use code with an IE-coded encounter resulted in higher sensitivities of 22% to 32% but more false positives and overall positive predictive value of <70%. This algorithm limited to age ≤45yo had the best, but still low, discrimination ability with an area under the receiver operating characteristic curve of 0.62.

CONCLUSION

Substance use and hepatitis C codes have poor ability to accurately classify an IE-coded encounter as IDU-IE or routine IE.

Trends in Hospitalizations for Serious Infections Among People With Opioid Use Disorder in Ontario, Canada

Opioid use among people who inject drugs can lead to serious complications, including infections. We sought to study trends in rates of these complications among people with an opioid use disorder (OUD) and the sequelae of those hospitalizations.

Care-engaged individuals with polysubstance use in Northeastern US are undertreated for methamphetamine use disorder: a retrospective cohort study

BACKGROUND

Stimulant use has increased across the US, with concomitant opioid and methamphetamine use doubling between 2011 and 2017. Shifting patterns of polysubstance use have led to rising psychostimulant-involved deaths. While it is known that individuals who use methamphetamine require greater access to treatment, there is still little known about methamphetamine use and treatment among individuals who are already engaged in outpatient substance use treatment.

OBJECTIVES

To characterize care-engaged individuals who use methamphetamine to guide harm reduction and treatment strategies.

METHODS

Retrospective cohort study of individuals at a large academic medical center in Massachusetts with ≥ 2 positive methamphetamine oral fluid toxicology tests between August 2019 and January 2020. We performed descriptive analysis of sociodemographic, medical, and drug use characteristics and a comparative analysis of injection methamphetamine use versus other routes of use.

RESULTS

Included were 71 individuals [56 male (80%), 66 non-Hispanic white (94%), median age 36 (IQR 30-42)]. Nearly all had opioid (94%) and stimulant use disorder (92%). Most had (93%) or were (83%) being treated with medications for opioid use disorder, but few received pharmacologic treatment for methamphetamine use disorder (24%). None received contingency management treatment. People who inject methamphetamine (68%) were more likely to have a history of overdose (91% vs. 70%; p = 0.02), have HCV (94% vs. 52%; p < 0.01), use fentanyl (93% vs. 65%; p = 0.02), and engage in sex work (19% vs. 0%; p = 0.03) compared to those who used via other routes. Both groups had prevalent homelessness (88% vs. 73%; p = 0.15), incarceration (81% vs. 64%; p = 0.11), depression (94% vs. 87%; p = 0.34), and bacteremia (27% vs. 22%; p = 0.63).

CONCLUSIONS

Individuals in our study had high prevalence of polysubstance use, particularly concomitant methamphetamine and opioid use. Individuals who were well connected to substance use treatment for their opioid use were still likely to be undertreated for their methamphetamine use disorder and would benefit from greater access to contingency management treatment, harm reduction resources, and resources to address adverse social determinants of health.

Attitudes toward syringe exchange programs in a rural Appalachian community

OBJECTIVES

To evaluate community attitudes concerning syringe exchange programs (SEPs) in a rural community as part of an effort to implement evidence-based harm reduction strategies and improve health outcomes related to opioid use disorder.

METHODS

Dissemination of a 24-item survey to individuals living in a rural community followed by comparative analysis of survey results based on support for SEPs.

RESULTS

Three hundred and sixty-one individuals responded. Overall, 49.3% of respondents indicated support for syringe exchange. Individuals who support syringe exchange as a harm reduction service are more likely to: agree that opioid use disorder is a real illness (p < 0.0001); agree that anyone can become addicted to pain medications (p = 0.01); agree that medication assisted treatment is effective (p < 0.0001); agree that individuals with OUD have the same right to a job (p < 0.0001); be willing to administer naloxone to a stranger (p < 0.0001); support HIV and HCV screening (p < 0.0001), condom distribution (p < 0.0001), and medication for opioid use disorder (p < 0.0001). They are less likely to believe that harm reduction services encourage drug use (p < 0.0001).

