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

Prevalence and predictors of multidrug resistant organism infections in critically ill patients with opioid use disorder: a multicenter retrospective cohort study

OBJECTIVE

Patients with Opioid Use Disorder (OUD) are prone to Multidrug-Resistant Organism (MDRO) colonization and infections, thus at risk for worse outcomes during critical illness. Understanding the prevalence and predictors of MDRO infections is essential to optimize interventions and treatments.

DESIGN

Retrospective cohort study.

METHODS

The study evaluated the prevalence of MDRO isolation among adults with OUD admitted to an intensive care unit (ICU) between January 1, 2018, and July 31, 2023. It included adults admitted to an ICU with bacterial infections and positive cultures obtained within 48 hours of admission. Demographics, clinical traits, and MDRO isolation rates were analyzed using descriptive statistics, univariate methods, and Least Absolute Shrinkage and Selection Operator (LASSO) regression.

RESULTS

MDRO isolation occurred in 178 of 790 patients (22.5%), with methicillin-resistant Staphylococcus aureus as the most frequently isolated organism. LASSO regression identified housing insecurity (OR: 1.79, 95% CI 1.09-2.93, P = .022), no receipt of medications for OUD treatment (OR: 1.56, 95% CI 1.06-2.29, P = .023), positive hepatitis C virus (HCV) status (OR: 2.19, 95% CI 1.19-4.03, P = .012), and intravenous antibiotic use in the prior 90 days (OR: 1.04 per 24 h, 95% CI 1.01-1.07, P = .007) as significant predictors of MDRO isolation.

CONCLUSIONS

The study highlights a high prevalence of MDRO isolation in critically ill OUD patients admitted for infection-related issues with positive cultures obtained within 48 hours of admission, influenced by factors like housing insecurity, no receipt of medications for OUD treatment, HCV status, and prior antibiotic use.

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.

Infective Endocarditis in People Who Inject Drugs-A 5-Year Follow-up: "I've Seen the Needle and the Damage Done"

Background

Infective endocarditis (IE) among people who inject drugs (PWID) has been associated with better short-term outcome. Long-term outcome of PWID with IE is poorly known.

Methods

This retrospective population-based study included PWID with IE and non-PWID adults with community-acquired IE who were diagnosed and treated in Southern Finland between 2013 and 2017 and survived the initial IE episode. All patients were followed for 5 years. Data were collected on drug use, receipt of medications for opioid use disorder (MOUD), survival, and subsequent IE episode during follow-up.

Results

Seventy-five PWID with IE and 98 patients with community-acquired IE were included. Buprenorphine and amphetamine or other stimulant were the most used substances among PWID. Sixteen PWID received MOUD before onset of IE, and 33 received MOUD at the time of discharge. Most PWID (86%) received addiction specialist consultation during the hospitalization. Fifteen patients in the PWID IE group experienced a new IE episode within 5-year follow-up as compared with 5 patients in the non-PWID IE group (odds ratio [OR], 4.65; P = .003). One-year all-cause mortality was 4.0% (3/75) in PWID IE and 4.1% (4/98) in non-PWID IE. Five-year all-cause mortality was 18.7% (14/75) in PWID IE and 13.3% (13/98) in non-PWID IE (P = .399). In multivariate analysis of the whole group, injection drug use (OR, 12.2), female gender (OR, 2.62), and higher age-adjusted comorbidity index were independent factors associated with death during 5-year follow-up.

Conclusions

Long-term survival of PWID with IE is poor, and they are at increased risk of a new IE episode as compared with non-PWID with community-acquired IE. More efforts in the treatment of addiction are needed.

Trends in the Management of Infective Endocarditis for Patients Who Inject Drugs: A Survey of Healthcare Facilities in Tennessee

Background

The current endocarditis management strategies among Tennessee healthcare facilities for people who inject drugs (PWID) were evaluated.

Methods

This was a survey-based study of healthcare facilities that treat infective endocarditis in PWID within Tennessee. The primary outcome of the study was to describe current practice among facilities regarding the treatment of endocarditis in PWID, including approaches to addiction management, antimicrobial therapy, and cardiac surgery.

Results

There were 17 facilities that responded to the survey but only 16 facilities completed the entire survey. Although 15 facilities (88%) responded that they evaluate patients for substance use disorders on admission, only 4 (24%) of those facilities offered addiction consultation service. Regarding antibiotic therapy, most facilities offered completion of intravenous antibiotic course inpatient or at a skilled nursing facility (94% and 75%, respectively). Other treatment options less commonly offered by facilities included: transition to oral antibiotics (56%), use of long-acting lipoglycopeptides (50%), and outpatient parenteral antibiotic therapy (25%). Of the 16 facilities that completed the survey, only 7 performed cardiac surgery and 6 performed catheter-based interventions.

Conclusions

Although most facilities surveyed offered completion of antibiotic therapy either as inpatient or at a skill nursing facility, they were less likely to offer alternative options such as home infusion antibiotics, long-acting antibiotics, or oral antibiotic treatment for endocarditis. Most facilities screened for substance abuse on admission, but few provided addiction services. There may be an opportunity to enhance care for PWID through alternative antibiotic therapies and addiction services.

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.

