Drug Use-associated Infective Endocarditis Research Articles

Long-term risk of serious infections and mortality among patients surviving drug use-associated infective endocarditis.

Among a statewide cohort of 1,874 patients surviving hospitalization for drug use-associated endocarditis during 2017-2020, the 3-year risk of death or future hospitalization was 38% (16% for death prior to later infection, 14% for recurrent endocarditis, 14% for soft-tissue, 9% for bacteremia, 5% for bone/joint, and 4% for spinal infections).

Patient characteristics, treatment patterns, and prognosis in drug-use-associated infective endocarditis in Denmark from 1999-2018

While the proportion of drug-use-associated infective endocarditis (DU-IE) has been increasing during the opioid crisis in the United States, it is unknown whether this is seen in Denmark, where several preventive means have been implemented. We aimed to assess the temporal proportion of DU-IE and examine the rate of IE recurrence and mortality. This nationwide cohort study identified all patients with first-time infective endocarditis in 1999-2018. Drug use was defined using ICD-8/10 codes or prescription filling of medication for opioid use disorder. Long-term mortality was examined with a Kaplan-Meier estimator and a multivariate Cox model. The recurrence of IE was examined with the Aalen-Johansen method and a multivariate cause-specific hazard model. We included 8,843 patients with IE: 407 with DU-IE (60.7% male, median age 43.8 years) and 8,436 with non-DU-IE (65.8% male, median age 71.5 years). The proportion of DU-IE decreased from 5.9% to 3.8% during our study period. The one-year cumulative incidence of all-cause mortality was 16.9% (CI 12.9%-20.8%) for patients with DU-IE and 17.3% (CI 16.4%-18.2%) for patients with non-DU-IE. Drug use was associated with higher one-year mortality (adjusted HR 1.64 (CI 1.23-2.21)). The one-year cumulative incidence of IE recurrence was 12.8% (CI 9.3%-16.3%) in patients with DU-IE and 4.3% (CI 3.8%-4.8%) in patients with non-DU-IE. Drug use was associated with a higher one-year recurrence of IE (adjusted HR 3.39 (CI 2.35-4.88)). In Denmark, the proportion of patients with DU-IE fell by one-third from 1999-2018. DU-IE was associated with higher mortality and recurrence rates than non-DU-IE.

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

ObjectivesHospitalizations 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). MethodsThis 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. ResultsHospitalizations 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. ConclusionFemales 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.

Abstract 12884: Impact of an Addiction Consult Team on the Management and Outcomes of Patients With Surgically Managed Drug Use Associated Infective Endocarditis

Background: Recurrent injection drug use is a major driver of poor long term outcomes in patients who undergo surgery for drug use associated infective endocarditis (DUA-IE). The effect of an inpatient addiction consult team (ACT) on this population is not well described. Methods: To assess the impact of an ACT on DUA-IE patients, we performed a single center retrospective review of all adults who underwent surgery for active DUA-IE and survived to discharge (DC) between 2012-2022 at a large academic teaching institution. An ACT was established in 9/2017. We compared measures of substance use disorder (SUD) care, readmission, reinfection, and death pre- and post- ACT implementation using logistic regression models. Results: The pre- and post-ACT groups were similar at baseline (Table 1). In a univariate analysis, post-ACT patients were more likely to receive medications for opiate use disorder (MOUD) pre-operatively, to receive MOUD at DC, and to have MOUD follow up appointments scheduled at DC. They were less likely to receive non-MOUD opiates at DC or to be readmitted at 30 or 90 days. Overall rates of SUD follow up care scheduled prior to DC were low. There were no differences in harm reduction measures, recurrent IE, or death. In a multivariate analysis, the association of the ACT with decreased 90 day readmissions remained significant (Table 2). Conclusion: Among surgically managed DUA-IE patients, ACT implementation was associated with improved metrics of SUD care and readmissions at 90 days, but not recurrent IE or death. Future efforts should focus on strengthening harm reduction interventions and ensuring SUD follow up to sustain longitudinal engagement in care.

Caring for Appalachians With Intravenous Drug Use-Associated Infective Endocarditis at End of Life: A Phenomenological Secondary Data Analysis.