CONCLUSIONS

Positive correlations exist between support for SEPs, awareness of OUD as a chronic illness, less stigmatizing attitudes toward individuals with OUD, and support for other harm reduction strategies. Efforts to increase awareness of OUD as a chronic illness may lead to greater acceptance of harm reduction strategies in rural areas, easing evolution of evidence-based healthy policy.

Intravenous Drug Use-Associated Infective Endocarditis in Pregnant Patients at a Hospital in West Virginia

Introduction Due to high levels of intravenous drug use (IVDU) in West Virginia (WV), there are increasing numbers of hospitalizations for infective endocarditis (IE). More specifically, pregnant patients with IE are a uniquely challenging population, with complex management and a clinical course that further affects the health of the fetus, with high morbidity and mortality. Timely recognition and awareness of the most common bacterial causes will provide hospitals and clinicians with valuable information to manage future patients. Methods This retrospective study analyzed the clinical course of pregnant patients admitted with IE and IVDU history presenting at Cabell Huntington Hospital from 2013 to 2018. Inclusion criteria were women between 16 and 45 years of age confirmed to be pregnant by urine pregnancy test and ultrasonography with at least eight weeks gestation, with a first-time diagnosis of endocarditis and an identified history of IVDU. We excluded charts with pre-existing risk factors including a history of valvular disease, rheumatic heart disease, surgical valve repair or mechanical valve replacement, or a diagnosis of coagulopathies. The resulting charts were evaluated for isolated organisms, reported clinical course, and complications of the pregnancy. Results A total of 10 patients were identified, with methicillin-susceptible and methicillin-resistant Staphylococcus aureus, Serratia marcescens, Haemophilus parainfluenza, and Enterococcus faecalis species. Complications included loss of fetus (30%), septic embolization (40%), hemorrhagic stroke (10%), and transfer to outside facilities for cardiothoracic surgical intervention (40%). Discussion IE in pregnancy, while rare, has serious complications. In the context of the IVDU epidemic, it has an increasing impact on WV hospitals. A better understanding of the clinical course may allow for early diagnosis and guide the development of rational empiric therapies. More effective management of IE in pregnant patients can reduce complications and potentially improve maternal and fetal morbidity or mortality.

Impact of the Opioid Epidemic

In recent years the prescription opioid overdose epidemic has decreased, but has been more than offset by increases in overdose caused by fentanyl and fentanyl analogues. Opioid overdose patients should receive naloxone if they have significant respiratory depression and/or loss of protective airway reflexes. Patients who receive naloxone should be observed for recurrent opioid effects. Patients with opioid overdose may be admitted to the intensive care unit for naloxone infusions, treatment of noncardiogenic pulmonary edema, autonomic instability, or sequelae of hypoxia-ischemia or cardiac arrest. Primary and secondary prevention are important to reduce the number of people with life-threatening opioid overdose.

Effect of initiation of medications for opioid use disorder on hospitalization outcomes for endocarditis and osteomyelitis in a large private hospital system in the United States, 2014-18

BACKGROUND AND AIMS

Opioid use disorder (OUD) has led to not only increases in overdose deaths, but also increases in endocarditis and osteomyelitis secondary to injection drug use (IDU). We studied the association between initiation of medications for opioid use disorder (MOUD) and treatment outcomes for people with infectious sequelae of IDU and OUD.

DESIGN AND SETTING

This is a retrospective cohort study reviewing encounters at 143 HCA Healthcare hospitals across 21 states of the United States from 2014 to 2018.

PARTICIPANTS

Adults aged 18-65 with the ICD diagnosis code for OUD and endocarditis or osteomyelitis (n = 1407).

