Abstract
Persons who inject drugs (PWID) represent a distinct demographic of patients with infective endocarditis. Many centers do not perform valvular surgery on these patients owing to concerns about poor outcomes. Addiction services are underused in hospitals. To compare clinical characteristics in first-episode infective endocarditis in PWID who are surgically vs medically managed and to identify variables associated with mortality. This case series studied PWID treated for a first episode of infective endocarditis between April 1, 2007, and March 30, 2016. Participants were adult patients (aged ≥18 years) admitted to any of 3 hospitals in London, Ontario, Canada. Analysis occurred between July 2016 and November 2017. Survival among PWID; the causative organisms, site of infection, and cardiac as well as noncardiac complications; referral to addiction services; and surgical vs medical management. Of 370 total first-episode cases of infective endocarditis, 202 (54.6%) were in PWID. Among PWID, 105 (52%) were male, the median (interquartile range) age was 34 (28-42) years, and patients were predominantly positive for the hepatitis C virus (69.8% [141 of 202]). Right-sided infection was more common (61.4% [124 of 202]), and most infections were caused by Staphylococcus aureus (77.2% [156 of 202]). Surgery occurred in 19.3% of patients (39 of 202). The all-cause mortality rate was 33.7% (68 of 202). Adjusting for age and sex, survival analysis demonstrated that surgery was associated with lower mortality (hazard ratio [HR], 0.44; 95% CI, 0.23-0.84; P = .01), as was referral to addiction treatment (HR, 0.29; 95% CI, 0.12-0.73; P = .008). Higher mortality was associated with left-sided infection (HR, 3.26; 95% CI, 1.82-5.84; P < .001) and bilateral involvement (HR, 4.51; 95% CI, 2.01-10.1; P < .001). This study presents the demographic characteristics of first-episode infective endocarditis in PWID. Results highlight the potentially important role of addictions treatment in this population. Further study to optimize selection criteria for surgery in PWID is warranted.
Highlights
Infective endocarditis (IE) refers to an infection of the endocardium and heart valves or of a prosthetic valvular implant.[1]
Among persons who inject drugs (PWID), 105 (52%) were male, the median age was 34 (28-42) years, and patients were predominantly positive for the hepatitis C virus (69.8% [141 of 202])
Adjusting for age and sex, survival analysis demonstrated that surgery was associated with lower mortality, as was referral to addiction treatment (HR, 0.29; 95% CI, 0.12-0.73; P = .008)
Summary
Infective endocarditis (IE) refers to an infection of the endocardium and heart valves or of a prosthetic valvular implant.[1] There has been a substantial shift in the demographics of patients with IE, in the developed world.[2] It remains a significant cause of morbidity and mortality,[3,4,5] and the overall incidence has remained stable,[6] the incidence has been increasing in persons who inject drugs (PWID).[7,8,9] Among non–drug users, increasing age is associated with degenerative valvular disease; health care–associated cases are more frequent and are attributed to procedures, indwelling lines, or intracardiac devices.[2,6,10] among PWID, susceptibility to infection is poorly understood but hypothesized to result primarily from endothelial damage from particulate material and repeated high-grade bacteremia introduced by direct inoculation.[11,12]. We sought to better characterize PWID hospitalized with a first episode of IE, identify factors associated with mortality, and clarify the association of surgical management with mortality in PWID
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