The purpose of this study was to describe the experiences of nurses caring for patients with intravenous drug use-associated infective endocarditis at the end of life in Appalachia. This study was a secondary analysis of 9 phenomenological unstructured interviews conducted by the author with nurses as part of a study exploring their lived experiences caring for this population. Data were analyzed using van Manen's 6-step approach. The analysis revealed 5 themes: (1) care at the end of life as a resolve to care for lost causes, (2) care at the end of life as an act of courageous communication, (3) care at the end of life as a resolve to endure chaos, (4) care at the end of life as a resolve to protect self and others, and (5) care at the end of life as a resolve to carry on and let go. Nurses perceived patients who use injection drugs as being at the end of life with eventual death. Patients with recurrent infective endocarditis from drug use are viewed as lost causes. To empower nurses, they need to be at the table of surgical decision making. Communication being one of a nurse's greatest tools, end-of-life communication education is needed. Administrative support should be a standard to safeguard nurses when dealing with emotionally challenging situations.

"I Just Need Proper Treatment": Being Hospitalized for Endocarditis among Individuals Who Inject Drugs Being Hospitalized for Endocarditis.

Rates of hospitalization for injection drug use-associated infective endocarditis (IDU-IE) are increasing. Much is known about the poor outcomes of patients with IDU-IE; less is known about the patient experience during hospitalization. To explore the experience of being hospitalized for endocarditis among individuals who inject drugs, providing a foundation on which to develop strategies to improve care for these patients. Qualitative interviews with hospitalized patients undergoing cardiothoracic surgery with a history of injection drug use between February 2021 and May 2022 at the Hospital of the University of Pennsylvania. Cardiothoracic surgery patients with a documented history of injection drug use and the ability to speak English were recruited during their hospital stay. Thematic analysis of interviews guided by phenomenology and harm reduction theory was used to identify recurrent themes. Interviews were digitally recorded and transcribed and analyzed using NVIVO software. Interviews from 13 participants resulted in four major themes around Hospital Experience: (1) Kindness as an Antidote to Dehumanizing Treatment; (2) Relationships with the Care Team; (3) Withdrawal and Pain Management; and (4) Anticipating and Experiencing the Transition out the Hospital. Participants recounted long histories of dehumanizing care during previous hospitalizations, noted the value of open, sincere, and non-judgmental communication with clinical teams, expressed overall satisfaction with the management of their symptoms during the current hospitalization, reported self-discharging during previous hospitalizations due to undertreated pain and withdrawal, and noted significant challenges around discharge planning and execution. Participants noted structural (e.g., discharge planning) and interpersonal (e.g., stigma from care team) barriers to quality hospital care. They also noted that expressions of kindness from hospital staff were meaningful and comforting. Patients with IDU-IE face multi-dimensional challenges in the hospital. Their perspectives can meaningfully inform programs and initiatives to improve their outcomes and support recovery.

Establishment of an in vivo Streptozotocin-Induced Type 1 Diabetes Model Recapitulating Early Brain and Retinal Fibrosis

Background: The addition of an addiction medicine consult service has been shown to improve mortality and decrease hospital costs but its impact on the proportion of patients discharged against medical advice (DAMA) and in-hospital initiation of medication for opioid use disorder (MOUD) has not been examined. Methods: A retrospective before-after cohort study was performed at an urban, academic medical center between January 1, 2015 and November 1, 2019. We included adult patients with infective endocarditis and injection drug use determined by admitting diagnosis ICD-9 or ICD-10 codes or documentation within the history section of electronic health recordEHR. Our institution implemented a formal addiction medicine consult service on July 1, 2018. We determined the proportion of patients DAMA and the proportion of patients started on MOUD among patients in the pre-intervention (i.e. hospitalized before July 1, 2018) and intervention (i.e. hospitalized July 1, 2018 or after) groups. Results: A total of 171 patients among hospitalized patients with injection drug use-associated infective endocarditis were included with 119 patients in the pre-intervention group and 52 patients in the intervention group. There was no statistically significant difference in patients DAMA [19% vs 15%, absolute risk difference 4.6% (95% confidence interval -8.6% to 17.7%)] between the intervention and pre-intervention groups. However, there was an increase in the proportion of inpatient MOUD initiation in the intervention group compared to the pre-intervention group [56% vs 21%, absolute risk difference 35% (95% confidence interval 19% to 50%)]. Conclusions: The initiation of an addiction medicine consult service was associated with a higher proportion of MOUD initiation but there was no statistically significant association with the proportion of patients DAMA.