MEASUREMENTS

Main exposure was the initiation of MOUD, defined as either methadone or buprenorphine at any dosage started during hospitalization. Primary outcomes were defined as patient-directed discharge (PDD), 30-day re-admission and days of intravenous antibiotic treatment. Covariates included biological sex, age, ethnicity, other co-occurring substance use disorders, and insurance status.

FINDINGS

MOUD was initiated among 269 (19.1%) patients during hospitalization. Initiation of MOUD was not associated with decreased odds of PDD. Initiation of MOUD did not impact 30-day re-admission. Patients who received MOUD, on average, had 5.7 additional days of gold-standard intravenous antibiotic treatment compared with those who did not [β = 5.678, 95% confidence interval (CI) = 3.563, 7.794), P < 0.05].

CONCLUSION

For people with opioid use disorder hospitalized with endocarditis or osteomyelitis, initiation of methadone or buprenorphine appears to be associated with improved receipt of gold-standard therapy, as quantified by increased days on intravenous antibiotic treatment.

Changes in health-related quality of life for HCV-infected people who inject drugs on opioid agonist treatment following sustained virologic response

BACKGROUND

Although efforts to treat hepatitis C virus (HCV) in people who inject drugs (PWID) yield high rates of sustained virologic response (SVR), the relationship between successful HCV treatment and health-related quality of life (HRQOL) among PWID is poorly understood. This study examined HRQOL changes throughout HCV treatment and post-treatment for PWID achieving SVR.

METHODS

Participants included 141 PWID who achieved SVR following HCV treatment onsite at three opioid agonist treatment (OAT) clinics in Bronx, NY. The EQ-5D-3L assesses five health dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), producing an index of HRQOL ranging from 0-1. EQ-5D-3L was measured at baseline, 4-, 8-, and 12-weeks during treatment and 12- and 24-weeks post-treatment. Linear mixed effects regression models were used to assess changes in the mean EQ-5D-3L index over time.

RESULTS

Mean EQ-5D-3L index baseline was 0.66 (SE=0.02). Whereas over half the population reported no baseline problems with self-care (85.1%), usual activities (56.0%), and mobility (52.5%), at least two-thirds reported problems with pain/discomfort (78.0%) and anxiety/depression (66.0%), with 22.0% and 21.3% reporting extreme problems for pain/discomfort and anxiety/depression, respectively. Twenty-four weeks post-treatment, proportions reporting pain/discomfort and anxiety/depression decreased by 25.7% and 24.0%, respectively. The mean EQ-5D-3L index significantly improved during treatment (p<0.0001), and improvement was sustained following treatment completion, with mean EQ-5D-3L index of 0.77 (SE=0.02) 12-weeks post-SVR.

CONCLUSIONS

HCV treatment led to sustained improvement in HRQOL for PWID on OAT who achieved SVR. Future research is necessary to determine whether improvements in HRQOL can be sustained beyond 12-weeks post-SVR.

Short- and long-term outcomes of infective endocarditis admission in adults: A population-based registry study in Finland

Infective endocarditis (IE) is associated with high mortality. However, data on factors associated with length of stay (LOS) in hospital due to IE are scarce. In addition, long-term mortality of more than 1 year is inadequately known. In this large population-based study we investigated age and sex differences, temporal trends, and factors affecting the LOS in patients with IE and in-hospital, 1-year, 5-year and 10-year mortality of IE. Data on patients (≥18 years of age) admitted to hospital due to IE in Finland during 2005–2014 were collected retrospectively from nationwide obligatory registries. We included 2166 patients in our study. Of the patients 67.8% were men. Women were older than men (mean age 63.3 vs. 59.5, p<0.001). The median LOS was 20.0 days in men and 18.0 in women, p = 0.015. In the youngest patients (18–39 years) the median LOS was significantly longer than in the oldest patients (≥80 years) (24.0 vs. 16.0 days, p = 0.014). In-hospital mortality was 10% with no difference between men and women. Mortality was 22.7% at 1 year whereas 5- and 10-year mortality was 37.5% and 48.5%, respectively. The 5-year and 10-year mortality was higher in women (HR 1.18, p = 0.034; HR 1.18, p = 0.021). Both in-hospital and long-term mortality increased significantly with aging and comorbidity burden. Both mortality and LOS remained stable over the study period. In conclusion, men had longer hospital stays due to IE compared to women. The 5- and 10-year mortality was higher in women. The mortality of IE or LOS did not change over time.

