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

Peripheral vascular emboli in patients with infective endocarditis are common

OBJECTIVE

Infective endocarditis (IE) is associated with significant morbidity and mortality and places patients at risk for subsequent peripheral vascular emboli. Our goals were to analyze the incidence of peripheral emboli and their associated complications and outcomes.

METHODS

A retrospective single-center review of all patients with IE from 2013 through 2021 was performed. Patients with IE who had peripheral vascular emboli were identified, and their clinical characteristics and outcomes were analyzed.

RESULTS

Overall, 525 patients with IE were identified, and of these, 14.3% had peripheral emboli. In patients with peripheral emboli, the average age was 47 years, and 58.7% were of male gender; race composition included 56% White and 24% Black patients. Comorbidities included hypertension (49.3%), congestive heart failure (30.7%), prior valve replacement/repair (26.7%), and diabetes (24%). Intravenous drug use (62.7%) was the most common cause of IE, followed by non-dental infectious sources (16%), an indwelling catheter (6.7%), or dental infection (4%). Valve distribution was mitral (45.3%), aortic (28%), and tricuspid (24%). Gram-positive organisms, including methicillin-resistant Staphylococcus aureus (30.7%) and methicillin-susceptible Staphylococcus aureus (25.3%), were the most commonly identified bacteria, and Candida was identified in 6.7% of patients. Splenic (57.3%; n = 43) and renal (32%; n = 24) arteries were the most common locations for peripheral vascular emboli, followed by lower (28%; n = 21) and upper extremity (2.7%; n = 2) arteries. Cerebrovascular emboli occurred concurrently in 20 patients (26.7%) with other peripheral emboli. The most common locations for embolism that underwent an intervention were the common femoral (54.4%), superficial femoral (54.4%), popliteal (36.4%), tibial (27.3%), deep femoral (27.3%), peroneal (9.1%), superior mesenteric (SMA) (9.1%), and brachial (9.1%) arteries. Although open surgical embolectomy (81.8%) was the most common intervention, one patient underwent an endovascular intervention. Other interventions included two lower extremity amputations (one primary and one after embolectomy), one infrapopliteal bypass for a popliteal artery occlusion, and an attempted SMA embolectomy stopped due to cardiac arrest. One patient with splenic and cerebrovascular emboli had a mycotic thoracic aneurysm, which was deemed nonoperative. At 30 days, 1 year, and 5 years, 92%, 83%, and 65% of patients with IE survived, respectively; among those with IE and peripheral emboli, 86%, 71%, and 43% of patients survived, respectively (P = .01). Those who underwent peripheral vascular interventions had a 1- and 5-year survival of 45.5% and 36.6%, respectively.

CONCLUSIONS

Peripheral vascular emboli are common in patients with IE and frequently occur in association with cerebral embolic events. Overall morbidity and mortality are high in this young population, in particular for those undergoing interventions.

Trends of infective endocarditis mortality in young adult population of US: A concerning rise and its association with substance abuse

Background

Substance Abuse (SA) is associated with Infective Endocarditis (IE) morbidity and mortality in the young adult population of the US. However, limited data is available for trends and disparities related to IE mortality and its association with SA in the young adult US population.

Methods

Data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research were analyzed from 1999 to 2022 for IE and SA-IE-related mortality in young adults aged 15 to 44 in the US. Age-adjusted mortality rates (AAMR) per 1000,000 people were used to calculate annual percent changes (APC) using Joinpoint regression analysis. Trends were stratified by sex, race/ethnicity, age groups, census region, urbanization classification, and states.

Results

IE caused 22,614 deaths in the young adult population of the US between 1999 and 2022. 7235 (32.0 %) of these deaths were associated with SA. AAMR for IE-associated mortality initially decreased from 6.2 in 1999 to 4.7 in 2010. Following that it increased by almost 3 folds to reach 13.5 in 2020 and 2021. SA-IE followed a similar trend, increasing more than 5 folds from an AAMR of 1.0 in 2010 to 5.4 by 2018. Between 1999 and 2009, 15-22 % of all IE deaths were associated with SA annually, which increased to >40 % for 2016-2022. Men had higher AAMR for IE though women witnessed a bigger jump in SA-associated IE mortality. Non-Hispanic American Indian or Alaskan natives, South region, and rural population had a worse increase.

Conclusions

IE mortality in the young adult population of the US has increased from 2010 onwards with a concerning rise in SA and IE-associated deaths.

Clinical, microbiological and laboratory predictors of on- and off-label dalbavancin treatment failure

BACKGROUND

Data about risk factors for treatment failure (TF) to dalbavancin are lacking. Our aim was to investigate the clinical, microbiological and laboratory predictors of TF in both on- and off-label dalbavancin treatments.

METHODS

We included all patients who received at least one dose of dalbavancin at our center from January 2018 to June 2024 and with available data on follow-up, collecting all clinical and laboratory parameters. TF was defined as the need for readmission, emergency department access, or death within 90 days after treatment. Factors correlating with TF and mortality rate were assessed by multivariable analyses and Kaplan Meier curves.

RESULTS

Three-hundred-fifty-one patients were included, mostly males (60.9%), median age of 64 years (IQR:49.5-75.5), 55.3% receiving dalbavancin in the emergency department/outpatient setting, and 44.7% for an early discharge, in 54.9% cases as off-label. The main off-label indications were osteomyelitis, prosthetic infections, and endocarditis (17.1%, 8.3%, and 7.7%). In 53.3% cases, a microbiological isolate was available (MRSA in 49.2% cases). Overall, TF rate was 19.4%. Overall, multivariable analysis showed that intravenous drug use (HR:7.99, p<0.001), diabetes (HR:6.1, p<0.001), obesity (HR: 4.5, p<0.001), cancer (HR:5.3, p<0.001), HIV (HR:4.88, p<0.001), levels of CRP at dalbavancin treatment initiation (HR=1.01, p<0.001, and HR=0.72, p=0.02) were associated with TF. Additionally, the duration of intravenous antibiotic therapy before being discharged influenced outcomes in the off-label group (HR=0.52, p=0.02).