Ghostly intrusion on a frightful Halloween night: a case report of dual valve endocarditis

Multivalvular endocarditis (MVE) is an uncommon presentation and mostly involves mitral and aortic valves. Here, we present a case of an MVE with an unusual and bizarre presentation on a Halloween night with a massive degree of valve destruction and right- and left-side involvement requiring emergent surgery. A 51-year-old male patient with intravenous drug usage presented with anorexia, fever, and dyspnea, rapidly progressing to septic shock with multiorgan dysfunction. Initial blood cultures detected meticillin-sensitive Staphylococcus aureus, and antibiotic therapy was started. Transesophageal echocardiography revealed extensive valve destruction of both mitral and tricuspid valves, namely a mitral valve with large vegetation resembling a ghostly figure, causing severe mitral regurgitation. The patient was transferred for emergent mitral and tricuspid surgery. The particularity of this case, besides the bizarre images, is that, as a drug user, there are specific considerations regarding surgical strategy and options in this scenario that we discussed here.

Percutaneous Mechanical Aspiration for Infective Endocarditis: Proceedings From an Inaugural Multidisciplinary Summit and Comprehensive Review

The clinical presentation and epidemiology of infective endocarditis (IE) have evolved over time. While the cornerstones of IE treatment remain antimicrobial therapy and surgery, percutaneous mechanical aspiration (PMA) has emerged as an option for carefully selected patients as a complementary modality, based on retrospective data, case series, and expert experience. In this comprehensive review, we summarize the proceedings from an inaugural summit dedicated to the discussion of PMA in the global management of IE, consisting of experts across multiple disciplines from diverse geographic regions and care environments. After conceptualizing the 3 major roles of PMA as a bridge to decision, destination therapy, and adjunctive therapy, we then review the clinical scenarios in which PMA might be considered by IE subtype. We discuss patient selection, the rationale for intervention, and the most recent evidence for each. Next, we consider PMA for IE in the larger context of our health care system across 3 domains: clinical collaboration, financial considerations, and academic innovation, emphasizing the importance of interdisciplinary teams and cross-organizational partnerships, reimbursement models, and the need for high-quality research. Finally, we outline what we determined to be the most pressing outstanding questions in this space. In doing so, we propose a national consortium to help organize efforts to move this field forward and share our progress in these endeavors to date. PMA for IE has great promise, but significant work remains if we are to fully realize its potential to safely and effectively improve outcomes for modern endocarditis patients.

Advancements and Challenges in the Management of Prosthetic Valve Endocarditis: A Review

Prosthetic valve endocarditis (PVE) is the medical term used to describe a focus of infection involving a valvular substitute within the heart. It is a significant concern in the field of cardiology, and the epidemiology of PVE has seen notable developments over the last five decades. The disease currently affects an older demographic and is becoming increasingly prevalent in patients with transcatheter-implanted valves. It is imperative that we urgently address the significant challenges posed by PVE. It is a disease that has a wide range of potential aetiologies, clinical presentations, and courses. In developed countries, Staphylococcus aureus is now the predominant causative organism, resulting in an aggressive form of disease that frequently afflicts vulnerable or elderly populations. However, it is clear that Enterococcus species present a significant challenge in the context of PVE following TAVR procedures, given their elevated prevalence. The 2023 Duke/International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria now include significant developments in microbiological and image-based techniques for diagnostic purposes, specifically the incorporation of fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography. These developments unequivocally enhance the diagnostic sensitivity for PVE, while maintaining the specificity. They do so in accordance with the results of studies conducted specifically for the purpose of validation. The lack of rigorous scientific studies and a shortage of funding and resources for research have led to a significant gap in our understanding. Randomized controlled trials could provide invaluable insight and guidance for clinical practice, but they are missing, which represents a major gap. It is clear that there is an urgent need for more research. PVE is a life-threatening condition that must be handled by a multidisciplinary endocarditis team at a cardiac centre in order to improve outcomes. The emergence of innovative surgical techniques has empowered clinicians to steer more patients away from surgical procedures, despite the presence of clear indications for them. A select group of patients can now complete parenteral or oral antimicrobial treatment at home. Additionally, antibiotic prophylaxis is the best option for individuals with prosthetic valves who are going to have invasive dental procedures. These individuals should be given antibiotics beforehand.

A Bundle of the "Top 10" Outpatient Parenteral Antimicrobial Therapy Publications in 2023

Outpatient parenteral antimicrobial therapy (OPAT) has become more common in infectious diseases practice settings. Similarly, OPAT-related publications have also increased. The objective of this article was to summarize clinically important OPAT-related publications from 2023. Eighty-one articles were found on initial search, with 52 meeting inclusion criteria. A survey containing the 19 articles that had at least 1 citation was sent to an email listserv of multidisciplinary clinicians with OPAT experience. This article summarizes the "top 10" 2023 OPAT articles from the survey results.

Management of People Who Inject Drugs With Serious Injection-Related Infections in an Outpatient Setting: A Scoping Review

Background

People who inject drugs (PWID) are at risk of severe injection-related infection (SIRI), which is challenging to manage. We conducted a scoping review to map the existing evidence on management of PWID with SIRI in an outpatient setting.

Methods

We conducted a literature search in MEDLINE, Embase, Cochrane Central, and CINAHL from their inception until 6 December 2023. Studies were included if they focused on PWID with SIRI requiring ≥2 weeks of antibiotic therapy, with a proportion of management occurring outside hospitals. Studies were categorized inductively and described.