Association of Nonacute Opioid Use and Cardiovascular Diseases: A Scoping Review of the Literature

BACKGROUND In this scoping review, we identified and reviewed 23 original articles from the PubMed database that investigated the relationship between nonacute opioid use (NOU) and cardiovascular outcomes. METHODS AND RESULTS We defined NOU to include both long-term opioid therapy and opioid use disorder. We summarized the association between NOU and 5 classes of cardiovascular disease, including infective endocarditis, coronary heart disease (including myocardial infarction), congestive heart failure, cardiac arrythmia (including cardiac arrest), and stroke. The most commonly studied outcomes were coronary heart disease and infective endocarditis. There was generally consistent evidence of a positive association between community prevalence of injection drug use (with opioids being the most commonly injected type of drug) and community prevalence of infective endocarditis, and between (primarily medically indicated) NOU and myocardial infarction. There was less consensus about the relationship between NOU and congestive heart failure, cardiac arrhythmia, and stroke. CONCLUSIONS There is a dearth of high-quality evidence on the relationship between NOU and cardiovascular disease. Innovative approaches to the assessment of opioid exposure over extended periods of time will be required to address this need.

Inconsistent Addiction Treatment for Patients Undergoing Cardiac Surgery for Injection Drug Use-associated Infective Endocarditis

INTRODUCTION

Cases of surgical injection drug use-associated infective endocarditis (IDU-IE) are on the rise, amid the US opioid epidemic. We aimed to describe nature of perioperative addiction treatment for these patients.

METHODS

This is a retrospective review of 56 surgical IDU-IE from 2011 to 2016 at a tertiary care center. Data collected included substances used, documented psychosocial consultations (social work or psychiatry), medications for addiction and evidence of enrollment in a drug rehabilitation program after discharge.Among patients with active drug use (ADU), we compared the 24-month survival of those who received comprehensive addiction treatment, defined as both psychosocial consultation and medications for opioid use disorder to that of those who received partial or no treatment.

RESULTS

Out of 56 patients, 42 (75%, n = 56) received a psychosocial consultation, 23 (41.1%, n = 56) received medications for opioid use disorder and 15 (26.8% n = 56) attended a drug rehabilitation program.Forty-two patients had ADU. Among those, 20 (47.6%, n = 42) received comprehensive addiction treatment, while 28 (52.4%, n = 42) received partial or no treatment, and 10 (23.8%, n = 42) attended drug rehabilitation. Most patients with ADU who attended drug rehabilitation (9, 90%) had received comprehensive addiction treatment. All patients with ADU who received comprehensive addiction treatment were alive after 24-months, while 7 patients (25%, n = 28) who received partial or no treatment were not.

CONCLUSION

Addiction treatment was inconsistent for surgical IDU-IE patients. Comprehensive addiction treatment predicted drug rehabilitation attendance, and was protective against 24-month mortality. Implementing protocols for comprehensive perioperative addiction treatment in IDU-IE patients is of the utmost importance.

Rural-urban differences in hospitalizations for opioid use-associated infective endocarditis in Kentucky, 2016-2019

PURPOSE

In 2016, the US rate of opioid use-associated infective endocarditis (OUA IE) hospitalizations was 3.86/100,000 for rural and 3.49/100,000 for urban residents. This study estimates the Kentucky OUA IE hospitalization rates, 2016-2019, describing differences in rural-urban residency trends, demographics, relevant comorbidities, and discharge disposition. OUA IE hospitalization rates between counties with and without syringe services programs (SSPs) are also compared.