CONCLUSION

The observed TF rate was high, particularly in the off-label uses and among individuals with multiple comorbidities or intravenous drug use. More evidences are needed to better define the optimal patient profile for effective dalbavancin treatment.

Comparison of Outcomes of Percutaneous Mechanical Aspiration vs Tricuspid Valve Surgery in Drug Use-Associated Endocarditis of the Tricuspid Valve

Background

People who inject drugs (PWID) and present with infective endocarditis (IE) of the tricuspid valve may need valve surgery due to persistent infection, heart failure, or embolic risk. Vacuum-assisted percutaneous mechanical aspiration (PMA) has been proposed as a potential option for those who cannot undergo surgery.

Methods

We queried TriNetX, a database that provides access to electronic medical record data across health care organizations, to identify PWID who had tricuspid valve IE and underwent PMA between 2016 and 2024, using diagnostic and procedure codes. Short-term procedural and clinical outcomes were compared with PWID who underwent tricuspid valve surgery.

Results

In total, 129 patients underwent the PMA procedure and 952 had valve surgery. A higher proportion of the PMA cohort was female (66% vs 57%) and of non-White race (32% vs 22.5%). At 1 month postprocedure, the surgical group had a lower rate of death (2.5% vs 7.9%, P = .001), while the PMA group had a lower risk of heart block or need for pacemaker implantation (0% vs 4%). After propensity matching between groups, these differences were not significant. At 1 year postprocedure, groups had similar rates of heart failure, tricuspid insufficiency, or offer of treatment intervention for opioid use disorder.

Conclusions

Short-term outcomes seem comparable between PMA and tricuspid valve surgery in tricuspid valve IE in PWID. Additional studies with larger cohort numbers are needed to further evaluate the difference in long-term postoperative outcomes between the groups.

Development of a Patient and Clinician Informed Website on Injection Drug Use Related Infective Endocarditis

BACKGROUND

Few patient-facing educational materials and interventions exist for the prevention of injection drug use-related infective endocarditis (IDU-IE). We developed a patient and clinician-informed website for patients about IDU-IE to promote education and prevention strategies.

METHODS

This mixed-methods study integrated surveys and semi-structured interviews with patients and clinician to develop a patient website about IDU-IE. Patient participants included hospitalized adults with an opioid use disorder, history of injection drug use, and an injection drug use-related infection. Interprofessional healthcare clinicians including trainees participated. A baseline survey and semi-structured interviews were conducted with patients to understand knowledge of IDU-IE and preferences in educational materials content and format. Interviews were analyzed using rapid qualitative analysis. Results informed development of the patient website. Finally, patients and clinicians provided 2 rounds of survey feedback after reviewing the website, assessing the likelihood of using and recommending it to others, helpfulness of information in the website sections, and content satisfaction.

RESULTS

Patient participants (n = 15) reported low baseline understanding of injection practice and risk of IDU-IE. After reviewing the website (n = 17), patients reported they were very likely to recommend the website as a reference for themselves (mean of 4.3; 4 = very likely) and for others (mean = 4.3). They found the following sections, on average, to be very helpful (4 = very helpful): complications from injection drug use (4.4), safer injection practice (4.4), and information about infective endocarditis (4.4). Patients on average were satisfied with the website content overall (4.8). Clinicians (n = 27) reported, on average, being very likely to recommend this website to a patient (4.4) and to use the website to counsel patients (4.1).

CONCLUSIONS

A patient and clinician-informed website on IDU-IE is acceptable for patients and clinicians to use as a patient education resource to help prevent IDU-IE-related harms.

Caring for Patients With Injection Drug Use-Associated Infective Endocarditis at the End of Life: A Modified Photo-Elicitation Phenomenological Study

Admissions for patients with injection drug use-associated infective endocarditis are increasing. Injection drug use-associated infective endocarditis is a serious and often fatal cardiac infection. Nurses are often frustrated when caring for these patients because these care assignments are physically and emotionally demanding. Nurses feel helpless, as they disposition young patients to a funeral homes, morgue, or hospice, or send them home to die, and yet a dearth of information regarding end-of-life care for injection drug use-associated infective endocarditis patients remains. This study explored the lived experiential impact these experiences have on nurses. The method was interpretive and participatory, a modified photo-elicitation phenomenological design. Twenty-nine nurses recruited by purposive sampling took photographs and wrote reflections, with 5 participating in an optional unstructured interview conducted by the author. Three themes emerged from the data that elucidated these experiences as (1) a "heartbreaking" experience to witness, (2) an "exhausting" experience to endure, and (3) a practice-altering experience that transforms. Data analysis reveals that nurses experience intense pain, exhaustion, and, yet, transformation, both negative and positive. Implications for nurses include the need for end-of-life education, formal debriefing process to mitigate turnover, and future research into nature-based therapies to help nurses process trauma, as a form of self-care.

Risk Factors for Infective Endocarditis and Serious Injection Related Infections Among People Who Inject Drugs in Los Angeles, CA and Denver, CO

BACKGROUND

Injection drug use-related infective endocarditis (IDU-IE) and bacterial infections have grown in the United States, but little is known about risk factors for these infections in community samples of people who inject drugs (PWID).

METHODS

During 2021-22, PWID were recruited from community settings and surveyed for history of IDU-IE, serious injection related symptoms (SIRI) and untreated infection symptoms in the last 3 months. We used bivariate analysis and multiple logistic regression to examine factors associated with these outcomes.