Results

The review included 68 articles with the following themes. PWID generally prefer outpatient management if deemed safe and effective. Most studies support outpatient management, finding it to be as effective and safe as inpatient care, as well as less costly. Successful transition to outpatient management requires multidisciplinary discharge planning with careful consideration of patient-specific factors. Emerging evidence supports the effectiveness and safety of outpatient parenteral antibiotic therapy, long-acting lipoglycopeptides, and oral antibiotic therapy, each having unique advantages and disadvantages. Various specialized outpatient settings, such as skilled nursing facilities and residential treatment centers, are available for management of these infections. Finally, all patients are likely to benefit from adjunctive addiction care.

Conclusions

Emerging evidence indicates that outpatient management is effective and safe for SIRI, which is preferred by most PWID. Key components of outpatient management include multidisciplinary discharge planning, appropriate antibiotic modality, suitable care settings, and adjunctive addiction care. These elements should be carefully tailored to patient needs and circumstances.

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.

Infective Endocarditis Among Women Who Inject Drugs

Importance

In the US and Canada, women comprise approximately one-third of people who inject drugs (PWID); however, clinical characteristics and outcomes of injection drug use complications in women are poorly described.

Objective

To identify clinical characteristics and outcomes of infective endocarditis (IE) among women who inject drugs (WWID).

Design, Setting, and Participants

This is a retrospective cohort study of PWID with definite IE (per 2023 Duke-International Society for Cardiovascular Infectious Diseases criteria) admitted from April 5, 2007, to March 15, 2018, at 5 tertiary-care hospitals in London, Ontario, and Regina, Saskatchewan, Canada. Data were analyzed from June 1, 2023, to August 2, 2024. Descriptive analyses were conducted for baseline characteristics at index hospitalization and stratified by sex.

Main Outcomes and Measures

The primary outcome was the difference in 5-year survival between female and male PWID with IE. The secondary outcome was 1-year survival. Multivariable time-dependent Cox proportional hazards regression analyses were conducted for variables of clinical importance to evaluate 5-year mortality.

Results

Of 430 PWID with IE, 220 (51.2%) were women; of 332 non-PWID with IE, 101 (30.4%) were women. WWID with IE were younger than men (median [IQR] age, 31.5 [27.0-38.5] vs 38.5 [31.0-49.0] years), and 11 of 220 (5.0%) were pregnant at index hospitalization, although only 12 of 220 (5.5%) had contraceptive use documented. Women had a larger proportion of right-sided IE than men (158 of 220 women [71.8%] vs 113 of 210 men [53.8%]). WWID living in urban areas had higher mortality than WWID in rural areas (adjusted hazard ratio [aHR], 2.70; 95% CI, 1.15-6.34; P = .02). Overall mortality was lower among PWID referred for substance use disorder counseling in centers with inpatient services compared with centers with only outpatient referrals (aHR, 0.29; 95% CI, 0.17-0.51; P < .001). Overall mortality was lower with right-sided heart disease for both women (aHR, 0.44; 95% CI, 0.27-0.71; P < .001) and men (aHR, 0.22; 95% CI, 0.10-0.50; P < .001) and was higher with congestive heart failure for both women (aHR, 2.32; 95% CI, 1.29-4.18; P = .005) and men (aHR, 1.73; 95% CI, 1.07-2.79; P = .02).

Conclusions and Relevance

In this cohort of PWID with IE, women were overrepresented. Reasons for women's disproportionately high IE incidence need further study. Inpatient substance use disorder services, contraception counseling, and enhanced social support for WWID living in urban areas need to be prioritized.

REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use

OBJECTIVE

Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, yet operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use.

METHODS

A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement.

RESULTS

Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 (97%) of 75 units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computed tomography angiography being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement.

CONCLUSION

This comprehensive consensus statement provides a strong insight into the standard of care for these patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Navigating Care Refusal and Noncompliance in Patients with Opioid Use Disorder

BACKGROUND

For many emergency physicians (EPs), deciding whether or not to allow a patient suffering the ill effects of opioid use to refuse care is the most frequent and fraught situation in which they encounter issues of decision-making capacity, informed refusal, and autonomy. Despite the frequency of this issue and the well-known impacts of opioid use disorder on decision-making, the medical ethics community has offered little targeted analysis or guidance regarding these situations.

DISCUSSION

As a result, EPs demonstrate significant variability in how they evaluate and respond to them, with highly divergent understandings and application of concepts such as decision-making capacity, informed consent, autonomy, legal repercussions, and strategies to resolve the clinical dilemma. In this paper, we seek to provide more clarity to this issue for the EPs.

CONCLUSIONS

Successfully navigating this issue requires that EPs understand the specific effects that opioid use disorder has on decision-making, and how that in turn bears on the ethical concepts of autonomy, capacity, and informed refusal. Understanding these concepts can lead to helpful strategies to resolve these commonly-encountered dilemmas.

How I manage severe bacterial infections in people who inject drugs

BACKGROUND

Injecting drug use is a risk factor for severe bacterial infection, but there is limited high-quality evidence to guide clinicians providing care to people who inject drugs. Management can be complicated by mistrust, stigma, and competing patient priorities.

OBJECTIVES

To review the management of severe infections in people who inject drugs, using an illustrative clinical scenario of complicated Staphylococcus aureus bloodstream infection.

SOURCES

The discussion is based on recent literature searches of relevant topics. Very few randomized clinical trials have focussed specifically on the management of severe bacterial infections among people who inject drugs. Most recommendations are, therefore, based on observational studies, extrapolation from other patient groups, and the experience and opinions of the authors.