METHODS

We used Kentucky statewide inpatient discharge records from 2016 to 2019. An OUA IE hospitalization was identified by an infective endocarditis discharge diagnosis in any diagnosis field and a concurrent diagnosis indicating opioid use. Rurality was determined based on the 2013 Rural-Urban Continuum Codes (RUCC).

FINDINGS

Kentucky's rate of OUA IE hospitalizations in 2016 was 8.9/100,000, with no significant variation between rural and urban residents. By 2019, the average rate for urban residents doubled to 17.9/100,000, significantly higher than the rural resident rate, 13.2/100,000. There were no significant rural-urban differences in percentages of those with concurrent diagnoses of HIV (<1%) or HCV (>60%). Counties that established SSPs in 2017-2018 had a 39.4% increase in OUA IE rates from 2016 to 2019, while counties without SSPs had a 79.5% increase.

CONCLUSION

The estimated 2016 Kentucky rates of OUA IE hospitalizations are 2 times higher than reported national rates, highlighting Kentucky as one of the areas most affected by this particular opioid use disorder complication. Despite challenges and barriers to the effectiveness of SSPs as a harm reduction measure, our study suggests a positive effect that should be further investigated.

Cardiac surgeons' practices and attitudes toward addiction care for patients with substance use disorders

INTRODUCTION

Rates of injection-drug use associated infective endocarditis (IDU-IE) are rising, and most patients with IDU-IE do not receive addiction care during hospitalization. We sought to characterize cardiac surgeons' practices and attitudes toward patients with IDU-IE due to their integral role treating them.

METHODS

This is a survey of 201 cardiac surgeons in the U.S who were asked about the addiction care they engage for patients with IDU-IE along with questions pertaining to stigma against people who use drugs (PWUD). Descriptive statistics and multivariable logistic regression were used to identify patterns in surgeons' practices and determine associations between attitudes toward substance use disorder (SUD) and beliefs about medications for opioid use disorder (MOUD).

RESULTS

A minority of surgeons have access to specialty addiction services (35%) in their hospital, but when available 93% consult them for patients with IDU-IE. A quarter of surgeons reported thinking that SUD is a choice and do not believe MOUD have a role in reducing IDU-IE recurrence. Conversely, 69% of surgeons agreed with the disease model of addiction and were four times more likely to believe that MOUD has a role in reducing IDU-IE recurrence (aOR 4.09, 95% CI 1.8-9.27, p = 0.001).

CONCLUSION

Access to addiction specialists is limited in most hospital settings, but when available, most surgeons report consulting them and supporting MOUD. However, a significant proportion of surgeons hold non-evidence-based attitudes toward SUD and PWUD. This suggests that lack of education and stigma may affect the care of patients with IDU-IE, highlighting the need for education about, and destigmatization of addiction within health systems.

Skin-cleaning among hospitalized people who inject drugs: a randomized controlled trial

AIMS

To test the hypothesis that among hospitalized people who inject drugs (PWID), a brief intervention in skin-cleaning would result in greater reductions in follow-up emergency department (ED) or hospitalization rates compared with a usual care condition.

DESIGN

Randomized, two-group (intervention, n = 128; usual care, n = 124), single-site clinical trial with12-month follow-up.

SETTING

Hospital inpatient services in Boston, Massachusetts, United States.

PARTICIPANTS

People who injected drugs on at least 3 days each week prior to hospital admission (n = 252). Participants averaged 37.9 (± 10.7) years of age; 58.5% were male, 59.3% were white and 61.1% had a diagnosis related to skin infection at enrollment.

INTERVENTION AND COMPARATOR

Intervention was a skin hygiene education and skills-training behavioral intervention [short-term efficacy data on a behavioral intervention (SKIN)] consisting of two education- and skills-based skin-cleaning sessions, one during hospitalization and another 4 weeks later. The comparator was treatment as usual: an informational brochure about substance use treatment options and needle exchange programs in the area and follow-up clinical appointments as arranged by the inpatient medical staff.