RESULTS

Among participants (n = 472), 7 % reported ever having IDU-IE, 14 % reported having SIRI symptoms and 20 % reported untreated infection symptoms in the last 3 months. Ever having IDU-IE was associated with HCV (adjusted odds ratio [AOR]=8.37; 95 % confidence interval [CI]=2.46, 28.49), prior MRSA infection (AOR=5.37; 95 % CI=2.44, 11.80), identifying as female and/or gender minority person (AOR=3.14; 95 % CI=1.42, 6.95). SIRI symptoms were associated with greater material hardship (compared to low; AOR=2.47; 95 % CI=1.17, 5.22), fentanyl use (AOR=2.15; 95 % CI=1.01, 4.61), sharing filter/cotton (AOR=1.93; 95 % CI=1.10, 3.39), and licking needle prior to injection (AOR=1.85; 95 % CI=1.02, 3.36). Untreated infection symptoms were associated with poor quality sleep (AOR=2.04; 95 % CI=1.21, 3.43), any mental health diagnoses (AOR=2.01; 95 % CI=3.56), any chronic pain (AOR=1.89; 95 % CI=1.14, 3.11), sharing filters (AOR=1.81; 95 % CI=1.10, 2.98), and prior MRSA infection (AOR=1.75; 95 % CI=1.04, 2.97).

CONCLUSION

Risk factors identified include treatable co-morbidities (i.e., HCV & MRSA history, mental health, pain, opioid use), modifiable health behaviors (i.e., equipment sharing, needle-licking), and addressable structural conditions (material hardship, housing).

Pilot Findings From the First Legalized Mobile Retail Pharmacy Clinic in the United States for Infectious Disease Treatment and Prevention Tailored to Reach People Who Use Drugs

Background

Mobile retail pharmacies were legalized in Connecticut in 2023 to provide primary care, human immunodeficiency virus (HIV) and hepatitis C virus (HCV) testing, preexposure prophylaxis (PrEP), immediate HIV antiretroviral therapy (ART), and medications for substance use disorders directly to people who use drugs (PWUD).

Methods

InMOTION mobile pharmacy and clinic (MPC) pilot findings describe services provided by pharmacists, clinicians, and community health workers.

Results

From 13 December 2023 through 5 November 2024, the MPC engaged with 414 participants, of whom 43% were female, 26% Black/African American, 32% uninsured, and 37% unhoused or unstably housed. Fifty-one had a previous diagnosis of an opioid use disorder (OUD), 163 accepted screening, 1 received a new diagnosis of moderate to severe OUD, and 37 received medication for OUD. Nine participants requested sexually transmitted infection testing; 3 people had positive results, all were prescribed treatment, and 1 received doxycycline postexposure prophylaxis. Four people had existing HIV diagnoses; 166 accepted rapid point-of-care (POC) testing, resulting in 1 positive test; all received ART (2 oral, 3 injectable); 9 who tested HIV negative accepted PrEP, and 1 accepted the injectable formulation. Twenty-two had known HCV, 157 accepted rapid POC HCV testing, 9 tested positive for HCV antibodies, and 11 underwent HCV viral load (VL) testing; 1 self-cleared, and 8 of 10 with detectable HCV VL received direct-acting antivirals from the MPC. Six were treated for xylazine-related wounds.

Conclusions

Health services delivered through an MPC demonstrate the potential to address healthcare gaps for PWUD and warrant exploration and expansion.

Decision making in surgery: honoring patient autonomy despite high mortality risk in a 36-year-old woman with endocarditis

Infective endocarditis (IE) is a common complication in patients who inject drugs. We present the case of a 36-year-old woman with IE affecting both the aortic and tricuspid valves, along with a cardiac implantable electronic device infection, 11 weeks after combined aortic valve replacement, tricuspid valve replacement, and pacemaker implantation. The patient declined the medically indicated cardiac surgery due to her recent taxing surgical and rehabilitation experiences. Clear preoperative communication was crucial to align the patient's goals with available treatment options. Decision making was achieved through multiple interdisciplinary discussions, fostering openness, and dialog. This case highlights the challenges of surgical decision making and provides a valuable example of a patient-centered approach to informed consent within a multidisciplinary team. Moreover, it demonstrates the successful integration of palliative care into surgical management.

Current trends and challenges in infective endocarditis

PURPOSE OF REVIEW

Infective endocarditis (IE) is a complex disease with increasing global incidence. This review explores recent trends in IE infection patterns, including healthcare-associated IE (HAIE), drug-use-associated IE (DUA-IE), multidrug-resistant organisms (MDROs), and challenges in managing prosthetic valve and device-related infections.

RECENT FINDINGS

Staphylococcus aureus has emerged as the leading cause of IE, especially in HAIE and DUA-IE cases. Increasingly prevalent MDROs, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, pose further clinical challenges. Advances in molecular diagnostics have improved the detection of culture-negative endocarditis. The introduction of the AngioVAC percutaneous aspiration device promises to change the management of right and possibly some left sided IE. Multidisciplinary team management and early surgery have demonstrated improved outcomes including partnerships with psychiatry and addictions services for those with intravenous DUA-IE.

SUMMARY

IE presents significant diagnostic and therapeutic challenges due to evolving infection patterns, MDROs, and HAIE. Early diagnosis using advanced imaging, appropriate early antimicrobial therapy, and multidisciplinary care, including timely surgery, are critical for optimizing patient outcomes.

Managing Recurrent Endocarditis in Substance Use Disorder: The Role of Civil Commitment and Comprehensive Care

BACKGROUND The incidence of drug-induced infectious endocarditis is rapidly rising in the United States. Healthcare providers face different challenges in the management of infectious endocarditis in persons who inject drugs, including addiction relapse, non-compliance with treatment, and the associated social stigma. These factors collectively complicate the management of drug-induced endocarditis, requiring comprehensive strategies that address both the medical condition and the underlying substance use disorder, as well as socio-behavioral aspects of patient care. CASE REPORT We present a case of a 33-year-old woman diagnosed with opioid use disorder and a history of tricuspid valve replacement who was transferred from a local emergency room to a general hospital for septic shock secondary to recurrent drug-induced infectious endocarditis. Psychiatry was consulted on day 13 of the admission after the patient was deemed, "not to be a surgical candidate" for second cardiac valve surgery because of a history of non-compliance and a high risk of drug relapse. Throughout her 4-month inpatient hospitalization, she received multiple forms of voluntary and involuntary treatment. The psychiatry consultation/liaison service played a significant role in the patient's care. She successfully engaged in multiple modalities of treatment that led to undergoing a second heart valve surgery. CONCLUSIONS This case highlights the importance of a multidisciplinary approach in management of infectious endocarditis in persons who inject drugs. The use of a civil commitment can allow for the provision of substance use disorder treatment and optimal medical care to an individual who may have lost hope and have temporarily impaired mental faculties.

