Expanding the Team: Optimizing the Multidisciplinary Management of Drug Use-Associated Infective Endocarditis

Abstract Background Patients with injection drug use (IDU) have increased risk of developing infective endocarditis (IE). Previous studies have reported recurrent IE, increased duration of hospital stay, poor adherence and compliance as well as higher mortality and worse outcomes after surgery in the IDU-IE patient group. Further studies are needed to provide a basis for optimized care and prevention of readmissions in this population. This study aims to describe the clinical characteristics and outcomes among patients with IDU-IE. Methods Data of adults with IDU-IE and non-IDU-IE, treated between 2008 and 2017 at the Karolinska University Hospital in Stockholm were obtained from the Swedish National Registry of Infective Endocarditis. Clinical characteristics, microbiological results, treatment durations, results from echocardiography and in-hospital mortality were compared between the groups. Results Of the total 522 patients, 165 (32%) had IDU-IE. Patients with IDU-IE were younger than the patients with non-IDU-IE (mean age IDU-IE: 41.6 years, SD 11.9 years; non-IDU-IE: 64.3 years, SD 16.4 years; P < 0.01). No difference in distribution of gender was observed, 33% were females in both the IDU-IE and the non-IDU-IE group. History of previous IE (IDU-IE: n = 49, 30%; non-IDU-IE: n = 34, 10%; P < 0.01) and vascular phenomena (IDU-IE: n = 101, 61%; non-IDU-IE: n = 120, 34%; P < 0.01) were more common among patients with IDU-IE while prosthetic heart valves (IDU-IE: n = 12, 7%; non-IDU-IE: n = 83, 23%; P < 0.01) and known valvular disease (IDU-IE: n = 3, 2%; non-IDU-IE: n = 78, 22%; P < 0.01) were more common among patients with non-IDU-IE. Aetiology of Staphylococcus aureus (IDU-IE: n = 123, 75%; non-IDU-IE: n = 118, 33%; P < 0.01) as well as tricuspid (IDU-IE: n = 91, 55%; non-IDU-IE: n = 23, 6%; P < 0.01) or pulmonary valve vegetations (IDU-IE: n = 7, 4%; non-IDU-IE: n = 2, 1%; P < 0.01) were more common in the IDU-IE group. The overall incidence of IDU-IE decreased during the study period, while the incidence of definite IE increased (P < 0.01). Conclusions This study presents that patients with IDU-IE were younger, less frequently treated with surgery and had higher prevalence of vascular phenomena and history of previous IE, aspects that are important for improved management of this population.

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Infective endocarditis secondary to injection drug use: A survey of Canadian cardiac surgeons

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2020.12.003 ◽

2021 ◽

Author(s):

Kevin R. An ◽

Jessica G.Y. Luc ◽

Derrick Y. Tam ◽

Olina Dagher ◽

Rachel Eikelboom ◽

...

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug ◽

Cardiac Surgeons

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Injection Drug Use–Associated Infective Endocarditis

JAMA ◽

10.1001/jama.2018.14071 ◽

2018 ◽

Vol 320 (18) ◽

pp. 1939 ◽

Cited By ~ 1

Author(s):

David Phillip Serota ◽

J. Deanna Wilson ◽

Jessica S. Merlin

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug

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

Journal of the American Psychiatric Nurses Association ◽

10.1177/10783903211037735 ◽

2021 ◽

pp. 107839032110377

Author(s):

Kendrea L. Todt ◽

Sandra P. Thomas

Keyword(s):

Substance Use ◽

Infective Endocarditis ◽

Drug Use ◽

Substance Use Disorder ◽

Phenomenological Study ◽

Care Delivery ◽

Intravenous Drug ◽

Intravenous Drug Use ◽

Central Theme ◽

Number Of Patients

BACKGROUND: 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. OBJECTIVE: To describe an unexplored phenomenon in Appalachia to inform nursing practice, nursing education, and health policy. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

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Drug use-related right-sided infective endocarditis complicated by empyema and bronchopleural fistula

BMJ Case Reports ◽

10.1136/bcr-2021-246663 ◽

2022 ◽

Vol 15 (1) ◽

pp. e246663

Author(s):

Lindsey M Shain ◽

Taha Ahmed ◽

Michele L Bodine ◽

Jennifer G Bauman

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Bronchopleural Fistula ◽

Disease Process ◽

Intravenous Drug ◽

Pulmonary Emboli ◽

Intravenous Drug Use ◽

Respiratory Complications

Right-sided infective endocarditis is frequently accompanied by septic pulmonary emboli, which may result in a spectrum of respiratory complications. We present the case of a 25-year-old woman diagnosed with infective endocarditis secondary to intravenous drug use. During a long and arduous hospital course, the patient developed empyema with bronchopleural fistula, representing severe but uncommon sequelae that may arise from this disease process. She was treated with several weeks of antibiotics as well as surgical thorascopic decortication and parietal pleurectomy.