MEASUREMENTS

Electronic medical records were reviewed and discharge diagnoses for each ED visit and hospital admission were categorized into injection-related bacterial events (e.g. cellulitis) and non-injection-related events. Negative binomial regression was used to test the intervention effects for the primary outcome and total ED visits, as well as the secondary outcomes, total number of hospitalizations, injection drug use-related (IDU-related) ED visits and IDU-related hospitalizations. We also tested whether the outcomes were moderated by whether the initial hospitalization was IDU-related.

FINDINGS

Of people assigned to SKIN, 66 completed two sessions, 55 completed one session and seven completed zero sessions. Adjusting for baseline covariates, the mean rate of total ED visits in the next 12 months was non-significantly higher [incidence rate ratio (IRR) = 1.13, 95% confidence interval (CI) = 0.96, 1.33, P = 0.152] compared with usual treatment. The intervention did not significantly reduce total hospitalizations or IDU-related hospitalizations. Adjusting for baseline covariates, the mean rate of injection drug use-related ED visits in the next 12 months was lower (IRR = 0.57, 95% CI = 0.35, 0.91, P = 0.019) compared with treatment as usual.

CONCLUSIONS

A skin-cleaning intervention for people who inject drugs delivered during a hospitalization did not significantly reduce either overall emergency department use or hospitalization. There was some evidence that it may have reduced injection drug use-related emergency department visits.

Surgical treatment of infective endocarditis in intravenous drug abusers

Background

Despite current progress in antibiotic therapy and medical management, infective endocarditis remains a serious condition presenting with high mortality rates. It also is a life-threatening complication in patients with a history of chronic intravenous drug abuse. In this study, we analyzed our institutional experience on the surgical therapy of infective endocarditis in patients with active intravenous drug abuse. The aim of the study is to identify the predictive factors of mortality and morbidity in this subgroup of patients.

Methods

Between 2007 and 2020, a total of 24 patients (7 female, mean age 38.5 ± 8.7) presenting with active intravenous drug abuse underwent a surgical treatment for the infective endocarditis at out center. The primary endpoint was survival at 30th day after the surgery. The secondary composite endpoint included freedom from death, recurrent endocarditis, re-do surgery, and postoperative stroke during the follow-up period. Mean follow-up was 4.2 ± 4.3 years.

Results

Staphylococcus species was the most common pathogen detected in the preoperative blood cultures. Infection caused by Enterococcus species as well as liver function impairment were identified as mortality predictor factors. Logistic EuroSCORE and EusoSCORE-II were also predictive factors for mortality in univariate analysis. Survival at 1 and 3 years was 78 and 72% respectively. Thirty-day survival was 88%. 30-day freedom from combined endpoint was 83% and after 1 and 3 years, 69 and 58% of the patients respectively were free from combined endpoint. Five patients (20.8%) were readmitted with recurrent infective endocarditis.

Conclusion

In patients presenting with active intravenous drug abuse, treatment of infective endocarditis should be performed as aggressively as possible and should be followed by antibiotic therapy to avoid high mortality rates and recurrent endocarditis. Early intervention is advisable in patients with an infective endocarditis and enterococcus species in the preoperative blood cultures, liver function deterioration as well as cardiac function impairment. Attention should be also payed to addiction treatment, due to the elevated relapse rate in patients who actively inject drugs. However, larger prospective studies are necessary to support our results. As septic shock is the most frequent cause of death, new treatment options, e.g. blood purification should be evaluated.