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

IntroductionLife-threatening infections such as infective endocarditis (IE) are increasing simultaneously with the injection drug use epidemic in West Virginia (WV). We utilized a newly developed, statewide database to describe epidemiologic characteristics and healthcare utilization among patients with (DU-IE) and without (non-DU-IE) drug use-associated IE in WV over five years.Materials and methodsThis retrospective, observational study, incorporating manual review of electronic medical records, included all patients aged 18–90 years who had their first admission for IE in any of the four university-affiliated referral hospitals in WV during 2014–2018. IE was identified using ICD-10-CM codes and confirmed by chart review. Demographics, clinical characteristics, and healthcare utilization were compared between patients with DU-IE and non-DU-IE using Chi-square/Fisher’s exact test or Wilcoxon rank sum test. Multivariable logistic regression analysis was conducted with discharge against medical advice/in-hospital mortality vs. discharge alive as the outcome variable and drug use as the predictor variable.ResultsOverall 780 unique patients had confirmed first IE admission, with a six-fold increase during study period (p = .004). Most patients (70.9%) had used drugs before hospital admission, primarily by injection. Compared to patients with non-DU-IE, patients with DU-IE were significantly younger (median age: 33.9 vs. 64.1 years; p < .001); were hospitalized longer (median: 25.5 vs. 15 days; p < .001); had a higher proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates (42.7% vs. 29.9%; p < .001), psychiatric disorders (51.2% vs. 17.3%; p < .001), cardiac surgeries (42.9% vs. 26.6%; p < .001), and discharges against medical advice (19.9% vs. 1.4%; p < .001). Multivariable regression analysis showed drug use was an independent predictor of the combined outcome of discharge against medical advice/in-hospital mortality (OR: 2.99; 95% CI: 1.67–5.64).Discussion and conclusionThis multisite study reveals a 681% increase in IE admissions in WV over five years primarily attributable to injection drug use, underscoring the urgent need for both prevention efforts and specialized strategies to improve outcomes.

Sex Differences in Characteristics of Patients with Infective Endocarditis: A Multicenter Study.

Infectious diseases like infective endocarditis (IE) may manifest or progress differently between sexes. This study sought to identify the differences in demographic and clinical characteristics among male and female patients with IE. Data were obtained from a newly developed registry comprising all adult patients with first IE admission at the four major tertiary cardiovascular centers in West Virginia, USA during 2014–2018. Patient characteristics were compared between males and females using Chi-square test, Fisher’s exact test, and Wilcoxon rank-sum test. A secondary analysis was restricted to IE patients with drug use only. Among 780 unique patients (390 males, 390 females), significantly more women (a) were younger than males (median age 34.9 vs. 41.4, p < 0.001); (b) reported drug use (77.7% vs. 64.1%, p < 0.001); (c) had tricuspid valve endocarditis (46.4% vs. 30.8%, p < 0.001); and (d) were discharged against medical advice (20% vs. 9.5%, p < 0.001). These differences persisted even within the subgroup of patients with drug use-associated IE. In a state with one of the highest incidences of drug use and overdose deaths, the significantly higher incident IE cases in younger women and higher proportion of women leaving treatment against medical advice are striking. Differential characteristics between male and female patients are important to inform strategies for specialized treatment and care.

Creation of a Multidisciplinary Drug Use Endocarditis Treatment (DUET) Team: Initial Patient Characteristics, Outcomes, and Future Directions.

