Dalbavancin, oritavancin preferred options for treating infective endocarditis in persons who inject drugs

Abstract Background Persons who inject drugs (PWID) represent a distinct demographic of patients with infective endocarditis (IE). Many centers do not perform valvular surgery on these patients due to concerns about poor outcomes. Methods Retrospective cohort study comparing PWID patients to non-PWID patients presenting between February 2007 and March 2016 in London, Ontario, among adult (>18) inpatients with first episode IE. Results In 370 first episode IE cases, 53.9% occurred in PWIDs. PWID patients were younger (35.4 SD 10.0 vs. 59.4 SD 14.9) (P < 0.001), more likely to have right-sided infection [125/202 (62%), vs. 16/168 (9.5%) (P < 0.001)], and more often due to S. aureus (156/202 (77.3%) vs. 54/168 (32.1%), P < 0.001). Myocardial and aortic root abscesses were less common in PWIDs [17/202 (8.4%) vs. 50/168 (30%) (P < 0.01)]. There was no difference in the frequency of noncardiac complications. In total, 36.5% of patients were treated surgically with PWID patients less likely to undergo surgery [39/202 (19.3%) vs. 98/168 (58%) P < 0.001]. Cox regression analysis identified the protective effect of cardiac surgery with regards to survival in all patients, with a hazard ratio of 0.49 (95% CI 0.31–0.76, P < 0.001), as well as among PWIDs (HR 0.39, 95% CI 0.17–0.87, P = 0.02). Among all patients, lower survival was associated with older age (HR 1.03, 95% CI 1.00–1.05, P < 0.001), injection drug use (HR 2.72, 95% CI 1.52–4.88, P < 0.001), left-sided infection (HR 3.48, 95% CI 2.01–6.03, P < 0.001), and bilateral infection (HR 3.19, 95% CI 1.45–7.01, P = 0.004). The lower survival of left-sided infection (HR 4.01, 95% CI 1.97–8.18, P < 0.001) or bilateral infection (HR 6.94, 95% CI 2.39–20.2,P < 0.001) was re-demonstrated in PWIDs. Conclusion This study identifies important clinical differences between PWIDs and nondrug users with respect to valve involvement, causative organism, complications, and management strategies. Our results highlight the important role of surgical treatment in a carefully selected PWID patient population. Disclosures All authors: No reported disclosures.

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Brucella Endocarditis in Persons Who Inject Drugs

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa063 ◽

2020 ◽

Vol 7 (4) ◽

Author(s):

John M Cafardi ◽

Douglas Haas ◽

Thomas Lamarre ◽

Judith Feinberg

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug Users ◽

Drug Users ◽

Cardiac Involvement ◽

Injection Drug ◽

Persons Who Inject Drugs ◽

Brucella Infection

Abstract We report 2 cases of infective endocarditis in injection drug users due to Brucella infection. Although cardiac involvement is a frequent sequela of brucellosis and endocarditis is often seen with injection drug use, Brucella endocarditis in persons who inject drugs without zoonotic exposure has not been reported to date.

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139. The Morbidity and Financial Burden of Infective Endocarditis in Persons Who Inject Drugs in the Deep South

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.214 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S97-S98

Author(s):

Danielle deMontigny ◽

Rachael A Lee ◽

Joshua Radney ◽

Ellen Eaton

Keyword(s):