Misclassification Error-Adjusted Prevalence of Injection Drug Use Among Infective Endocarditis Hospitalizations in the United States: A Serial Cross-Sectional Analysis of the 2007-2016 National Inpatient Sample

Administrative health databases have been used to monitor trends in infective endocarditis hospitalization related to nonprescription injection drug use (IDU) using International Classification of Diseases (ICD) code algorithms. Because no ICD code for IDU exists, drug dependence and hepatitis C virus (HCV) have been used as surrogate measures for IDU, making misclassification error (ME) a threat to the accuracy of existing estimates. In a serial cross-sectional analysis, we compared the unadjusted and ME-adjusted prevalences of IDU among 70,899 unweighted endocarditis hospitalizations in the 2007-2016 National Inpatient Sample. The unadjusted prevalence of IDU was estimated with a drug algorithm, an HCV algorithm, and a combination algorithm (drug and HCV). Bayesian latent class models were used to estimate the median IDU prevalence and 95% Bayesian credible intervals and ICD algorithm sensitivity and specificity. Sex- and age group-stratified IDU prevalences were also estimated. Compared with the misclassification-adjusted prevalence, unadjusted estimates were lower using the drug algorithm and higher using the combination algorithm. The median ME-adjusted IDU prevalence increased from 9.7% (95% Bayesian credible interval (BCI): 6.3, 14.8) in 2008 to 32.5% (95% BCI: 26.5, 38.2) in 2016. Among persons aged 18-34 years, IDU prevalence was higher in females than in males. ME adjustment in ICD-based studies of injection-related endocarditis is recommended.

A qualitative assessment of discharge against medical advice among patients hospitalized for injection-related bacterial infections in West Virginia

BACKGROUND

The incidence of infective endocarditis (IE) and other systemic bacterial infections is increasing, and people who inject drugs (PWID) have higher rates of discharge against medical advice (AMA) for these infections than patients whose infections are not injection-related. In this study, we characterize factors that contribute to AMA hospital discharge among PWID.

METHODS

We conducted qualitative interviews with twenty PWID hospitalized with serious injection-related bacterial infections in West Virginia. Participants completed a brief survey and in-depth qualitative interview. Interviews were recorded and transcribed verbatim and analyzed using a codebook developed based on deductive and inductive thematic analysis. We also conducted medical records abstraction and used descriptive statistics to summarize medical and survey data.

RESULTS

Average age was 34 years, 55% were female, 95% identified as white, and 75% had a primary diagnosis of IE. Drugs injected prior to hospitalization were methamphetamine (60%), prescription opioids (38%), and/or heroin/fentanyl (25%). Participants cited multiple contributors to AMA discharge including negative interactions with hospital staff that they perceived as stigmatizing, including being searched or monitored for illicit drug use; inadequate management of pain and withdrawal; boredom and confinement during lengthy hospitalizations; and isolation from family and other social supports.

CONCLUSION

We identified multiple factors contributing to AMA discharge that are amenable to intervention. Given the significant morbidity, mortality, and financial costs associated with hospitalizing PWID for serious injection-related bacterial infections, hospitals should be highly motivated to develop and test interventions designed to improve outcomes among these patients.

Not Just Endocarditis: Hospitalizations for Selected Invasive Infections Among Persons With Opioid and Stimulant Use Diagnoses-North Carolina, 2010-2018

BACKGROUND

While increases in overdoses, viral hepatitis, and endocarditis associated with drug use have been well-documented in North Carolina, the full scope of invasive drug-related infections (IDRIs) has not. We characterized trends in IDRIs among hospitalized patients in North Carolina.

METHODS

We compared invasive infections that were related or not related to drug use among hospitalized patients aged 18-55 years based on retrospective review of administrative records from 2010-2018. Hospitalizations for endocarditis, central nervous system/spine infections, osteomyelitis, and septic arthritis were labeled as IDRIs if discharge codes included opioid and/or amphetamine misuse. Trends, rates, and distributions were calculated.