BackgroundConsensus guidelines recommend multidisciplinary models to manage infective endocarditis, yet often do not address the unique challenges of treating people with drug use–associated infective endocarditis (DUA-IE). Our center is among the first to convene a Drug Use Endocarditis Treatment (DUET) team composed of specialists from Infectious Disease, Cardiothoracic Surgery, Cardiology, and Addiction Medicine. MethodsThe objective of this study was to describe the demographics, infectious characteristics, and clinical outcomes of the first cohort of patients cared for by the DUET team. This was a retrospective chart review of patients referred to the DUET team between August 2018 and May 2020 with DUA-IE.ResultsFifty-seven patients were presented to the DUET team between August 2018 and May 2020. The cohort was young, with a median age of 35, and injected primarily opioids (82.5% heroin/fentanyl), cocaine (52.6%), and methamphetamine (15.8%). Overall, 14 individuals (24.6%) received cardiac surgery, and the remainder (75.4%) were managed with antimicrobial therapy alone. Nearly 65% of individuals were discharged on medication for opioid use disorder, though less than half (36.8%) were discharged with naloxone and only 1 patient was initiated on HIV pre-exposure prophylaxis. Overall, the cohort had a high rate of readmission (42.1%) within 90 days of discharge.ConclusionsMultidisciplinary care models such as the DUET team can help integrate nuanced decision-making from numerous subspecialties. They can also increase the uptake of addiction medicine and harm reduction tools, but further efforts are needed to integrate harm reduction strategies and improve follow-up in future iterations of the DUET team model.

Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use–Associated Infective Endocarditis

Emerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use-associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown. To compare the added value of inpatient addiction care services and the cost-effectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE. This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Cost-effectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty. The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy). Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs). All modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416 570 per person, with 77.6% of hospitalized patients completing treatment. Life expectancy was extended by each alternative strategy. The partial oral antibiotic strategy yielded the highest treatment completion rate (80.3%) compared with the OPAT strategy (78.8%) and the usual care/addiction care strategy (77.6%). The OPAT strategy was the least expensive at $412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163 370 per LY. Increasing IDU-IE treatment uptake and decreasing treatment discontinuation made the partial oral antibiotic strategy more cost-effective compared with the OPAT strategy. When assuming that all patients with IDU-IE were eligible to receive partial oral antibiotic therapy, the strategy was cost-saving and resulted in 0.0247 additional discounted LYs. When treatment discontinuation was decreased from 3.30% to 2.65% per week, the partial oral antibiotic strategy was cost-effective compared with OPAT at the $100 000 per LY threshold. In this decision analytical modeling study, incorporation of OPAT or partial oral antibiotic approaches along with addiction care services for the treatment of patients with IDU-IE was associated with increases in the number of people completing treatment, decreases in mortality, and savings in cost compared with the usual care strategy of providing inpatient IV antibiotic therapy alone.

Antibiotic therapy completion for injection drug use-associated infective endocarditis at a center with routine addiction medicine consultation: a retrospective cohort study

BackgroundAddiction medicine consultation and medications for opioid use disorder are shown to improve outcomes for patients hospitalized with infective endocarditis associated with injection drug use. Existing studies describe settings where addiction medicine consultation and initiation of medications for opioid use disorder are not commonplace, and rates of antibiotic therapy completion are infrequently reported. This retrospective study sought to quantify antibiotic completion outcomes in a setting where these interventions are routinely implemented.MethodsMedical records of patients hospitalized with a diagnosis of bacteremia or infective endocarditis at an urban hospital between October 1, 2015 and December 31, 2017 were screened for active injection drug use within 6 months of hospitalization and infective endocarditis. Demographic and clinical parameters, receipt of antibiotics and medications for opioid use disorder, and details of re-hospitalizations within 1 year of discharge were recorded.ResultsOf 567 subjects screened for inclusion, 47 had infective endocarditis and active injection drug use. Addiction medicine consultation was completed for 41 patients (87.2%) and 23 (48.9%) received medications for opioid use disorder for the entire index admission. Forty-three patients (91.5%) survived to discharge, of which 28 (59.6%) completed antibiotic therapy. Twenty-nine survivors (67.4%) were re-hospitalized within 1 year due to infectious complications of injection drug use.ConclusionsAmong patients admitted to a center with routine addiction medicine consultation and initiation of medications for opioid use disorder, early truncation of antibiotic therapy and re-hospitalization were commonly observed.