I Don't Want to Shoot up the Meth Anymore: Pipe Distribution as a Harm Reduction Service for People Who Use Methamphetamine

BACKGROUND

Methamphetamine use is disproportionately high in rural settings, with rates increasing during the COVID-19 pandemic. While syringe service programs reduce disease transmission among people who inject drugs, limited research exists around the value of smoking equipment, specifically pipes, in minimizing harms associated with rural methamphetamine use.

METHODS

We conducted semi-structured interviews with people who use methamphetamine in rural southern Illinois. Inclusion criteria involved methamphetamine use in the past 30 days. Interview guides explored attitudes and behaviors regarding pipe use practices and pipe access. Interviews were recorded, transcribed, and coded. The data were analyzed for emergent themes using a sequential, deductive process.

RESULTS

Nineteen participants, average age 37.1 (SD + 8.7), were interviewed. 53% were women, and 89% were white. All reported smoking methamphetamine, and 84% reported injecting. Participants reported engaging in smoking instead of injection to decrease wounds, pain, and infections. Smoking enabled some to use socially as opposed to alone, as was typically the case when they injected. Participants expressed interest in pipe distribution through a harm reduction agency. They shared that, were a harm reduction agency to distribute pipes, it would connect people to other services such as HIV testing, naloxone, and safer sex supplies.

CONCLUSIONS

Pipe distribution may function as a harm reduction strategy by decreasing injection and solitary drug use and linking patients to additional services. Given disproportionate methamphetamine use in rural regions, this intervention could specifically address drug-related harms that impact rural populations.

A case report of fungal endocarditis presenting with low back pain as the initial symptom

RATIONALE

Fungal endocarditis (FE) is a rare form of infective endocarditis. Compared to bacterial endocarditis, FE develops more slowly and insidiously, with nonspecific clinical manifestations, making diagnosis more challenging. Cases presenting with low back pain as the initial symptom are exceedingly rare, leading to a high risk of misdiagnosis or delayed diagnosis.

PATIENT CONCERNS

A 61-year-old male was admitted due to recurrent low back pain accompanied by fever for 2 months. He had no history of invasive procedures or immunosuppressive therapy.

DIAGNOSES

The patient was diagnosed with FE.

INTERVENTIONS

The patient underwent surgical treatment, during which the excrescence was removed, and mitral valve replacement was performed. Postoperatively, he received a full course of antifungal therapy.

OUTCOMES

Postoperatively, the patient experienced relief from low back pain and was afebrile. He was discharged after completing antifungal treatment and, upon follow-up after 1 year, had no recurrence of low back pain.

LESSONS

In this case, the patient initially presented with low back pain, which, despite the presence of fever and other signs of infection, did not readily suggest a cardiac etiology. This case highlights the importance of not being misled by superficial symptoms and underscores the need for comprehensive and accurate physical examinations and targeted investigations for proper diagnosis.

A Case of Left-Sided Infective Endocarditis Secondary to Intravenous Drug Use Resulting in Septic Renal Emboli

Methicillin-sensitive Staphylococcus aureus (MSSA) is a gram-positive, coagulase-positive coccus implicated in the pathogenesis of infective endocarditis (IE) due to intravenous drug use (IDU). The tricuspid valve is the most commonly affected valve; however, there is an increased incidence of mitral valve involvement. In this case report, we present a 41-year-old female with no known past medical history but a social history significant for IDU who presented with MSSA bacteremia, sepsis, and IE with vegetations on the mitral valve. This patient had no predisposing immunocompromising conditions; however, her repeated IDU history increased her risks for IE. This patient subsequently developed fatal complications of renal septic emboli. She was treated with broad-spectrum intravenous antibiotics, vancomycin, and ceftriaxone, which was de-escalated to nafcillin following blood culture sensitivity data results. She was ultimately transferred to another facility for surgical management of her condition. We write this case report to bring awareness to this rare but fatal condition and to highlight the presentation of mitral valve vegetations.

A Challenging Case of Isolated Pulmonic Valve Endocarditis With Septic Embolic and High-Grade Bacteremia

Isolated pulmonic valve endocarditis is a rare entity attributed to multiple factors, including lower pressures on the right side of the heart, as well as lower oxygen content of venous blood. Herein, we present a challenging case of isolated pulmonic valve endocarditis complicated with septic emboli and high-grade methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. A 31-year-old female presented to the emergency department with fever, chills, fatigue, left-sided pleuritic pain, shortness of breath, and an 8-pound weight loss for the past two weeks. She is an active intravenous drug user. Notable was a grade four diastolic murmur most prominent on the upper left sternal border. Chest CT with contrast showed multiple pulmonary emboli with cavitating nodules suspicious of a septic etiology. Transthoracic echo revealed an isolated large irregularly shaped (3.0 cm x 1.5 cm) vegetation on the pulmonic valve with moderate-to-severe pulmonary regurgitation. The course was notable for persistent high-grade MSSA bacteremia for a total of 10 days, which was treated with ertapenem and cefazolin. The patient did not undergo valve replacement. Close outpatient follow-up was established with a recommendation to treat with an additional two doses of dalbavancin 1,500 mg one week apart. Isolated pulmonic valve endocarditis is a very rare entity. Prompt recognition of isolated pulmonic valve endocarditis and multidisciplinary management is key to improving outcomes among patients with this extremely rare condition.