CONTENT

We discuss evidence and options regarding the following management issues for severe bacterial infections among people who inject drugs: initial management of sepsis; indications for surgical management; assessment and management of substance dependence; approaches to antibiotic administration following clinical stability; opportunistic health promotion; and secondary prevention of bacterial infections. Throughout, we highlight the importance of harm reduction and strategies to optimize patient engagement in care through a patient-centred approach.

IMPLICATIONS

We advocate for a multi-disciplinary trauma-informed approach to the management of severe bacterial infection among people who inject drugs. We emphasize the need for pragmatic trials to inform management guidelines, including those that are co-designed with the community. In particular, research is needed to establish the comparative effectiveness, safety, and cost-effectiveness of inpatient intravenous antibiotics vs. early oral antibiotic switch, outpatient parenteral therapy, and long-acting lipoglycopeptide antibiotics in this scenario.

PICC Your Poison: Resident Beliefs and Attitudes Regarding Discharge Parenteral Antibiotics for Patients Who Inject Drugs

Background

Serious injection-related infections (SIRIs) in people who inject drugs often lead to prolonged hospitalizations or premature discharges. This may be in part due to provider reluctance to place peripherally inserted central catheters (PICCs) for outpatient parenteral antibiotic therapy in this population. Because internal medicine (IM) residents are often frontline providers in academic centers, understanding their perspectives on SIRI care is important to improve outcomes.

Methods

We surveyed IM residents in a large urban multicenter hospital system about SIRI care with a novel case-based survey that elicited preferences, comfort, experience, and stigma. The survey was developed using expert review, cognitive interviewing, and pilot testing. Results are reported with descriptive statistics and linear regression.

Results

Of 116 respondents (response rate 34%), most (73%) were uncomfortable discharging a patient with active substance use home with a PICC, but comfortable (87%) with discharge to postacute facilities. Many (∼40%) endorsed high levels of concern for PICC misuse or secondary line infections, but larger numbers cited concerns about home environment (50%) or loss to follow-up (68%). While overall rates were low, higher stigma was associated with more concerns around PICC use (r = -0.3, P = .002). A majority (58%) believed hospital policies against PICC use in SIRI may act as a barrier to discharge, and 74% felt initiation of medications for opioid use disorder (MOUD) would increase their comfort discharging with a PICC.

Conclusions

Most IM residents endorsed high levels of concern about PICC use for SIRI, related to patient outcomes and perceived institutional barriers, but identified MOUD as a mitigating factor.

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.

National HIV and HCV Screening Rates for Hospitalized People who Use Drugs Are Suboptimal and Heterogeneous Across 11 US Hospitals

Background

To end the HIV and hepatitis C virus (HCV) epidemics, people who use drugs (PWUD) need more opportunities for testing. While inpatient hospitalizations are an essential opportunity to test people who use drugs (PWUD) for HIV and HCV, there is limited research on rates of inpatient testing for HIV and HCV among PWUD.

Methods

Eleven hospital sites were included in the study. Each site created a cohort of inpatient encounters associated with injection drug use. From these cohorts, we collected data on HCV and HIV testing rates and HIV testing consent policies from 65 276 PWUD hospitalizations.

Results

Hospitals had average screening rates of 40% for HIV and 32% for HCV, with widespread heterogeneity in screening rates across facilities. State consent laws and opt-out testing policies were not associated with statistically significant differences in HIV screening rates. On average, hospitals that reflexed HCV viral load testing on HCV antibody testing did not have statistically significant differences in HCV viral load testing rates. We found suboptimal testing rates during inpatient encounters for PWUD. As treatment (HIV) and cure (HCV) are necessary to end these epidemics, we need to prioritize understanding and overcoming barriers to testing.

Medications for opioid use disorder associated with reduced readmissions for patients with severe injection-related infections: A matched cohort study

INTRODUCTION

Hospitalizations due to severe injection-related infections (SIRIs) and patient-directed discharge (PDD) in people who inject drugs (PWID) are increasing, but research on readmission outcomes at PDD is limited. In this retrospective, matched cohort study we evaluated predictors of 30-day readmission by discharge status among PWID.

METHODS

Among patients diagnosed with SIRIs at a tertiary hospital, Fisher's exact tests assessed differences in readmission rates by discharge status. Medications for opioid use disorder (MOUD) at discharge was defined as either having a buprenorphine dose dispensed within 24 h of discharge and buprenorphine being included in the discharge summary as a prescription, or a methadone dose dispensed inpatient within 24 h of discharge. Logistic regression analyses evaluated predictors of readmission outcomes.

RESULTS

Among 148 PWID with SIRI diagnosis, 30-day readmission rate following PDD was higher than standard discharge (25.7 % vs. 9.5 %, p = 0.016) and MOUD decreased odds of 30-day readmission (OR = 0.32, 95 % CI: 0.12,0.83, p = 0.012). >7 missed days of antibiotic treatment increased odds of 30-day readmission (OR 4.65, 95 % CI: 1.14, 31.72, p = 0.030) within PDD patients.

CONCLUSIONS

PDD carries higher 30-day readmission rate compared to standard discharge. Strategies to reduce PDD rates and increase MOUD initiation may improve readmission outcomes.