Surgeons’ Perspectives on Valve Surgery in People With Drug Use-Associated Infective Endocarditis

BackgroundHospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons’ perspectives about the process of decision making around operation for people with DUA-IE are largely unknown. MethodsThis multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University. ResultsNineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care. ConclusionsCardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis.

Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.

Abstract 12690: Outcomes of Tricuspid Valve Surgery in Patients With Septic Pulmonary Embolism From Drug-Associated Tricuspid Valve Endocarditis

Introduction: Septic pulmonary emboli (PE) are a common sequela of drug-use associated infective endocarditis (DU-IE) of the tricuspid valve and is considered an indication for surgery. Methods: The Healthcare Cost and Utilization Project’s National Inpatient Sample was queried from 2008-2017 for adult patients hospitalized for septic PE with the diagnosis of DU-IE of the tricuspid valve. In-hospital outcomes of patients who underwent tricuspid valve operation (TVO) were compared with patients who did not. The primary outcome was perioperative major adverse cardiovascular events (MACE) defined as a composite of death, myocardial infarction (MI), stroke, cardiogenic shock, and cardiac arrest. Results: A total of 6,758 cases of DU-IE with septic PE were identified (mean age 32.2), of which 2,262 (33.6%) had a TVO during hospital admission. Patients who underwent a TVO had longer length of stay (32.3 vs 17.7, p&lt;0.05), higher hospital costs ($97,486 vs $34,728, p&lt;0.05), and more discharges to a long-term facility (33.7% vs 27.9%, p&lt;0.05). MACE was significantly higher in patients undergoing TVO (12.5% vs 7.1%, p&lt;0.05), which was driven by higher rates of stroke (5.0% vs 2.7%, p&lt;0.05) and cardiogenic shock (4.8% vs 0.8%, p&lt;0.05) but notably, a lower rate of mortality (2.0% vs 4.0%, p&lt;0.05). In addition, patients who underwent TVO had more pulmonary complication (49.0% vs 29.5%, p&lt;0.05), acute kidney injury (44.3% vs 34.0%, p&lt;0.05), permanent pacemaker placement (15.0% vs 0.2%, p&lt;0.05), and tracheostomy (3.7% vs 1.8%, p&lt;0.05). After multivariable adjustment, TVO was associated with an increased risk for MACE (aOR=1.55, 95% CI 1.25 - 1.86). Conclusion: The utility of surgical intervention remains controversial given the lower rate of mortality, but higher rate of adverse outcomes in this young patient population. Alternative management strategies including percutaneous intervention should be considered given the morbidity associated with this disease presentation.

A Proposal for Addiction and Infectious Diseases Specialist Collaboration to Improve Care for Patients With Opioid Use Disorder and Injection Drug Use-Associated Infective Endocarditis.

Patients with injection drug use-associated infective endocarditis and opioid use disorder often receive treatment for the infection that fails to address its underlying cause. People who inject drugs (PWID) and develop serious infections also face disparities in antibiotic management, particularly with regards to use of outpatient parenteral antimicrobial therapy (OPAT). We highlight literature on OPAT in PWID challenging the notion that PWID cannot be managed with OPAT. Given that OPAT use amongst PWID and non-PWID yields similar outcomes, we argue that a bias against OPAT use in PWID is unwarranted and may reflect stigma rather than data. We further note the proven value of comprehensive OUD treatment on endocarditis treatment outcomes, which also addresses the potential safety concerns of OPAT in PWID, and propose a treatment model in which Addiction and Infectious Disease specialists collaborate to integrate opioid use disorder treatment into injection drug use-associated infective endocarditis care.

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

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

The Lived Experience of Nurses Caring for Patients Diagnosed With Intravenous Drug Use-Associated Infective Endocarditis in Appalachia: A Phenomenological Study.