Bacillus thuringiensis Bacteremia in a 30-Year-Old Intravenous Drug User: A Report of a Rare Case

Bacillus thuringiensis is a gram-positive bacterium used in agriculture, with rare human infections that typically occur in immunocompromised individuals through environmental exposure. This report discusses the case of a 30-year-old intravenous drug user and polysubstance abuser who developed bacteremia due to Bacillus thuringiensis. The patient originally presented with fever and leg ulcers from injection sites, and he was successfully treated with vancomycin. This case underscores the importance of recognizing atypical pathogens like Bacillus thuringiensis in intravenous drug users, particularly when contaminated drug paraphernalia is involved. Although generally low in virulence, this bacterium can cause systemic infections under certain conditions. Prompt identification and treatment are crucial to prevent complications, highlighting the need for increased clinical awareness and appropriate microbiological investigations in this vulnerable population.

Medication for Opioid Use Disorder After Serious Injection-Related Infections in Massachusetts

Importance

Serious injection-related infections (SIRIs) cause significant morbidity and mortality. Medication for opioid use disorder (MOUD) improves outcomes but is underused. Understanding MOUD treatment after SIRIs could inform interventions to close this gap.

Objectives

To examine rehospitalization, death rates, and MOUD receipt for individuals with SIRIs and to assess characteristics associated with MOUD receipt.

Design, Setting, and Participants

This retrospective cohort study used the Massachusetts Public Health Data Warehouse, which included all individuals with a claim in the All-Payer Claims Database and is linked to individual-level data from multiple government agencies, to assess individuals aged 18 to 64 years with opioid use disorder and hospitalization for endocarditis, osteomyelitis, epidural abscess, septic arthritis, or bloodstream infection (ie, SIRI) between July 1, 2014, and December 31, 2019. Data analysis was performed from November 2021 to May 2023.

Exposure

Demographic and clinical factors potentially associated with posthospitalization MOUD receipt.

Main Outcomes and Measures

The main outcome was MOUD receipt measured weekly in the 12 months after hospitalization. We used zero-inflated negative binomial regression to examine characteristics associated with any MOUD receipt and rates of treatment in the 12 months after hospitalization. Secondary outcomes were receipt of any buprenorphine formulation, methadone, and extended-release naltrexone examined individually.

Results

Among 8769 individuals (mean [SD] age, 43.2 [12.0] years; 5066 [57.8%] male) who survived a SIRI hospitalization, 4305 (49.1%) received MOUD, 5919 (67.5%) were rehospitalized, and 973 (11.1%) died within 12 months. Of those treated with MOUD in the 12 months after hospitalization, the mean (SD) number of MOUD initiations during follow-up was 3.0 (1.7), with 956 of 4305 individuals (22.2%) receiving treatment at least 80% of the time. MOUD treatment after SIRI hospitalization was significantly associated with MOUD in the prior 6 months (buprenorphine: adjusted odds ratio [AOR], 16.51; 95% CI, 13.81-19.74; methadone: AOR, 28.46; 95% CI, 22.41-36.14; or naltrexone: AOR, 2.05; 95% CI, 1.56-2.69). Prior buprenorphine (incident rate ratio [IRR], 1.17; 95% CI, 1.11-1.24) or methadone (IRR, 1.89; 95% CI, 1.79-2.01) use was associated with higher treatment rates after hospitalization, and prior naltrexone use (IRR, 0.86; 95% CI, 0.77-0.95) was associated with lower rates.

Conclusions and Relevance

This study found that in the year after a SIRI hospitalization in Massachusetts, mortality and rehospitalization were common, and only half of patients received MOUD. Treatment with MOUD before a SIRI was associated with posthospitalization MOUD initiation and time receiving MOUD. Efforts are needed to initiate MOUD treatment during SIRI hospitalizations and subsequently retain patients in treatment.

Crossroads of Care: Navigating Injection Drug Use-Associated Endocarditis

Infective endocarditis (IE), with its high morbidity and mortality, is a frequent complication of injection drug use (IDU). We present a case highlighting the complexities in the management of IDU-associated IE (IDU-IE) in a 46-year-old male with active IDU who presented with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia and a large tricuspid valve vegetation. Urgent tricuspid valve surgery was indicated due to the size of the vegetation measuring up to 4 cm, along with recurrent pulmonary septic emboli. The patient underwent an uncomplicated and successful complete vegetectomy, tricuspid valve repair, and completed a 42-day antibiotic course. During the six-week follow-up, he showed complete recovery and maintained successful abstinence from illicit drug use, supported by an addiction medicine specialist. This case underscores the importance of early recognition, appropriate antibiotic therapy, and individualized surgical intervention in optimizing outcomes. Effective management of IE necessitates a multidisciplinary IE team, including addiction medicine specialists. Addressing the underlying substance use disorder (SUD) is crucial to reducing the risk of recurrent IE.

Infective Endocarditis-Characteristics and Prognosis According to the Affected Valves

BACKGROUND

Infective endocarditis (IE) continues to be a disease with high mortality despite medical advances.

OBJECTIVE

The objective of this study was to investigate the characteristics and prognosis of IE according to the affected valves.

MATERIALS AND METHODS

This study was retrospective and single-centered, and it included 270 patients with a diagnosis of IE, for the period 2005-2021, who received treatment at the University Hospital "St. Georgi" in Plovdiv, Bulgaria.