The Clinical Challenge of Prosthetic Valve Endocarditis: JACC Focus Seminar 3/4

During the past 6 decades, there have been numerous changes in prosthetic valve endocarditis (PVE), currently affecting an older population and increasing in incidence in patients with transcatheter-implanted valves. Significant microbiologic (molecular biology) and imaging diagnostic (fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography) advances have been incorporated into the 2023 Duke-International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria, thus increasing the diagnostic sensitivity for PVE without sacrificing specificity in validation studies. PVE is a life-threatening disease requiring management by multidisciplinary endocarditis teams in cardiac centers to improve outcomes. Novel surgical options are now available, and an increasing set of patients may avoid surgical intervention despite indication. Selected patients may complete parenteral or oral antimicrobial treatment at home. Finally, patients with prosthetic valves implanted surgically or by the transcatheter approach are candidates for antibiotic prophylaxis before invasive dental procedures.

Strategies to Improve Patient-Centered Care for Drug Use-Associated Infective Endocarditis: JACC Focus Seminar 2/4

Drug use-associated infective endocarditis (DUA-IE) is a major cause of illness and death for people with substance use disorder (SUD). Investigations to date have largely focused on advancing the care of patients with DUA-IE and included drug use disorder treatment, decisions about surgery, and choice of antibiotics during the period of hospitalization. Transitions from hospital to outpatient care are relatively unstudied and frequently a key factor of uncontrolled infection, continued substance use, and death. In this paper, we review the evidence supporting cross-disciplinary care for people with DUA-IE and highlight domains that need further clinician, institutional, and research investment in clinicians and institutions. We highlight best practices for treating people with DUA-IE, with a focus on addressing health disparities, meeting health-related social needs, and policy changes that can support care for people with DUA-IE in the hospital and when transitioning to the community.

Early Outcomes From a Multicenter Transcatheter Self-Expanding Pulmonary Valve Replacement Registry

BACKGROUND

Transcatheter pulmonary valve replacement (TPVR) with the self-expanding Harmony valve (Medtronic) is an emerging treatment for patients with native or surgically repaired right ventricular outflow tract (RVOT) pulmonary regurgitation (PR). Limited data are available since U.S. Food and Drug Administration approval in 2021.

OBJECTIVES

In this study, the authors sought to evaluate the safety and short-term effectiveness of self-expanding TPVR in a real-world experience.

METHODS

This was a multicenter registry study of consecutive patients with native RVOT PR who underwent TPVR through April 30, 2022, at 11 U.S.

CENTERS

The primary outcome was a composite of hemodynamic dysfunction (PR greater than mild and RVOT mean gradient >30 mm Hg) and RVOT reintervention.

RESULTS

A total of 243 patients underwent TPVR at a median age of 31 years (Q1-Q3: 19-45 years). Cardiac diagnoses were tetralogy of Fallot (71%), valvular pulmonary stenosis (21%), and other (8%). Acute technical success was achieved in all but 1 case. Procedural serious adverse events occurred in 4% of cases, with no device embolization or death. Hospital length of stay was 1 day in 86% of patients. Ventricular arrhythmia prompting treatment occurred in 19% of cases. At a median follow-up of 13 months (Q1-Q3: 8-19 months), 98% of patients had acceptable hemodynamic function. Estimated freedom from the composite clinical outcome was 99% at 1 year and 96% at 2 years. Freedom from TPVR-related endocarditis was 98% at 1 year. Five patients died from COVID-19 (n = 1), unknown causes (n = 2), and bloodstream infection (n = 2).

CONCLUSIONS

In this large multicenter real-world experience, short-term clinical and hemodynamic outcomes of self-expanding TPVR therapy were excellent. Ongoing follow-up of this cohort will provide important insights into long-term outcomes.

Percutaneous Mechanical Aspiration in Infective Endocarditis: Applications, Technical Considerations, and Future Directions

In recent years, there has been a shift in the epidemiology of patients with infective endocarditis (IE). This has been characterized by an alarming increase in IE in patients who inject drugs, cardiac implantable electronic device-related IE, and those with comorbid conditions and high surgical risk. This unmet need has mandated a reevaluation of complex management strategies in these patients and introduction of unconventional approaches in treatment. Percutaneous mechanical aspiration has emerged as both a diagnostic and therapeutic option in selected patients with IE. In this review, the authors discuss the gaps in care of IE, rationale, device armamentarium, procedural, and technical considerations and applications of percutaneous mechanical aspiration in IE.

Standardized order set for the management of infective endocarditis

BACKGROUND

Infective endocarditis (IE) is a potentially life-threatening infection that affects the inner lining of the heart, particularly the heart valves. Patients with preexisting heart conditions, damaged heart valves, or a history of intravenous drug use are at a higher risk of acquiring IE.

LOCAL PROBLEM

A rural acute care facility reported that 68.75% of patients who had a methicillin-resistant Staphylococcus aureus infection were diagnosed with IE. Review of medical records showed that 65% of patients with IE did not have antibiotic start/stop dates and 51% were discharged before the 6-week completion date.

METHODS

The quality-improvement project used a pretest and posttest design. An order set was created based on evidence-based guidelines to assist with the management of patients with IE. The order set included administering intravenous (IV) antibiotics for a minimum of 6 weeks for patients with IE and included a set of recommended weekly follow-up laboratory tests.

INTERVENTIONS

An order set with the standard of care and reminders in the electronic health records (EHRs) were implemented for the management of IE, including antibiotic start and stop dates and weekly follow-up labs.

RESULTS

After implementation, there was an improvement in the completion of IV antibiotics, documentation of start/stop dates for IV antibiotics, and completion of recommended laboratory tests.

CONCLUSIONS

An order set with the standard of care and reminders in the EHR reduced variations in care and improved patient outcomes by ensuring that all providers were following the same evidence-based guidelines for the management of IE.

