Injection Drug Use-associated Endocarditis Research Articles

Association of Treatment With Medications for Opioid Use Disorder With Mortality After Hospitalization for Injection Drug Use–Associated Infective Endocarditis

Although hospitalizations for injection drug use-associated infective endocarditis (IDU-IE) have increased during the opioid crisis, utilization of and mortality associated with receipt of medication for opioid use disorder (MOUD) after discharge from the hospital among patients with IDU-IE are unknown. To assess the proportion of patients receiving MOUD after hospitalization for IDU-IE and the association of MOUD receipt with mortality. This retrospective cohort study used a population registry with person-level medical claims, prescription monitoring program, mortality, and substance use treatment data from Massachusetts between January 1, 2011, and December 31, 2015; IDU-IE-related discharges between July 1, 2011, and June, 30, 2015, were analyzed. All Massachusetts residents aged 18 to 64 years with a first hospitalization for IDU-IE were included; IDU-IE was defined as any hospitalization with a diagnosis of endocarditis and at least 1 claim in the prior 6 months for OUD, drug use, or hepatitis C and with 2-month survival after hospital discharge. Data were analyzed from November 11, 2018, to June 23, 2020. Receipt of MOUD, defined as any treatment with methadone, buprenorphine, or naltrexone, within 3 months after hospital discharge excluding discharge month for IDU-IE. The main outcome was all-cause mortality. The proportion of patients who received MOUD in the 3 months after hospital discharge was calculated. Multivariable Cox proportional hazard regression models were used to examine the association of MOUD receipt with mortality, adjusting for sex, age, medical and psychiatric comorbidities, and homelessness. In the secondary analysis, receipt of MOUD was considered as a monthly time-varying exposure. Of 679 individuals with IDU-IE, 413 (60.8%) were male, the mean (SD) age was 39.2 (12.1) years, 298 (43.9%) were aged 18 to 34 years, 419 (72.3) had mental illness, and 209 (30.8) experienced homelessness. A total of 134 individuals (19.7%) received MOUD in the 3 months before hospitalization and 165 (24.3%) in the 3 months after hospital discharge. Of those who received MOUD after discharge, 112 (67.9%) received buprenorphine. The crude mortality rate was 9.2 deaths per 100 person-years. MOUD receipt within 3 months after discharge was not associated with reduced mortality (adjusted hazard ratio, 1.29; 95% CI, 0.61-2.72); however, MOUD receipt was associated with reduced mortality in the month that MOUD was received (adjusted hazard ratio, 0.30; 95% CI, 0.10-0.89). In this cohort study, receipt of MOUD was associated with reduced mortality after hospitalization for injection drug use-associated endocarditis only in the month it was received. Efforts to improve MOUD initiation and retention after IDU-IE hospitalization may be beneficial.

Treatment Outcomes and Subsequent Healthcare Utilization Among Patients With Injection Drug Use–Associated Endocarditis