RESULTS

Single-valve IE (SIE) was found in 82.6% (n-223), multivalvular IE (MIE) in 16.66% (n = 45) and device IE (CDRIE) in 0.74% (n = 2) of patients. The most commonly affected valve was the aortic valve, in 44.8% (n = 121). The predominant multivalvular involvement was aortic-mitral valves (AV-MV) (13.7%, n = 37). The patients with tricuspid valve (TV) IE were significantly younger, at 39 (30) years, and were more frequently male (80.8%). Mortality was higher in MIE than in SIE (31.1% vs. 23.8%) and was the highest in multivalve aortic-tricuspid (AV-TV) IE (75%). Early surgery was performed most in AV-MV IE, in 29.7% (n = 11). The Charlson comorbidity index (CCI) was significantly higher in MV 4 (4) and AV 3 (3) vs. TV IE 1 (5) (p = 0.048 and p = 0.011, respectively). Septic shock occurred most frequently in AV-TV involvement (75%; p = 0.0001). The most common causative agents were of the Staphylococcus group. Staphylococcus aureus more often affected TV alone (46.2%, n = 124) vs. AV (9.9%, n = 14; p = 0.0001) and vs. MV (22.6%, n = 17; p = 0.022); Staphylococcus coagulase-negative (CNG) was the prevalent cause of MV IE (22.7%, n = 17) vs. AV-MV (2.7%, n = 1; p = 0.007). Streptococci were represented in a low percentage and only in left-sided IE, more frequently in AV-MV (18.9%, n = 7) vs. AV (6.6%, n = 8; p = 0.025).

CONCLUSIONS

The aortic valve is the most frequently affected valve, as single-valve IE or as multivalve AV-MV, with the predominant causative agents being of the Staphylococcus group. AV-TV IE has the worst prognosis, with the most common complication of septic shock and the highest in-hospital mortality.

A path to recovery for overlooked populations and their unique challenges: integrating rehabilitation in palliative care for patients with substance use disorders

Palliative care is a growing medical specialty focusing on providing compassionate and holistic management for those facing life-threatening diseases. These patients frequently present with physical, functional, emotional, and psychosocial problems that require comprehensive interdisciplinary management. However, there is a substantial opportunity to improve care for patients in palliative care who also have a substance use disorder (SUD). These opportunities include direct provision of SUD treatments by specialist palliative care providers and the integration of physical medicine and rehabilitation services. The purpose of this article is to examine the misunderstood and underutilized interaction between palliative care and SUDs, as well as describing the unique opportunities provided by physical medicine and rehabilitation providers to achieve a patient's palliative care goals and optimize overall quality of life. Substance Use Disorder is a chronic, often relapsing, illness that is relevant to palliative care practice due to the potential for significant morbidity and mortality through organ failure, chronic infections, and overdose syndromes. In traditional palliative care practice, it has been observed that past or current SUD diagnoses are often left untreated, resulting in increased distress, and exacerbating an already complex medical situation. Furthermore, many of these patients also experience physical, functional, or psychosocial changes that, when left untreated, will worsen distress and quality of life. To provide more comprehensive and successful palliative care for patients with SUD, the authors recommend an increased emphasis on specialist palliative care training in SUD management, proactive integration of rehabilitation services into the palliative care team, and consistent advocacy for these steps in various arenas. Combined, these actions can improve the care team's ability to provide a holistic, patient-centered approach that can have substantial positive outcomes for patients, health systems, and society.

Manifestations of Prosthetic Valve Endocarditis: Lessons From Multimodality Imaging and Pathological Correlation

Heart valve replacement has steadily increased over the past decades due to improved surgical mortality, an aging population, and the increasing use of transcatheter valve technology. With these developments, prosthetic valve complications, including prosthetic valve endocarditis, are increasingly encountered. In this review, we aim to characterize the manifestations of prosthetic valve endocarditis using representative case studies from our institution to highlight the advances and contributions of modern multimodality imaging techniques.

Endocarditis, drug use and biological sex: A statewide analysis comparing sex differences in drug use-associated infective endocarditis with other drug-related harms

OBJECTIVES

Hospitalizations for drug use-associated infective endocarditis (DUA-IE) have risen sharply across the United States over the past decade. The sex composition of DUA-IE remains less clear, and studies have indicated a possible shift to more females. We aimed to compare more recent statewide hospitalization rates for DUA-IE in females versus males and contextualize them among other drug-related harms in North Carolina (NC).

METHODS

This study was a retrospective analysis using public health datasets of all NC hospital discharges for infective endocarditis from 2016 to 2020. Drug use-related hospitalizations were identified using ICD-10-CM codes. Discharge rates by year and sex for DUA-IE and non-DUA-IE were calculated and compared to fatal overdoses and acute hepatitis C (HCV). Temporal, demographic, and pregnancy trends were also assessed.

RESULTS

Hospitalizations rates for DUA-IE were 9.7 per 100,000 over the five-year period, and 1.2 times higher among females than males. Females composed 57% of DUA-IE hospitalizations over the period. Conversely, fatal overdose, acute HCV, and non-DUA-IE hospitalization rates were higher among males. Age, county of residence, and pregnancy status did not explain the higher DUA-IE among females.

CONCLUSION

Females now comprise the majority of DUA-IE hospitalizations in NC, unlike other drug-related harms. No clear demographic or geographic associations were found, and further research is needed to explain this phenomenon. Preventing invasive infections among females who inject drugs should be prioritized.

Partial oral versus full intravenous antibiotic treatment of endocarditis in people who inject drugs: A systematic review

Background

Prolonged intravenous (IV) antibiotic therapy may not be optimal for people who inject drugs (PWID) with infective endocarditis (IE) due to unique social and medical needs. The role of partial IV antibiotic therapy with continued oral (PO) antibiotic therapy is unclear.

Methods

A systematic review was performed using EMBASE and MEDLINE databases. Included studies compared PO to IV antibiotic treatment for IE in PWID.

