Abstract
Background: Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Current IE guidelines recommend transesophageal echocardiogram (TEE) over transthoracic echocardiogram (TTE) to diagnose infective endocarditis. Management of IE in people who inject drugs (PWID) in many medical centers is mainly conservative with prolonged intravenous antibiotics. Cardiac valve replacement in these patients remains controversial, given the high risk of reinfection. This study’s purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients.Methods: A retrospective cohort of patients who are 18 years of age or older and inject drugs with definite MRSA IE between 2013 and 2019 were studied. Their echocardiographic reports and overall management plans were reviewed.Results: One hundred and twenty-six patients met the inclusion criteria. TTE was performed in 121 patients and, of these patients, 69 (57%) had detectable valvular vegetations while 52 (43%) did not. Of the 52 patients with a negative TTE, 44 underwent TEE, 28 (53%) of which showed vegetation. A total of 18 (14%) patients underwent surgery. Of these, six (33%) patients had a positive TTE only, with no subsequent TEE. Ten (56%) patients had both a positive TTE and TEE, and two (11%) patients had a negative TTE but positive TEE.Conclusion: In this retrospective cohort, obtaining a sequential TEE after a TTE in PWID with proven MRSA native IE by modified Duke’s criteria changed the management plan in two patients. The decision to perform a TEE in these patients needs to be individualized. Larger studies are needed to better evaluate the role of TEE in this patient population.
Highlights
Infective endocarditis (IE) due to illicit injection drug use is becoming a major public health concern in the United States of America with increasing incidence from 27% in 2003 to 42% in 2013 [1,2]
The European Journal of Echocardiography published in 2010 as well as the American College of Cardiology/American Heart Association andInfectious Disease Society of America(IDSA) recommend thatallpatients withStaphylococcus aureus bacteremia (SAB) undergoinitialevaluation with atransthoracic echocardiogram (TTE),given itslow cost, availability, safety, and diagnostic yieldresulting inasensitivity of 70% and specificity of 95% in native valves[3,7].If the TTE is negative and suspicion remains high, current guidelines advise proceeding with a transesophageal echocardiogram (TEE),given its ability of increased spatial resolution, enhanced visualization of cardiac valves, and diagnostic yield with a sensitivity and specificity of over 95% [7,8]
Reasons for transition to comfort care were mostly related to worsening septic shock in 10 patients (77%) along with aortic valve rupture in one patient (7.7%) who was deemed as not a surgical candidate, spinal cord infarction, progressive central nervous system (CNS) embolization in one patient (7.7%), and shock with disseminated intravascular coagulation (DIC) in one patient (7.7%)
Summary
Infective endocarditis (IE) due to illicit injection drug use is becoming a major public health concern in the United States of America with increasing incidence from 27% in 2003 to 42% in 2013 [1,2]. Methicillin-resistant Staphylococcus aureus (MRSA) IE is associated with high morbidity and mortality [5].As outlined in the modified Duke criteria, echocardiogram, while not required to make the diagnosis,is an essential diagnostictool to adequately assess the location, extent, and functional impact of the infection, which istypicallywarrantedin all cases of suspectedand confirmedIE[3,6]. The European Journal of Echocardiography published in 2010 as well as the American College of Cardiology/American Heart Association andInfectious Disease Society of America(IDSA) recommend thatallpatients withStaphylococcus aureus bacteremia (SAB) undergoinitialevaluation with atransthoracic echocardiogram (TTE),given itslow cost, availability, safety, and diagnostic yieldresulting inasensitivity of 70% and specificity of 95% in native valves[3,7].If the TTE is negative and suspicion remains high, current guidelines advise proceeding with a transesophageal echocardiogram (TEE),given its ability of increased spatial resolution, enhanced visualization of cardiac valves, and diagnostic yield with a sensitivity and specificity of over 95% [7,8]. Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. This study’s purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients
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