Substance Use ◽

Infective Endocarditis ◽

Length Of Stay ◽

Substance Use Disorder ◽

Financial Burden ◽

Direct Costs ◽

Nonparametric Tests ◽

Medical Examiner ◽

P Value ◽

Persons Who Inject Drugs

Abstract Background In the context of the opioid epidemic, infective endocarditis (IE) poses an economic challenge in Alabama. The objective of this proposal is to analyze the outcomes and financial burden of IE in persons who inject drugs (PWID) at The University of Alabama at Birmingham (UAB) Hospital, the largest tertiary referral center in this rural, Southern state. We hypothesized that those with the most severe substance use disorder would be most costly. Methods This is a retrospective study of PWID receiving care for IE at UAB Hospital from October 1, 2016 to March 1, 2019. IE was defined by Infectious Diseases consultation. Clinical data were obtained from the electronic medical record (EMR). Deaths were obtained from both the EMR and the regional medical examiner. Hospital costs (direct costs, overall charges) were obtained from financial accounts. To stratify patients by severity of substance use disorder, we used a 9-item risk assessment for PWID (see table). We then evaluated the association between clinical factors and outcomes (death, cost) using parametric and nonparametric tests when appropriate. A P-value < 0.05 was considered significant. Results A total of 69 persons met criteria (Table 1). The average length of stay was 30.8 days. Thirty-four (52%) had documentation of antibiotic completion (in or outpatient). Seventeen received surgery: 16 with valve replacement and one device removal. Overall, 14 (20%) died over the study period. There was no significant association between antibiotic completion or 9-item risk and death. When stratified into low risk (<4 items) vs. high risk (≥5), there was no difference in overall direct costs, LOS, or whether patients received surgery. Conclusion PWID with IE at a hospital serving a rural, Southern population have a greater length of stay, discharges against advice, surgical interventions, and costs than other regions, relative to existing literature. The lack of association between 9-item risk and outcomes suggests that death and high costs are attributable to factors beyond substance use. Costs of providing care for this population are exorbitant and likely devastating for rural county hospitals within the context of the current public health and payment framework, including Medicaid non-expansion. Disclosures All authors: No reported disclosures.

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Repeat Infective Endocarditis in Persons Who Inject Drugs: “Take Another Little Piece of my Heart”*

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy304 ◽

2018 ◽

Vol 5 (12) ◽

Cited By ~ 6

Author(s):

Glen Huang ◽

Erin W Barnes ◽

James E Peacock

Keyword(s):

Infective Endocarditis ◽

Medical Center ◽

Prescription Opioid ◽

First Episode ◽

Opioid Use ◽

Persons Who Inject Drugs ◽

Single Episode ◽

Duke Criteria ◽

Few Data ◽

Prescription Opioid Use

Abstract Background Injection drug use (IDU) is a major risk factor for infective endocarditis (IE). Few data exist on repeat IE (rIE) in persons who inject drugs (PWID). Methods Patients ≥18 years old seen at Wake Forest Baptist Medical Center from 2004 to 2017 who met Duke criteria for IE and who self-reported IDU in the 3 months before admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after diagnosis of the first episode, was then reviewed. Results Of the 87 PWID who survived their first episode of IE, 22 (25.3%) experienced rIE and 77.3% had rIE within a year of the first episode. All patients who experienced rIE resumed IDU between episodes of IE. Of the patients with rIE, 54.5% had an infection caused by S. aureus and 22.7% required surgical intervention. Mortality at 1 year was 36.3%. Compared with their first IE episode, patients with rIE had fewer S. aureus infections (P = .01). Compared with PWID who experienced single-episode IE, intravenous prescription opioid use (P = .01), surgery (P < .01), tricuspid valve involvement (P = .02), and polymicrobial infection (P = .03) occurred more often during first episodes of IE in individuals who then developed rIE. Conclusions rIE is common among IDU-related IE and confers a high 1-year mortality rate. The microbiology of rIE is varied, with S. aureus being less frequently isolated. More studies on modification of social and clinical risk factors are needed to prevent rIE.

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Risk Factors Of Infective Endocarditis In Persons Who Inject Drugs

10.21203/rs.2.22402/v1 ◽

2020 ◽

Author(s):

Meera Shah ◽

Ryan Wong ◽

Laura Ball ◽

Charlie Tan ◽

Esfandiar Shojaei ◽

...