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The Need for Multidisciplinary Hospital Teams for Injection Drug Use-Related Infective Endocarditis

Journal of Addiction Medicine ◽

10.1097/adm.0000000000000916 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Melissa B. Weimer ◽

Caroline G. Falker ◽

Nikhil Seval ◽

Marjorie Golden ◽

Sarah C. Hull ◽

...

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug ◽

Hospital Teams

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The Evolving Burden of Drug Use Associated Infective Endocarditis in the United States

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2020.03.089 ◽

2020 ◽

Vol 110 (4) ◽

pp. 1185-1192 ◽

Cited By ~ 1

Author(s):

Arnar Geirsson ◽

Asher Schranz ◽

Oliver Jawitz ◽

Makoto Mori ◽

Liqi Feng ◽

...

Keyword(s):

United States ◽

Infective Endocarditis ◽

Drug Use ◽

The United States

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155. Infective Endocarditis and Cardiac Valve Surgery During the Opioid Epidemic in North Carolina, 2007 to 2017

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy209.025 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S12-S12

Author(s):

Asher Schranz ◽

Aaron Fleischauer ◽

Vivian H Chu ◽

David Rosen

Keyword(s):

North Carolina ◽

Infective Endocarditis ◽

Drug Use ◽

Fold Increase ◽

International Classification Of Diseases ◽

Valve Surgery ◽

Cardiac Valve ◽

Hospital Charges ◽

Opioid Epidemic ◽

Cardiac Valve Surgery

Abstract Background Infective endocarditis (IE) associated with drug use (DA-IE) is rising nationally. North Carolina (NC), a state hard-hit by the opioid epidemic, saw an over 12-fold increase in DA-IE from 2010 to 2015. Concerns about surgery exist due to the risk of ongoing drug use and reinfection after valvuloplasty. We evaluated trends, characteristics, and outcomes of valve surgery for DA-IE, compared with IE not associated with drug use (non-DA-IE), in NC. Methods We analyzed the NC Discharge Database, which includes administrative data from all hospital discharges in NC. Using International Classification of Diseases codes, we identified all persons ≥18 years of age with IE from July 1, 2007 to June 30, 2017. Hospitalizations were deemed DA-IE by a diagnosis code related to illicit drug use, dependence, poisoning or withdrawal (excepting marijuana), or Hepatitis C in a person born after 1965. All others were labeled non-DA-IE. Procedure codes were queried to identify cardiac valve surgery. Year-to-year trends in surgery for IE by drug-associated status were reported. Demographics, length of stay (LOS), charges, and disposition were compared among DA-IE and non-DA-IE. Results A total of 22,809 hospitalizations were coded for IE. Valve surgery occurred in 1,652. Of surgical hospitalizations, 17% overall and 42% in the final study year were DA-IE. Hospitalizations for DA-IE where surgery was done increased from <10 through 2012–2013 to 109 in 2016–2017 (figure). Compared with non-DA-IE, those undergoing surgery for DA-IE were younger (median age 33 vs. 56), female (47% vs. 33%), White (89% vs. 64%), uninsured (34% vs. 11%), insured by Medicaid (39% vs. 13%), and had tricuspid valve surgery (38% vs. 11%). DA-IE had longer median LOS (27 vs. 17 days) and were less often discharged home (51% vs. 59%). For the 287 DA-IE admissions with surgery, median hospital charges were $247,524, totaling over $79,000,000. All comparisons were significant at P < 0.0001. Conclusion From 2007 to 2017, valve surgeries for DA-IE in NC rose over tenfold and are approaching half of all surgeries for IE. This phenomenon is an underappreciated and morbid component of the opioid epidemic that burdens hospital and state resources. Research into best practices for managing patients with DA-IE and addressing addiction in this setting is critically needed. Disclosures All authors: No reported disclosures.