Infective endocarditis presentations during the COVID-19 pandemic: have they paid an untold toll?

Background: COVID-19 caused restrictions and re-allocation of medical resources among all healthcare services. During the peak of the pandemic, several unrelated-yet critical-conditions had silently taken their toll. Infective endocarditis (IE), owing to its non-specific clinical presentation, may have been largely mislabeled as COVID-19 in a number of cases. Results: This retrospective observational study reviewed all IE presentations at an IE unit in a university hospital during the peak of COVID-19. Patient characteristics, courses, and outcomes were compared with historical controls from our IE database published before the COVID era. We identified 30 IE cases [Group A] during the COVID-19 peak in our region (June 2021 to June 2022), with a 25% decrease compared to the usual annual rate. This is in contrast to the expected surge during the pandemic. Compared with group B (398 published IE cases from our database), group A had significantly longer symptoms-to-presentation intervals (60 [31-92] vs. 28 [14-72] days, p = 0.01). Male sex dominated both groups, but group A had significantly less pre-existing structural heart disease. Despite the more liberal use of empirical antibiotics in the COVID-era, group-A had lower rates of culture-negative IE. Compared to group B, group A demonstrated a better response to medical therapy, fewer arterial embolizations, fewer indications for surgery, and fewer overall complications, except for increased acute kidney injury. This can be explained by the abundant use of non-steroidal anti-inflammatory drugs. The data analysis strongly suggests that there might have been a natural selection or selection bias of IE patients with favorable profiles to survive the pandemic to the appropriate diagnosis. Conclusions: The diagnosis of IE and commencing the appropriate workup were significantly undermined during the COVID-19 pandemic. The inexplicable decline in IE referral rate and the favorable outcomes witnessed during the pandemic strongly suggest a referral bias and natural selection of those who survived the pandemic to the appropriate IE diagnosis.

Endocarditis

Infectious endocarditis (IE) is a universally fatal condition if left unmanaged, requiring urgent evaluation and treatment. Fever, new heart murmur, vegetations found by echocardiogram, and bacteremia are the most common symptoms and findings. Blood cultures and echocardiography are obligatory diagnostic modalities and should be used with the modified Duke criteria, the accepted diagnostic aid, when establishing a diagnosis of IE. When IE is suspected, consultations with cardiology, infectious disease, and cardiothoracic surgery teams should be made early. Staphylococci, Streptococci, and Enterococci are common pathogens, necessitating bactericidal antimicrobial therapy. Importantly, up to 50% of patients with IE will require cardiothoracic surgical intervention.

Features of infective endocarditis in a contemporary cohort of persons who inject drugs: a matched comparison analysis of long-term prognostic factors

The objective of the study was to assess the short- and long-term mortality of infective endocarditis (IE) among people who inject drugs (PWID). Using prospectively collected data on hospitalized patients (years 2000 through 2021) with IE, PWID were identified and included in this study. Survival analysis was performed to analyze short- and long-term mortality and study their risk factors among PWID and a matched group of non-intravenous drug users (N-IDU). In a study of 485 patients admitted for IE, 55 (11%) of them were PWID. These PWID patients were 1:1 age- and sex- matched to an N-IDU group (N = 55 per group). Both groups had similar baseline comorbid conditions, including congestive heart failure, type 2 diabetes, and neoplastic diseases. However, PWID were more likely to have HCV co-infection (62% vs 16%, respectively, p < 0.001) and advanced liver disease/cirrhosis (52% vs 7.9%, respectively, p < 0.001). IE in PWID more often affected the tricuspid valve (42% vs 22%, respectively, p = 0.024) and presented with more embolic events (66% vs 35%, respectively, p < 0.01). S. aureus was the primary cause of IE in PWID (44% vs 21%, respectively, p = 0.01). After adjusting for other variables, PWID (HR = 2.99, 95% CI [1.06, 8.43], p = 0.038) and valve bioprosthetic replacement (HR = 5.37, 95% CI [1.3, 22.1], p = 0.02) were independently associated with increased mortality risk, whereas IE caused by tricuspid valve infection was associated with reduced mortality risk (HR = 0.25, 95% CI [0.06, 0.97], p = 0.046). In this cohort, PWID had increased risk of long-term mortality after hospital discharge for IE, when compared to matched N-IDU with similar baseline characteristics. The reasons behind the significant increase in mortality warrant further investigation.

Infective Endocarditis in Patients Addicted to Injected Opioid Drugs

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous mechanical aspiration in patients with right-sided infective endocarditis: An analysis of the national inpatient sample database-2016-2020

BACKGROUND

Given the challenges of conventional therapies in managing right-sided infective endocarditis (RSIE), percutaneous mechanical aspiration (PMA) of vegetations has emerged as a novel treatment option. Data on trends, characteristics, and outcomes of PMA, however, have largely been limited to case reports and case series.

AIMS

The aim of the current investigation was to provide a descriptive analysis of PMA in the United States and to profile the frequency of PMA with a temporal analysis and the patient cohort.

METHODS

The International Classification of Diseases, 10th Revision codes were used to identify patients with RSIE in the national (nationwide) inpatient sample (NIS) database between 2016 and 2020. The clinical characteristics and temporal trends of RSIE hospitalizations in patients who underwent PMA was profiled.