The number of patients admitted with infective endocarditis (IE) from intravenous drug use (IVDU) in Appalachia is increasing, a direct downstream effect of the opioid crisis. Extant literature highlights the pejorative attitudes health care workers have toward patients with substance use disorder, with nurses among the most punitive. Rather than describe attitudes, the purpose of this study was to describe the lived experiences of nurses caring for patients diagnosed with IE from IVDU in Appalachia. To describe an unexplored phenomenon in Appalachia to inform nursing practice, nursing education, and health policy. Qualitative phenomenological study using the University of Tennessee method based on the tenets of Maurice Merleau-Ponty. Nine nurses (ages 29-53 years) recruited using purposive and snowball sampling participated in unstructured phenomenological interviews. The essential meaning or central theme of the nurse experience working with these patients was a sense of hopelessness/hope, with four interrelated themes derived from the central theme: (1) guarding/escaping, (2) responsibility and revulsion, (3) apathy/empathy, and (4) grief and sorrow/cold and unemotional. Universally, nurses perceived caring for this population as futile, feeling a sense of powerlessness to change the outcome. These care experiences frustrated nurses, who described being physically and emotionally drained. To improve care delivery and improve patient outcomes, emphasis must be placed on nurse addiction education and standardizing nurse to patient with substance use disorder ratios to decrease work-related stress on nurses.

Low Use of Outpatient Parenteral Antimicrobial Therapy for Drug Use-Associated Infective Endocarditis in an Urban Hospital System.

BackgroundThe opioid crisis in the United States has led to increasing hospitalizations for drug use-associated infective endocarditis (DUA-IE). Outpatient parenteral antimicrobial therapy (OPAT), the preferred modality for intravenous antibiotics for infective endocarditis, has demonstrated similar outcomes among patients with DUA-IE versus non-DUA-IE, but current studies suffer selection bias. The utilization of OPAT for DUA-IE more generally is not well studied.MethodsThis retrospective cohort study compared OPAT use for DUA-IE versus non-DUA-IE in adults hospitalized between January 1, 2015 and September 1, 2019 at 3 urban hospitals. We used multivariable regression analysis to assess the association between DUA-IE and discharge with OPAT, adjusting for clinically significant covariables.ResultsThe cohort included 518 patients (126 DUA-IE, 392 non-DUA-IE). Compared to those with non-DUA-IE, DUA-IE patients were younger (53.0 vs 68.2 years, P < .001) and more commonly undomiciled (9.5% vs 0.3%, P < .01). Patients with DUA-IE had a significantly lower odds of discharge with OPAT than non-DUA-IE patients (adjusted odds ratio [aOR] = 0.20; 95% confidence interval [CI], 0.10–0.39). Odds of discharge with OPAT remained lower for patients with DUA-IE after excluding undomiciled patients (aOR = 0.22; 95% CI, 0.11–0.43) and those with patient-directed discharges (aOR = 0.27; 95% CI, 0.14–0.52).ConclusionsSignificantly fewer patients with DUA-IE were discharged with OPAT compared to those with non-DUA-IE, and undomiciled patients or patient-directed discharges did not fully account for this difference. Efforts to increase OPAT utilization among patients with DUA-IE could have important benefits for patients and the healthcare system.

Infective Endocarditis Secondary to Injection Drug Use: A Survey of Canadian Cardiac Surgeons

Injection drug use-associated infective endocarditis (IDU-IE) is a growing epidemic. The objective of this survey was to identify the beliefs and practice patterns of Canadian cardiac surgeons regarding surgical management of IDU-IE. A 30-question survey was developed by a working group and distributed to all practicing adult cardiac surgeons in Canada. Data were analyzed using descriptive statistics. Of 146 surgeons, 94 completed the survey (64%). Half of surgeons (49%) would be less likely to operate on patients with IE if associated with IDU. In the case of prosthetic valve IE owing to continued IDU, 36% were willing to reoperate once and 14% were willing to reoperate twice or more. Most surgeons required commitments from patients before surgery (73%), and most referred patients to addiction services (81%). Some surgeons would offer a Ross procedure (10%) or homograft (8%) for aortic valve IE, and 47% would consider temporary mechanical circulatory support. Whereas only 17% of surgeons worked at an institution with an endocarditis team, 71% agreed that there was a need for one at each institution. Most surgeons supported the development of IDU-IE-specific guidelines (80%). Practice patterns and surgical management of IDU-IE vary considerably across Canada. Areas of clinical unmet needs include the development of a formal addiction services referral protocol for patients, the development of an interdisciplinary endocarditis team, as well as the creation of IDU-IE clinical practice guidelines.