Endocarditis In Injection Drug Users Research Articles

Features of infective endocarditis in injection drug users

Aim . To reveal the peculiarities of clinical manifestations of infectious endocarditis in injection drug addicts. Material and methods . Clinical, laboratory, echocardiographic manifestations of infectious endocarditis in 40 injecting drug addicts and in 21 patients of control group were analysed. Among injection drug users there were 22 men aged 40,0±2,9 years and 18 women aged 29,5±2,3 years. The history of the disease, clinical manifestations, laboratory markers of inflammation, the results of bacteriological blood tests, and the dynamics of the state during therapy were analyzed. Echocardiography at admission to hospital and at the end of treatment was carried out on a Vivid E-9 apparatus using transthoracic and transesophageal probes. The electrocardiogram was recorded in 12 standard leads. All patients underwent an x-ray examination of thoracic organs or multispiral pulmonary tomography, ultrasound of the liver and spleen. Statistical analysis of the research results was conducted using Statistica 7.0, Microsoft Office Excel. Results . We determined significantly younger age of patients in the group of injection drug users (p<0,05). The most frequently detected manifestation of infective endocarditis in both groups was fever. According to echocardiography data, tricuspid valve isolated localization of endocarditis was found in 90%. Radiographically, 8,2% of drug-dependent patients had signs of pneumonia (often bilateral multisegmental), regarded as a manifestation of the thromboembolic syndrome by vegetation particles. Splenomegaly (75%) was detected in the majority of drug addicts, less often — hepatomegaly (47,5%). Manifestations of chronic heart failure were detected only in 12,5% of patients who use drugs, the kidneys were less involved in the process. An association of infective endocarditis with HIV infection (72,5%) and hepatitis C was detected in 97,5% of patients. Conclusion . Knowing of the infective endocarditis features in drug addicts makes it possible to improve the approaches to the diagnostics in earlier periods of its progression and thus makes the treatment of these patients more promising.

Clinical Outcomes of Infective Endocarditis in Injection Drug Users

BackgroundRising rates of hospitalization for infective endocarditis (IE) have been increasingly tied to rising injection drug use (IDU) associated with the opioid epidemic. ObjectivesThis study analyzed recent trends in IDU-IE hospitalization and characterized outcomes and readmissions for IDU-IE patients. MethodsThe authors evaluated the National Readmissions Database (NRD) for IE cases between January 2010 and September 2015. Patients were stratified by IDU status and surgical versus medical management. Primary outcome was 30-day readmission and cause, with secondary outcomes including mortality, length of stay (LOS), adjusted costs, and 180-day readmission. The Kruskal-Wallis and chi-square tests were used to analyze baseline differences by IDU status. Multivariable regressions were used to analyze mortality, readmissions, LOS, and adjusted costs. ResultsThe survey-weighted sample contained 96,344 (77.8%) non–IDU-IE and 27,432 (22.2%) IDU-IE cases. IDU-IE increased from 15.3% to 29.1% of IE cases between 2010 and 2015 (p < 0.001). At index hospitalization, IDU-IE was associated with reduced mortality (6.8% vs. 9.6%; p < 0.001) but not 30-day readmission (23.8% vs. 22.9%; p = 0.077) relative to non–IDU-IE. Medically managed IDU-IE patients had higher LOS (β = 1.36 days; 95% confidence interval [CI]: 0.71 to 2.01), reduced costs (β = −$4,427; 95% CI: −$7,093 to −$1,761), and increased readmission for endocarditis (18.1% vs. 5.6%; p < 0.001), septicemia (14.0% vs. 7.3%; p < 0.001), and drug abuse (4.3% vs. 0.7%; p < 0.001) compared with medically managed non–IDU-IE. Surgically managed IDU-IE patients had increased LOS (β = 4.26 days; 95% CI: 2.73 to 5.80) and readmission for septicemia (15.6% vs. 5.2%; p < 0.001) and drug abuse (7.3% vs. 0.9%; p < 0.001) compared with non−IDU-IE. ConclusionsThe incidence of IDU-IE continues to rise nationally. Given the increased readmission for endocarditis, septicemia, and drug abuse, IDU-IE presents a serious challenge to current management of IE.