RESULTS

An estimated 117,955 RSIE-related hospital admissions in the United States over the 5-year study period were estimated and 1675 of them included PMA. Remarkably, the rate of PMA for RSIE increased 4.7-fold from 2016 (0.56%) to 2020 (2.62%). Patients identified with RSIE who had undergone PMA were young (medial age 36.5 years) and had few comorbid conditions (median Charlson Comorbidity Index, 0.6). Of note, 36.1% of patients had a history of hepatitis C infection, while only 9.9% of patients had a cardiovascular implantable electronic device. Staphylococcus aureus was the predominant (61.8%) pathogen. Concomitant transvenous lead extraction and cardiac valve surgery during the PMA hospitalization were performed in 18.2% and 8.4% of admissions, respectively. The median hospital stay was 19.0 days, with 6.0% in-hospital mortality.

CONCLUSIONS

The marked increase in the number of PMA procedures in the United States suggests that this novel treatment option has been embraced as a useful tool in select cases of RSIE. More work is needed to better define indications for the procedure and its efficacy and safety.

Impact of Potential Case Misclassification by Administrative Diagnostic Codes on Outcome Assessment of Observational Study for People Who Inject Drugs

Introduction

Initiation of medications for opioid use disorder (MOUD) within the hospital setting may improve outcomes for people who inject drugs (PWID) hospitalized because of an infection. Many studies used International Classification of Diseases (ICD) codes to identify PWID, although these may be misclassified and thus, inaccurate. We hypothesized that bias from misclassification of PWID using ICD codes may impact analyses of MOUD outcomes.

Methods

We analyzed a cohort of 36 868 cases of patients diagnosed with Staphylococcus aureus bacteremia at 124 US Veterans Health Administration hospitals between 2003 and 2014. To identify PWID, we implemented an ICD code-based algorithm and a natural language processing (NLP) algorithm for classification of admission notes. We analyzed outcomes of prescribing MOUD as an inpatient using both approaches. Our primary outcome was 365-day all-cause mortality. We fit mixed-effects Cox regression models with receipt or not of MOUD during the index hospitalization as the primary predictor and 365-day mortality as the outcome.

Results

NLP identified 2389 cases as PWID, whereas ICD codes identified 6804 cases as PWID. In the cohort identified by NLP, receipt of inpatient MOUD was associated with a protective effect on 365-day survival (adjusted hazard ratio, 0.48; 95% confidence interval, .29-.81; P < .01) compared with those not receiving MOUD. There was no significant effect of MOUD receipt in the cohort identified by ICD codes (adjusted hazard ratio, 1.00; 95% confidence interval, .77-1.30; P = .99).

Conclusions

MOUD was protective of all-cause mortality when NLP was used to identify PWID, but not significant when ICD codes were used to identify the analytic subjects.

Management of isolated native tricuspid valve infective endocarditis by a multidisciplinary program: a single-center retrospective cohort study

Background

Isolated native tricuspid valve infective endocarditis remains a challenging disease to treat given the large number of patients with substance use disorder. There is limited data on the optimal treatment strategy and the impact of a multidisciplinary endocarditis program on outcomes for this population.

Objectives

To assess the clinical outcomes associated with management of native tricuspid valve infective endocarditis by a multidisciplinary team.

Design

Single-center, retrospective cohort study.

Methods

Patient cases were identified from the registry of the institutional multidisciplinary endocarditis team. Patients with left-sided endocarditis, multivalvular endocarditis, prosthetic tricuspid valves and cardiac implantable electronic devices were excluded.

Results

Between September 7th, 2021 and February 1st, 2024 72 consecutive patients with isolated native tricuspid valve infective endocarditis were identified. Sixty-six (91.7%) patients were managed medically. Five patients underwent percutaneous mechanical aspiration of tricuspid valve vegetations and one patient underwent tricuspid valve replacement during the index hospitalization. In-hospital mortality was 1.4% and 90-day mortality was 2.8%. Nineteen (26.4%) patients discharged before medically advised and 25% were re-admitted within 30 days. Ten (13.9%) patients underwent elective tricuspid valve replacements after outpatient follow-up.

Conclusion

Among 72 patients with isolated native tricuspid valve infective endocarditis managed by a multidisciplinary endocarditis program over a 2.5-year period, in-hospital, 90-day mortality and 1-year mortality were very low despite low rates of percutaneous mechanical aspiration and tricuspid valve surgery. Multidisciplinary follow-up can lead to elective tricuspid valve surgery in a delayed fashion.

Impact of Hemoglobin Level, White Blood Cell Count, Renal Dysfunction, and Staphylococcus as the Causative Organism on Prediction of In-Hospital Mortality from Infective Endocarditis

Infective endocarditis (IE) is a highly fatal disease in cases of delayed diagnosis and treatment, although its incidence is low. However, there have been few single-center studies in which the risk of in-hospital death from IE was stratified according to laboratory findings on admission and the organism responsible for IE. In this study, a total of 162 patients who were admitted to our hospital during the period from 2009 to 2021, who were suspected of having IE according to the modified Duke classification, and for whom IE was confirmed by transesophageal echocardiography were retrospectively analyzed. Patients were observed for a mean-period of 43.7 days with the primary endpoint being in-hospital death. The in-hospital death group had a lower level of hemoglobin (Hb), higher white blood cell (WBC) count, lower level of estimated glomerular filtration rate (eGFR), and higher frequency of Staphylococcus being the causative agent than those in the non-in-hospital death group. In overall multivariate analysis, Hb, WBC count, eGFR, and Staphylococcus as the causative agent were identified to be significant prognostic determinants. IE patients with Hb < 10.6 g/dL, WBC count > 1.4 × 104/μL, eGFR < 28.1 mL/minute/1.7 m2, and Staphylococcus as the causative agent had significantly and synergistically increased in-hospital death rates compared to those in other IE patients. Low level of Hb, high WBC count, low eGFR, and Staphylococcus as the causative agent of IE were independent predictors of in-hospital mortality, suggesting that these 4 parameters may be combined to additively stratify the risk of in-hospital mortality.