Results

Four studies met eligibility. Observational studies included full IV treatment groups and partial IV, partial PO treatment groups for severe injection-related infections. PWID with IE comprised 41.0%-64.7% of the study populations but outcomes specific to IE were not separately reported. All-cause 90-day readmission rates were comparable between the IV treatment group (27.9%-31.5%) and partial IV, partial PO treatment group (24.8%-32.5%). Ninety-day mortality was non-significantly different between IV treatment (4.9%-10.7%) and partial IV, partial PO treatment groups (2.4%-13.0%). One small randomized clinical trial compared IV oxacillin or vancomycin with gentamicin to PO ciprofloxacin plus rifampin. The cure rates were 91% and 90%, respectively.

Conclusion

There is limited evidence comparing IV treatment to partial IV, partial PO antibiotic treatment in PWID with IE. Observational studies suggest that PO antibiotic therapy after initial IV treatment may be equivalent to full IV treatment alone within specific parameters, but randomized trials are needed to inform recommendations. Substantial clinical and social benefits for PWID and advantages for the health care system will result if PO treatment strategies with equal efficacy can be implemented.

Exploring the Applicability of Pre-Anesthetic Cardiac POCUS in Unexpected Conditions: Could it be Helpful?

Formal preoperative echocardiography has traditionally been recommended when there is substantial cardiovascular disease without recent follow up, unexplained dyspnea, a functional class less than 4 METS or a Duke Activity Status Index less than 34. However, it is important to note that certain patients may present with a variety of cardiac abnormalities due to their preexisting condition or multiple treatments, and these individuals warrant consideration. The objective of pre-anesthetic cardiac POCUS is to provide clinical information in a timely manner. Although it does not aim to replace conventional echocardiography, cardiac POCUS can undoubtedly assist anesthesia practitioners in identifying asymptomatic and potentially hazardous conditions, allowing for more accurate risk allocation and individualized patient care.

Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care

OBJECTIVES

We conducted a pilot randomized controlled trial (RCT) to explore whether a hospital inpatient addiction consult team (Substance Use Treatment and Recovery Team [START]) based on collaborative care was feasible, acceptable to patients, and whether it could improve uptake of medication in the hospital and linkage to care after discharge, as well as reduce substance use and hospital readmission. The START consisted of an addiction medicine specialist and care manager who implemented a motivational and discharge planning intervention.

METHODS

We randomized inpatients age ≥ 18 with a probable alcohol or opioid use disorder to receive START or usual care. We assessed feasibility and acceptability of START and the RCT, and we conducted an intent-to-treat analysis on data from the electronic medical record and patient interviews at baseline and 1-month postdischarge. The study compared RCT outcomes (medication for alcohol or opioid use disorder, linkage to follow-up care after discharge, substance use, hospital readmission) between arms by fitting logistic and linear regression models.

FINDINGS

Of 38 START patients, 97 % met with the addiction medicine specialist and care manager; 89 % received ≥8 of 10 intervention components. All patients receiving START found it to be somewhat or very acceptable. START patients had higher odds of initiating medication during the inpatient stay (OR 6.26, 95 % CI = 2.38-16.48, p < .001) and being linked to follow-up care (OR 5.76, 95 % CI = 1.86-17.86, p < .01) compared to usual care patients (N = 50). The study found no significant differences between groups in drinking or opioid use; patients in both groups reported using fewer substances at the 1-month follow-up.

CONCLUSIONS

Pilot data suggest START and RCT implementation are feasible and acceptable and that START may facilitate medication initiation and linkage to follow-up for inpatients with an alcohol or opioid use disorder. A larger trial should assess effectiveness, covariates, and moderators of intervention effects.

The Impact of Discharge Against Medical Advice on Readmission After Opioid Use Disorder-Associated Infective Endocarditis: a National Cohort Study

BACKGROUND

Hospitalizations for infective endocarditis (IE) associated with opioid use disorder (O-IE) have increased in the USA and have been linked to high rates of discharge against medical advice (DAMA). DAMA represents a truncation of care for a severe infection, yet patient outcomes after DAMA are unknown.

OBJECTIVE

This study aimed to assess readmissions following O-IE and quantify the impact of DAMA on outcomes.

DESIGN

A retrospective study of a nationally representative dataset of persons' inpatient discharges in the USA in 2016 PARTICIPANTS: A total of 6018 weighted persons were discharged for O-IE, stratified by DAMA vs. other discharge statuses. Of these, 1331 (22%) were DAMA.

MAIN MEASURES

The primary outcome of interest was 30-day readmission rates, stratified by discharge type. We also examined the total number of hospitalizations during the year and estimated the effect of DAMA on readmission.

KEY RESULTS

Compared with non-DAMA, those experiencing DAMA were more commonly female, resided in metropolitan areas, lower income, and uninsured. Crude 30-day readmission following DAMA was 50%, compared with 21% for other discharge types. DAMA was strongly associated with readmission in an adjusted logistic regression model (OR 3.72, CI 3.02-4.60). Persons experiencing DAMA more commonly had ≥2 more hospitalizations during the period (31% vs. 18%, p<0.01), and were less frequently readmitted at the same hospital (49% vs 64%, p<0.01).

CONCLUSIONS

DAMA occurs in nearly a quarter of patients hospitalized for O-IE and is strongly associated with short-term readmission. Interventions to address the root causes of premature discharges will enhance O-IE care, reduce hospitalizations and improve outcomes.

Association of Intravenous Drug Use and Length of Stay Following Infective Endocarditis

INTRODUCTION

Intravenous drug use (IVDU) and associated infective endocarditis (IE) has been on the rise in the US since the beginning of the opioid epidemic. IVDU-IE has high morbidity and mortality, and treatment can be lengthy. We aim to quantify the association between IVDU and length of stay (LOS) in IE patients.

METHODS

The National Inpatient Sample database was used to identify IE patients, which was then stratified into IVDU-IE and non-IVDU-IE groups. Weighted values of hospitalizations were used to generate national estimates. Multivariable linear and logistic regression analyses were applied to estimate the effects of IVDU on LOS.