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Drug Use and Postoperative Mortality Following Valve Surgery for Infective Endocarditis: A Systematic Review and Meta-analysis

Clinical Infectious Diseases ◽

10.1093/cid/ciy1064 ◽

2018 ◽

Vol 69 (7) ◽

pp. 1120-1129 ◽

Cited By ~ 15

Author(s):

Ryan Hall ◽

Michael Shaughnessy ◽

Griffin Boll ◽

Kenneth Warner ◽

Helen W Boucher ◽

...

Keyword(s):

Systematic Review ◽

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Systematic Reviews ◽

Meta Analysis ◽

Postoperative Mortality ◽

Valve Surgery ◽

Injection Drug ◽

Significant Difference

AbstractBackgroundInfective endocarditis (IE) often requires surgical intervention. An increasingly common cause of IE is injection drug use (IDU-IE). There is conflicting evidence on whether postoperative mortality differs between people with IDU-IE and people with IE from etiologies other than injection drug use (non–IDU-IE). In this manuscript, we compare short-term postoperative mortality in IDU-IE vs non–IDU-IE through systematic review and meta-analysis.MethodsThe review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Publication databases were queried for key terms included in articles up to September 2017. Randomized controlled trials, prospective cohorts, or retrospective cohorts that reported on 30-day mortality or in-hospital/operative mortality following valve surgery and that compared outcomes between IDU-IE and non–IDU-IE were included.ResultsThirteen studies with 1593 patients (n = 341 [21.4%] IDU-IE) were included in the meta-analysis. IDU-IE patients more frequently had tricuspid valve infection, Staphylococcus infection, and heart failure before surgery. Meta-analysis revealed no statistically significant difference in 30-day postsurgical mortality or in-hospital mortality between the 2 groups.ConclusionsDespite differing preoperative clinical characteristics, early postoperative mortality does not differ between IDU-IE and non–IDU-IE patients who undergo valve surgery. Future research on long-term outcomes following valve replacement is needed to identify opportunities for improved healthcare delivery with IDU-IE.

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Maternal Bacteremia Caused by Staphylococcus Aureus With a Focus on Infective Endocarditis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa239 ◽

2020 ◽

Vol 7 (8) ◽

Author(s):

Morgan K Morelli ◽

Michael P Veve ◽

Mahmoud A Shorman

Keyword(s):

Staphylococcus Aureus ◽

Infective Endocarditis ◽

Drug Use ◽

Hospital Mortality ◽

Injection Drug Use ◽

Pregnant Patient ◽

Infectious Complications ◽

Injection Drug ◽

Secondary Outcome ◽

Targeted Interventions

Abstract Background Sepsis is an important cause of morbidity and mortality in the pregnant patient. Injection drug use in pregnant populations has led to increased cases of bacteremia and infective endocarditis (IE) due to Staphylococcus aureus. We describe all cases of S. aureus bacteremia and IE among admitted pregnant patients at our hospital over a 6-year period. Methods This was a retrospective review of pregnant patients hospitalized with S. aureus bacteremia between April 2013 and November 2019. Maternal in-hospital mortality and fetal in-hospital mortality were the primary outcomes measured; the secondary outcome was the rate of 6-month maternal readmission. Results Twenty-seven patients were included; 15 (56%) had IE. The median (interquartile range [IQR]) age was 29 (25–33) years; 22 (82%) patients had methicillin-resistant S. aureus. Infection onset occurred at a median (IQR) of 29 (23–34) weeks’ gestation. Twenty-three (85%) mothers reported active injection drug use, and 21 (78%) were hepatitis C seropositive. Fifteen (56%) mothers required intensive care unit (ICU) care. Twenty-two (81%) patients delivered 23 babies; of the remaining 5 mothers, 3 (11%) were lost to follow-up and 2 (7%) terminated pregnancy. Sixteen (73%) babies required neonatal ICU care, and 4/25 (16%) infants/fetuses died during hospitalization. One (4%) mother died during hospitalization, and 7/26 (27%) mothers were readmitted to the hospital within 6 months for infectious complications. Conclusions Injection drug use is a modifiable risk factor for S. aureus bacteremia in pregnancy. Fetal outcomes were poor, and mothers were frequently readmitted secondary to infection. Future targeted interventions are needed to curtail injection drug use in this population.

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