Validation of a prediction rule for endocarditis in febrile injection drug users

BackgroundInfectious endocarditis (IE) in febrile injection drug users (IDUs) is a critical diagnosis to identify in the emergency department (ED). A decision tool that identifies patients at very low risk for endocarditis using readily available clinical data could reduce admissions and cost. ObjectiveTo evaluate the diagnostic performance of a previously derived decision instrument to rule out endocarditis in febrile IDUs (Prediction Rule for Endocarditis in Injection Drug Users [PRE-IDU]) and to develop a prediction model for likelihood of endocarditis for those who are not ruled out by PRE-IDU. MethodsFebrile IDUs admitted to rule out endocarditis were prospectively enrolled from 2 urban EDs in June 2007 to March 2011. Clinical data from ED presentation (first 6 hours) and outcome data from inpatient records were recorded and reviewed by 2 independent investigators. Diagnosis of IE was based on modified Duke criteria and discharge summaries. The diagnostic performance of PRE-IDU, which combines tachycardia, cardiac murmur, and absence of skin infection, was determined using recursive partitioning and logistic regression modeling. ResultsOf the 249 subjects, 18 (7%) had IE. Recursive partitioning yielded an instrument with 100% sensitivity (95% confidence interval [CI], 84%-100%) and 100% negative predictive value (95% CI, 91%-100%), but low specificity (13%; 95% CI, 12%-13%). Multiple logistic regression modeling with the 3 clinical predictors allowed risk stratification with posttest probabilities ranging from 3% to 20%. ConclusionThe PRE-IDU instrument predicted IE with high sensitivity and ruled out IE with high negative predictive value. Our logistic regression model provided posttest probabilities ranging from 3% to 20%. The PRE-IDU instrument and the associated model may help guide hospital admission and diagnostic testing in evaluation of febrile IDUs in the ED.

367 Validation of a Prediction Instrument for Endocarditis in Injection Drug Users With Fever

To validate the diagnostic performance of a previously derived endocarditis prediction instrument to rule out endocarditis in febrile injection drug users. From June 2007 to March 2001, we collected clinical prediction data from the first 6 hours of emergency department (ED) presentation of febrile injection drug users patients admitted from 2 urban EDs. Outcome data from inpatient records (echocardiogram, blood culture results, and discharge diagnoses) were independently abstracted by 2 investigators who were blinded to the ED prediction data. Diagnosis of endocarditis was based on Modified Duke criteria and documentation of endocarditis upon discharge. We determined the screening performance of the individual criteria and the endocarditis prediction instrument (combination of tachycardia, cardiac murmur, and absence of skin infection) Table 1.Tabled 1Screening performance of clinical criteriaTachycardiaCardiac MurmurAbsence of skin infectionDecision instrument (All 3)CXR infiltratesHistory of endocarditisSensitivity (95% CI)0.889 (0.653–0.986)0.722 (0.465–0.903)0.944 (0.727–0.999)1.000 (0.815–1.000)0.444 (0.215–0.692)0.556 (0.308–0.785)Specificity (95% CI)0.433 (0.368–0.500)0.706 (0.642–0.764)0.433 (0.368–0.500)0.134 (0.093–0.185)0.840 (0.786–0.885)0.879 (0.830–0.918)Positive predictive value (95% CI)0.109 (0.064–0.171)0.160 (0.088–0.259)0.115 (0.068–0.178)0.083 (0.050–0.127)0.178 (0.080–0.321)0.263 (0.134–0.431)Negative predictive value (95% CI)0.980 (0.931–0.998)0.970 (0.932–0.990)0.990 (0.946–1.000)1.000 (0.888–1.000)0.951 (0.912–0.976)0.962 (0.927–0.984)Odds ratio (95% CI)6.107 (1.522–24.320)6.232 (2.219–17.434)12.977 (2.155–77.483)Infinite4.195 (1.597–11.050)9.063 (3.386–24.263) Open table in a new tab Of the 249 subjects enrolled, 18 (7.3%) were diagnosed with endocarditis. Absence of skin infection had the highest sensitivity and diagnostic odds ratio. Other useful screening criteria were infiltrates on chest x-ray and history of endocarditis. Hyponatremia, thrombocytopenia, leukocytosis, and HIV status were poorly predictive of endocarditis. Endocarditis prediction instrument had 100% sensitivity (95% CI 81.5-100), 100% negative predictive value (95% CI 88.8-100), and 13.4% specificity (95% CI 9.3-18.5). In this internal validation study, the endocarditis prediction instrument consisting of tachycardia, murmur, and absence of skin infection effectively ruled out endocarditis with 100% sensitivity and 100% negative predictive value, consistent with the derivation study results. If external validation demonstrates similar screening performance, the endocarditis prediction instrument may safely decrease admissions for “rule out endocarditis” in febrile injection drug users.