RESULTS

Among 44 851 hospitalizations for the specified infections, 2830 (6.3%) were IDRIs. The proportion of infections attributable to drug use increased from 1.5% (2010) to 13.1% (2018), and the rate grew from 1.2 to 15.1 per 100 000. Compared with those who had non-drug-related infections, patients with IDRIs were younger (median age, 35 vs 46 years), more likely to be non-Hispanic white (81% vs 56%), and had longer hospitalizations (median, 8 vs 6 days). 43% of hospitalizations for IDRIs involved infective endocarditis.

CONCLUSIONS

The rate of IDRIs in North Carolina increased substantially during 2010-2018, indicating an urgent need for enhanced infection prevention, harm reduction, and addiction services aimed at community and inpatient settings.

A Comparison of Medication for Opioid Use Disorder Treatment Strategies for Persons Who Inject Drugs With Invasive Bacterial and Fungal Infections

BACKGROUND

Patients with opioid use disorder (OUD) are frequently admitted for invasive infections. Medications for OUD (MOUD) may improve outcomes in hospitalized patients.

METHODS

In this retrospective cohort of 220 admissions to a tertiary care center for invasive infections due to OUD, we compared 4 MOUD treatment strategies: methadone, buprenorphine, methadone taper for detoxification, and no medication to determine whether there were differences in parenteral antibiotic completion and readmission rates.

RESULTS

The MOUDs were associated with increased completion of parenteral antimicrobial therapy (64.08% vs 46.15%; odds ratio [OR] = 2.08; 95% CI, 1.23-3.61). On multivariate analysis, use of MOUD maintenance with either buprenorphine (OR = 0.38; 95% CI, .17-.85) or methadone maintenance (OR = 0.43; 95% CI, .20-.94) and continuation of MOUD on discharge (OR = 0.35; 95% CI, .18-.67) was associated with lower 90-day readmissions. In contrast, use of methadone for detoxification followed by tapering of the medication without continuation on discharge was not associated with decreased readmissions (OR = 1.87; 95% CI, .62-5.10).

CONCLUSIONS

Long-term MOUDs, regardless of selection, are an integral component of care in patients hospitalized with OUD-related infections. Patients with OUD should have arrangements made for MOUDs to be continued after discharge, and MOUDs should not be discontinued before discharge.

Evolution of epidemiological characteristics of infective endocarditis in Greece

OBJECTIVE

The clinical profile, management and outcome of infective endocarditis (IE) may be influenced by socioeconomic issues.

METHODS

A nationwide prospective study evaluated IE during the era of deep economic crisis in Greece. Epidemiological data and factors associated with 60-day mortality were analyzed through descriptive statistics, logistic and Cox-regression models.

RESULTS

Among 224 patients (male 72.3%, mean age 62.4 years), Staphylococcus aureus (n = 62; methicillin-resistant S. aureus (MRSA) 33.8%) predominated in the young without impact on mortality (p = 0.593), whilst Enterococci (n = 36) predominated in the elderly. Complications of IE were associated with mortality: heart failure [OR 2.415 (95% CI: 1.159-5.029), p = 0.019], stroke [OR 3.206 (95% CI: 1.190-8.632), p = 0.018] and acute kidney injury [OR 2.283 (95% CI: 1.085-4.805), p = 0.029]. A 60-day survival benefit was solely related to cardiac surgery for IE during hospitalization [HR 0.386 (95% CI: 0.165-0.903), p = 0.028] and compliance with antimicrobial treatment guidelines [HR 0.487 (95% CI: 0.259-0.916), p = 0.026]. Compared with a previous country cohort study, history of rheumatic fever and native valve predisposition had declined, whilst underlying renal disease and right-sided IE had increased (p < 0.0001); HIV infection had emerged (p = 0.002). No difference in rates of surgery and outcome was assessed.

CONCLUSIONS

A country-wide survey of IE highlighted emergence of HIV, right-sided IE and predominance of MRSA in the youth during a severe socioeconomic crisis. Compliance with treatment guidelines promoted survival.