RESULTS

We identified 1,114,257 adult IE patients, among which 123,409 (11.1%) were IVDU-IE. Compared to non-IVDU-IE patients, IVDU-IE patients were younger, had fewer comorbidities, and had an overall longer LOS (median [interquartile range]: 10 [5-20] versus 7 [4-13] d, P < 0.001), with a greater percentage of patients with a LOS longer than 30 d (13.7% versus 5.7%, P < 0.001). After adjusting for multiple demographic and clinical factors, IVDU was independently associated with a 1.25-d increase in LOS (beta-coefficient = 1.25, 95% confidence interval [CI]: 0.95-1.54, P < 0.001) and 35% higher odds of being hospitalized for more than 30 d (odds ratio = 1.35, 95% CI: 1.27-1.44, P < 0.001).

CONCLUSIONS

Among IE patients, being IVDU has associated with a longer LOS and a higher risk of prolonged hospital stay. Steps toward the prevention of IE in the IVDU population should be taken to avoid an undue burden on the healthcare system.

Grayken lessons: the role of an interdisciplinary endocarditis working group in evaluating and optimizing care for a woman with opioid use disorder requiring a second tricuspid valve replacement

BACKGROUND

Injection drug use-related endocarditis is increasingly common among hospitalized patients in the United States, and associated morbidity and mortality are rising.

CASE PRESENTATION

Here we present the case of a 34-year-old woman with severe opioid use disorder and multiple episodes of infective endocarditis requiring prosthetic tricuspid valve replacement, who developed worsening dyspnea on exertion. Her echocardiogram demonstrated severe tricuspid regurgitation with a flail prosthetic valve leaflet, without concurrent endocarditis, necessitating a repeat valve replacement. Her care was overseen by our institution's Endocarditis Working Group, a multidisciplinary team that includes providers from addiction medicine, cardiology, infectious disease, cardiothoracic surgery, and neurocritical care. The team worked together to evaluate her, develop a treatment plan for her substance use disorder in tandem with her other medical conditions, and advocate for her candidacy for valve replacement.

CONCLUSIONS

Multidisciplinary endocarditis teams such as these are important emerging innovations, which have demonstrated improvements in outcomes for patients with infective endocarditis and substance use disorders, and have the potential to reduce bias by promoting standard-of-care treatment.

Mycotic Aneurysms and Recurrent Intracranial Hemorrhages in a Patient With Infective Endocarditis

The increase in the use of IV drugs has been accompanied by an increase in the incidence of infective endocarditis (IE). The clinical picture, vitals, examination, blood cultures, laboratory tests, and imaging can help diagnose IE. The Duke criteria also play a role in the diagnosis of IE. Prolonged antibiotic use and even interventions may be needed in the management of specific cases. Rare complications such as mycotic aneurysms and intracranial hemorrhages can be fatal and must be promptly addressed to prevent loss of life and serve debilitation in these patients.

"I have such a hard time hitting myself, I thought it'd be easier": perspectives of hospitalized patients on injecting drugs into vascular access devices

Background

Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians’ concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms.

Methods

Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually.

Results

A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms.

Conclusions

VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.

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.

An observational study on the use of long acting buprenorphine (ublocade) and a amper resistant PICC for utpatient IV antibiotic administration in atients with serious infections and pioid se isorder; The project

What is STOP OUD?

The STOP OUD project is an observational study on the use of long-acting buprenorphine (Sublocade) and a Tamper resistant PICC clamp for Outpatient IV antibiotic administration in Patients with serious infections and Opioid Use Disorder (STOP OUD).

Background

The US opioid crisis is driving up serious infections related to intravenous drug use. These infections require prolonged courses of antibiotics, often resulting in lengthy hospital stays. Extended hospitalizations for monitored parenteral antibiotics for patients with opioid use disorder are challenging for patients, reduce bed capacity, and are associated with significant cost. This observational study reviews the administration of intravenous (IV) antibiotics in a monitored outpatient setting using long-acting injectable buprenorphine (Sublocade, Indivior Inc., North Chesterfield, VA) and a tamper resistant clamp in patients with opioid use disorder .

Methods

Long-acting buprenorphine and a tamper resistant clamp were used to treat patients with serious infections and opioid use disorder as outpatients.

Results

Hospital days avoided were 30-days per STOP OUD project participant. Eleven of thirteen STOP OUD project participants completed their antibiotic courses as prescribed, there was no evidence of peripherally inserted central catheter (PICC) tampering, and they rated their care as a mean of 4.9/5 (SD 0.4). Institutional savings per STOP OUD patient was $33,000. Outpatient infusion costs were $9,300 for a net savings of $23,700 per STOP OUD project participant. Infections resolved in all participants.

Conclusions

The STOP OUD project reduced hospital length of stay for patients with opioid use disorder and serious infections, and had a favorable financial impact.

Research on substance use disorders during the COVID-19 pandemic

The COVID-19 pandemic has triggered changes in the substance use disorder (SUD) treatment delivery system, in the availability of legal and illicit drugs, and in other social and economic factors. As such, these changes necessitate that the field re-evaluate research approaches to SUDs, including in epidemiology, clinical trials, health services, implementation and policy research, as well as basic and translational neuroscience. COVID-19 has reduced researchers' access to target populations and made it difficult for them to obtain timely data to monitor changes in patterns of drug use and overdoses. These changes have increased researchers' interest in virtual technologies to expand and accelerate access to populations; increased modifications in the design, conduct, and analysis of clinical trials; and increased emphasis on implementation. Similarly, as researchers better understand the biology of COVID-19, they will better understand potential effects of COVID-19 on neurotransmitter receptors and signaling pathways, mechanisms underlying COVID-19 associated neurological and psychiatric sequelae, and interactions between COVID-19 treatments and psychoactive substances. The pandemic has also revealed the need for research that addresses health disparities. Overall, the COVID-19 pandemic has challenged several aspects of current research on SUD. Responding to these challenges provides opportunities to develop robust research approaches that align with the goals of improving patient outcomes and public health and are resilient to the challenges of future crises.