A pilot study to develop a prediction instrument for endocarditis in injection drug users admitted with fever

Objective Seeking to evaluate the feasibility of a prediction instrument for endocarditis in febrile injection drug users (IDUs), we determined (1) the frequency percentage of IDUs admitted with fever diagnosed with endocarditis and (2) whether individual or combinations of emergency department (ED) clinical criteria (patient history, physical examination findings, and laboratory tests) are associated with endocarditis in IDUs admitted to rule out endocarditis. Methods The ED and inpatient charts of all IDUs with a diagnosis of rule out endocarditis admitted at 3 urban hospitals in 2006 were reviewed. Screening performance of individual criteria was determined, and the most sensitive combination of criteria was derived by classification tree analysis. Results Of 236 IDUs admitted with fever, 20 (8.5%) were diagnosed with endocarditis. Lack of skin infection, tachycardia, hyponatremia, pneumonia on chest radiograph, history of endocarditis, thrombocytopenia, and heart murmur had the best screening performance. The classification tree–derived best criteria combination of tachycardia, lack of skin infection, and cardiac murmur had a sensitivity of 100% (95% confidence interval, 84%-100%) and negative predictive value of 100% (95% confidence interval, 88%-100%). Conclusions Using ED clinical criteria, a multicenter prospective study to develop an instrument for endocarditis prediction in febrile IDUs is feasible, with an estimated target enrollment of 588 patients.

118: External Site Testing of an Instrument to Predict Endocarditis in Injection Drug Users With Fever

To externally test a previously derived decision instrument (100% sensitivity and 44% specificity in prior study) for endocarditis prediction in injection drug users (IDUs) admitted from the ED with fever.

Endocarditis Caused by Staphylococcus aureus

Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis.Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status.Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications.Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE.The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively).Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18).S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE.

Community-Associated Methicillin-Resistant Staphylococcus aureus Infective Endocarditis with Panton-Valentine Leukocidin Gene in an Injection Drug User with HIV Infection

Reports of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) isolates carrying Panton-Valentine leukocidin (PVL) gene that causes infective endocarditis in injection drug users (IDUs) with human immunodeficiency virus (HIV) infection are rare in the English language literature. We present a case of CA-MRSA infective endocarditis with bilateral septic lung emboli in a previously healthy 45-year-old IDU. This case suggests that PVL gene-positive CA-MRSA should be considered as a potential pathogen in IDUs with infective endocarditis.

Infective endocarditis due to community-associated methicillin-resistant Staphylococcus aureus in injection drug users may be associated with Panton-Valentine leukocidin-negative strains

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) isolates that cause infective endocarditis in injection drug users (IDUs) are distinct from CA-MRSA strains that cause endocardial infection as a complication of skin and soft tissue infections. We present a case of CA-MRSA infective endocarditis, review pertinent cases previously published, and describe the molecular characteristics of strains from IDUs and patients with skin and soft tissue infections.

Clinical manifestations and outcome in Staphylococcus aureus endocarditis among injection drug users and nonaddicts: a prospective study of 74 patients

BackgroundEndocarditis is a common complication in Staphylococcus aureus bacteremia (SAB). We compared risk factors, clinical manifestations, and outcome in a large, prospective cohort of patients with S. aureus endocarditis in injection drug users (IDUs) and in nonaddicts.MethodsFour hundred and thirty consecutive adult patients with SAB were prospectively followed up for 3 months. Definite or possible endocarditis by modified Duke criteria was found in 74 patients: 20 patients were IDUs and 54 nonaddicts.ResultsEndocarditis was more common in SAB among drug abusers (46%) than in nonaddicts (14%) (odds ratio [OR], 5.12; 95% confidence interval [CI], 2.65–9.91; P < 0.001). IDUs were significantly younger (27 ± 15 vs 65 ± 15 years, P < 0.001), had less ultimately or rapidly fatal underlying diseases (0% vs 37%, P < 0.001) or predisposing heart diseases (20% vs 50%, P = 0.03), and their SAB was more often community-acquired (95% vs 39%, P < 0.001). Right-sided endocarditis was observed in 60% of IDUs whereas 93% of nonaddicts had left-sided involvement (P < 0.001). An extracardiac deep infection was found in 85% of IDUs and in 89% of nonaddicts (P = 0.70). Arterial thromboembolic events and severe sepsis were also equally common in both groups. There was no difference in mortality between the groups at 7 days, but at 3 months it was lower among IDUs (10%) compared with nonaddicts (39%) (OR, 5.73; 95% CI, 1.20–27.25; P = 0.02).ConclusionS. aureus endocarditis in IDUs was associated with as high complication rates including extracardiac deep infections, thromboembolic events, or severe sepsis as in nonaddicts. Injection drug abuse in accordance with younger age and lack of underlying diseases were associated with lower mortality, but after adjusting by age and underlying diseases injection drug abuse was not significantly associated with mortality.

Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis.

Infective endocarditis of the right-side heart valves occurs commonly in injection drug users. Although a variety of hypotheses have been put forward to explain this clinical observation, no single hypothesis is adequate. In this article, basic scientific, clinical, and microbiological data on this topic are presented. It is apparent that no clear unifying mechanism emerges to explain the well-documented clinical predilection for the infection of the right-side heart valves in this population. Further investigation of this topic utilizing large international clinical registries may help to clarify matters further.

Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: Prospective randomized comparison with parenteral therapy

To compare the efficacy and safety of inpatient oral antibiotic treatment (oral) versus standard parenteral antibiotic treatment (intravenous) for right-sided staphylococcal endocarditis in injection drug users. In a prospective, randomized, non-blinded trial, febrile injection drug users were assigned to begin oral or intravenous (IV) treatment on admission, before blood culture results were available. Oral therapy consisted of ciprofloxacin and rifampin. Parenteral therapy was oxacillin or vancomycin, plus gentamicin for the first 5 days. Antibiotic dosing was adjusted for renal dysfunction. Administration of other antibacterial drugs was not permitted during the treatment or follow-up periods. Bacteremic subjects having right-sided staphylococcal endocarditis received 28 days of inpatient therapy with the assigned antibiotics. Test-of-cure blood cultures were obtained during inpatient observation 6 and 7 days after the completion of antibiotic therapy, and again at outpatient follow-up 1 month later. Criteria for treatment failure and for drug toxicity were prospectively defined. Of 573 injection drug users who were hospitalized because of a febrile illness and suspected right-sided staphylococcal endocarditis, 93 subjects (16.2%) had two or more sets of blood cultures positive for staphylococci; 85 of these bacteremic subjects (14.8%) satisfied diagnostic criteria for at least possible right-sided staphylococcal endocarditis (no other source of bacteremia was apparent) and entered the trial. Forty-four (oral, 19; IV, 25) of these 85 subjects completed inpatient treatment and evaluation including test-of-cure blood cultures. There were four treatment failures (oral, 1 [5.2%]; IV, 3 [12.0%]; not significant, Fisher's exact test). Drug toxicity was significantly more common in the parenterally treated group (oral, 3%; IV, 62%; P < 0.0001), consisting largely of oxacillin-associated increases in liver enzymes. For selected patients with right-sided staphylococcal endocarditis, oral ciprofloxacin plus rifampin is effective and is associated with less drug toxicity than is intravenous therapy.

Infective endocarditis in injection drug users: importance of human immunodeficiency virus serostatus and degree of immunosuppression.

Human immunodeficiency virus (HIV)-infected patients are at increased risk for serious and recurrent bacterial infections. We hypothesized that the degree of immunosuppression may play an important role in outcomes for HIV-seropositive patients with infective endocarditis (IE). To test our hypothesis, we retrospectively reviewed 144 cases of IE in injection drug users. One hundred two patients with documented HIV status (45 HIV-seropositive patients and 57 HIV-seronegative patients) were included in the analysis. Eleven patients (6 HIV-seropositive patients and 5 HIV-seronegative patients) died in the hospital. Staphylococcus aureus, the most common etiologic pathogen causing IE in our series, was isolated from 32 HIV-seropositive patients (71.1%) and 32 HIV-seronegative patients (56.1%). A clear inverse correlation between mortality rate and CD4 cell count was demonstrated (r = -.625; P < .001). Both univariate and multivariate analyses supported the finding of significantly higher mortality rates among patients with CD4 cell counts of < 200/mm3 than among patients with CD4 cell counts of > 500/mm3 (OR, 14.7; 95% CI, 2.64-81.9).

Short-course antibiotic therapy proposed for right-sided endocarditis in injection drug users

Short-course antibiotic therapy proposed for right-sided endocarditis in injection drug users

Prolong Fever with Murmur in Heart in a patient with History of Intravenous Drug Abuse - A Case Report

Right sided endocarditis accounts for 10% of all IE in population based surveys and a higher proportion of IE in injection drug users. Among injection drug users presenting with fever, 13% will have Echocardiographic evidence of IE. Staphylococcal endocarditis in injection drug users is now the dominant form of the disease in many urban communities where there is a high incidence of injection drug use and homelessness. Modern echocardiographic techniques have considerably augmented our ability to diagnose IE and to understand its natural history. Despite this, there are many areas in which our understanding of right sided IE remains incomplete. Keywords: Infective endocarditis; Tricuspid valve IVDU DOI: 10.3329/cardio.v3i1.6436Cardiovasc. j. 2010; 3(1): 101-103