A Multidisciplinary Approach to Staphylococcus aureus Triple-Valve Infective Endocarditis With Multi-Organ Involvement

Multivalvular endocarditis is a rare and potentially fatal complication that can occur in people who inject drugs. Currently, there are few cases that have been studied or reported in literature. A complication of this manifestation that worsens prognosis and treatment is the distribution of septic emboli throughout the body which highlights the dissemination of the infection. There are no specific guidelines on the treatment of multivalvular endocarditis, but its complexity can present challenges in administering medical and surgical treatment. In this case of a 37-year-old man with infective endocarditis of 3 valves, a comprehensive work-up found septic emboli in the lungs, kidneys, ribs, spine, and brain with ophthalmologic involvement that resulted in visual impairment. This case highlights important complications that can occur with septic emboli and management of these issues using a multidisciplinary approach including the treatment of substance use disorder.

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

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

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.

Trends in Infective Endocarditis Mortality in the United States: 1999 to 2020: A Cause for Alarm

BACKGROUND

Data on national trends in mortality due to infective endocarditis (IE) in the United States are limited.

METHODS AND RESULTS

Utilizing the multiple causes of death data from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2020, IE and substance use were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Between 1999 and 2020, the IE-related age-adjusted mortality rates declined. IE-related crude mortality accelerated significantly in the age groups 25-34 years (average annual percentage change, 5.4 [95% CI, 3.1-7.7]; P<0.001) and 35-44 years (average annual percentage change, 2.3 [95% CI, 1.3-3.3]; P<0.001), but remained stagnant in those aged 45-54 years (average annual percentage change, 0.5 [95% CI, -1.9 to 3]; P=0.684), and showed a significant decline in those aged ≥55 years. A concomitant substance use disorder as multiple causes of death in those with IE increased drastically in the 25-44 years age group (P<0.001). The states of Kentucky, Tennessee, and West Virginia showed an acceleration in age-adjusted mortality rates in contrast to other states, where there was predominantly a decline or static trend for IE.

CONCLUSIONS

Age-adjusted mortality rates due to IE in the overall population have declined. The marked acceleration in mortality in the 25- to 44-year age group is a cause for alarm. Regional differences with acceleration in IE mortality rates were noted in Kentucky, Tennessee, and West Virginia. We speculate that this acceleration was likely due mainly to the opioid crisis that has engulfed several states and involved principally younger adults.

Contemporary Management of Staphylococcus aureus Bacteremia-Controversies in Clinical Practice

Staphylococcus aureus bacteremia (SAB) carries a high risk for excess morbidity and mortality. Despite its prevalence, significant practice variation continues to permeate clinical management of this syndrome. Since the publication of the 2011 Infectious Diseases Society of America (IDSA) guidelines on management of methicillin-resistant Staphylococcus aureus infections, the field of SAB has evolved with the emergence of newer diagnostic strategies and therapeutic options. In this review, we seek to provide a comprehensive overview of the evaluation and management of SAB, with special focus on areas where the highest level of evidence is lacking to inform best practices.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence and incidence of emergency department presentations and hospital separations with injecting-related infections in a longitudinal cohort of people who inject drugs

People who inject drugs are at risk of acute bacterial and fungal injecting-related infections. There is evidence that incidence of hospitalizations for injecting-related infections are increasing in several countries, but little is known at an individual level. We aimed to examine injecting-related infections in a linked longitudinal cohort of people who inject drugs in Melbourne, Australia. A retrospective descriptive analysis was conducted to estimate the prevalence and incidence of injecting-related infections using administrative emergency department and hospital separation datasets linked to the SuperMIX cohort, from 2008 to 2018. Over the study period, 33% (95%CI: 31-36%) of participants presented to emergency department with any injecting-related infections and 27% (95%CI: 25-30%) were admitted to hospital. Of 1,044 emergency department presentations and 740 hospital separations, skin and soft tissue infections were most common, 88% and 76%, respectively. From 2008 to 2018, there was a substantial increase in emergency department presentations and hospital separations with any injecting-related infections, 48 to 135 per 1,000 person-years, and 18 to 102 per 1,000 person-years, respectively. The results emphasize that injecting-related infections are increasing, and that new models of care are needed to help prevent and facilitate early detection of superficial infection to avoid potentially life-threatening severe infections.

Role of multimodality imaging in infective endocarditis: Contemporary diagnostic and prognostic considerations

Infective endocarditis (IE) describes the infection of native and prosthetic cardiac valves as well as cardiac implantable electronic devices. Echocardiography is the most widely used imaging technique for evaluation of IE. Due to its reduced sensitivity in detection of prosthetic valve IE and cardiac implantable electronic device related IE and related complications, complementary techniques such as cardiac computed tomography (CT) and 18-flurodeoxyglucose positron emission tomography/CT play an emerging role. Therefore, multiple guidelines recommend the use of multimodality imaging in the diagnosis and management of IE. In this review, we aim to compare the various guidelines and to discuss the role of imaging in the diagnosis, detection of complications, monitoring of treatment response, and prognostication of IE.