Background: Addiction medicine consultation and medication-assisted treatment (MAT) have been promoted as a way to improve outcomes for patients hospitalized with injection drug use–associated endocarditis (IDU-IE). However, IDU-IE outcomes have not been evaluated in settings where these services are commonplace. Objective: In this study, we evaluated IDU-IE outcomes in a setting where involvement of addiction medicine consultants and use of MAT is well integrated into patient care. Methods: Medical records of patients hospitalized with a diagnosis of bacteremia or infective endocarditis (IE) between October 1, 2015, and December 31, 2017, at a safety-net hospital in Boston were screened for evidence of active injection drug use (IDU) within 6 months of hospitalization (as documented by providers or as supported by urine toxicology assays) for suspected or definite IE using modified Duke criteria. Patients without active IDU or IE were excluded, as were those with a diagnosis of IDU-IE over the 6 months prior to the index hospitalization. Demographic parameters, receipt of antibiotics and MAT, other clinical information, and details of rehospitalizations were recorded. Analyses of descriptive statistics were performed. Results: Of 567 subjects screened for inclusion, 47 patients met inclusion criteria. All had opiate use disorder (OUD); 41 patients (87.2%) had polysubstance abuse. Addiction medicine consultation was completed for 41 patients (87.2%). Of the 47 subjects, 23 patients (54.8%) received MAT (methadone or buprenorphine/naloxone) over their entire hospitalization, and 31 patients (73.8%) received MAT for >75% of the index admission. Moreover, 43 patients (91.5%) survived to discharge, of whom 28 (59.6%) completed antibiotic therapy. Relapsed IDU was observed in 33 patients (76.7%). Relapsed IDU trended toward significance among undomiciled patients (OR, 4.07,; 95% CI, 0.93–17.85; P = .06). Also, 24 patients (55.8%) were rehospitalized within 1 year due to infectious complications of IDU; undomiciled patients were readmitted more frequently (OR, 20.45; 95% CI, 1.09–383.99; P = .04). Completion of IDU-IE antibiotic therapy, relapse of IDU, and rehospitalization were not associated with prior AMA discharges, duration or variety of IDU, receipt of MAT during the index admission, or addiction medicine consultation. The rate of readmission due to an infectious complication of IDU within 1 year was unrelated to the proportion of hospital days where MAT was prescribed. Conclusions: In settings with high rates of addiction medicine consultation and in-hospital MAT administration, inpatient interventions targeting OUD may not necessarily be protective against morbidity and rehospitalization. Focusing on housing instability and outpatient continuation of MAT may be beneficial.Funding: NoneDisclosures: None

1023. A Controlled-Release Prescription Oral Opioid Can Prolong S. aureus Survival in Injection Drug Preparation Equipment and Potentially Increase Bacteremia Risk

Background S. aureus is the most common pathogen associated with injection drug use-associated endocarditis (IDUaIE). Our center has a high incidence of IDUaIE and the opiate of choice in our population is hydromorphone-controlled release (HCR), a prescribed oral opiate widely used in Canada and Europe. The complex technique for preparation for injection provides multiple opportunities for contamination of the solution and the controlled-release preparation contains several excipients (carbohydrates, protein, and iron), which could enhance Staphylococcal survival. A large amount of drug remains in the injection drug preparation equipment (IDPE) after each use and therefore, used IDPE is saved by people who inject drugs (PWID) for subsequent reuse by adding more water and then injecting the solution intravenously.MethodsUsed IDPE was collected from active PWID, rinsed with sterile water, aspirated into a syringe in a technique which mimicked reuse of equipment by PWID, and then plated on Mannitol salt agar (MSA). Bacterial isolates from local bacteremic PWID were used to test the survival of S. aureus (MRSA and MSSA) and S. pyogenes on unused IDPE with HCR or hydromorphone immediate release (HIR). The solutions were aspirated using techniques similar to that of local PWID and then plated on MSA and Blood agar.ResultsA total of 109 used IDPE samples were collected between March 2017 and March 2018. S. aureus was detected in 15/94 (16%) IDPE samples that had been used for injection of HMC (seven MRSA, seven MSSA, and two borderline resistant [one sample contained both MRSA and MSSA]), but 0/15 (0%) samples used for hydromorphone immediate release (HIR). HCR, but not HM, was associated with greater survival of MSSA and MRSA (but not S. pyogenes) in solutions of the drug when compared with sterile water vehicle control (Figure 1). There was a 2-log reduction in the number of viable S. aureus when IDPE containing HCR solutions spiked with MRSA or MSSA were heated with a cigarette lighter until bubbling (<10 seconds).ConclusionIDPE that has been used in the preparation of HCR is frequently contaminated with S. aureus; and in vitro HCR, but not HM, prolongs the survival of MRSA and MSSA. Heating IDPE may be an effective harm-reduction strategy to reduce bacterial complications of injection of HCR. Disclosures All authors: No reported disclosures.