Keyword(s):

Risk Factors ◽

Infective Endocarditis ◽

Drug Users ◽

Best Practice ◽

Protective Factor ◽

Tertiary Care ◽

Surrogate Marker ◽

Persons Who Inject Drugs ◽

Injection Process ◽

Injection Practices

Abstract Background: The rising incidence of infective endocarditis (IE) among people who inject drugs (PWID) has been a major concern across North America. Details of injection practices leading to IE are not well characterized.Methods: A case-control study, using one-on-one interviews to understand risk factors and injection practices associated with IE among PWID was conducted. Eligible participants included those who had injected drugs within the last 3 months, were > 18 years old and either never had or were currently admitted for an IE episode. Cases were recruited from the tertiary care centers and controls were recruited from outpatient clinics in patients without IE and addiction clinics in London, Ontario. Results: 33 cases (PWID IE+) and 102 controls (PWID but IE-) were interviewed. Using clean injection equipment from the provincial distribution network was a protective factor against IE (p<0.001). Furthermore, using lighters during the injection process was also protective for IE (OR 2.5; 95% CI 1.11–5.63). Female sex (OR 3.63; 95% CI 1.58-8.36) and injection into multiple sites (OR 4.31; 95% CI 1.33-13.93) were associated with IE. Injection into the feet (57.6% cases; 36.6% control; p= 0.034) was also associated with IE. Discussion: Our pilot study highlights the importance of distributing clean injection materials for IE prevention. Injection into multiple areas may indicate a greater difficulty in accessing common and safer injection sites such as the arm, and thus multi-site injections may be a surrogate marker for injection-related venous damage in entrenched drug users. Moreover, the use of lighters may be correlated with the best practice of heating preparations of drugs prior to injection, which is known to reduce bacterial burden. Lastly, gender differences in injection techniques, which may place women at higher risk of IE, requires further study.

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153. A Review of Ten Cases of Pulmonic Valve Infective Endocarditis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.228 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S103-S103

Author(s):

Harry E Hicklin ◽

Glen Huang ◽

Kyle A Davis ◽

Erin W Barnes ◽

James E Peacock

Keyword(s):

Infective Endocarditis ◽

Diagnostic Yield ◽

Medical Center ◽

Causative Organism ◽

Pulmonary Emboli ◽

Rare Entity ◽

Median Length ◽

Persons Who Inject Drugs ◽

Pulmonic Valve ◽

Duke Criteria

Abstract Background Pulmonic valve (PV) infective endocarditis (IE) is a rare entity, accounting for ~1.5–2% of all cases of IE. As a result, published literature describing the diagnosis and management of patients with PVIE is limited. Methods A retrospective review of patients ≥18 years old admitted to Wake Forest Baptist Medical Center from 2012 to 2017 with a diagnosis of PVIE based on the modified Duke criteria was performed. Results Ten patients were identified as having PVIE, 9 of whom had isolated PV involvement and 1 of whom had concurrent aortic valve involvement. The diagnosis of IE was definite per the modified Duke criteria in 8 patients. The median age was 41 years and 30% were female. Two patients had pacemakers, 1 had a prosthetic PV, and 1 had congenital heart disease. Six patients were identified as persons who inject drugs (PWID). On admission, 5 patients manifested fever and 5 had a documented murmur. Seven patients had septic pulmonary emboli with 4 of 7 patients manifesting pulmonary hypertension. Transthoracic echocardiography (TTE) revealed vegetations in 4 of 10 patients whereas PV vegetations were demonstrated in all 8 patients undergoing transesophageal echocardiography (TEE). S. aureus was the most common causative organism, accounting for 5 of the cases of PVIE with four of the five isolates being methicillin-resistant. Bacteremia persisted for a median of 3 days. One patient underwent PV replacement. The planned median duration of antimicrobial therapy was 6 weeks. The median length of stay was 18 days. Three patients died during the index hospitalization, 1 of whom was a PWID. No episodes of repeat PVIE occurred within 1 year. Conclusion PVIE is a rare disease. Only 40% of our patients had vegetations on TTE in contrast to a reported diagnostic yield of >90% in the literature. As such, PVIE may be underdiagnosed. S aureus was the most common organism isolated, which is in keeping with prior reports. PWID appear to be at high risk for PVIE. In view of the worsening opioid epidemic, more research on PVIE is warranted. Disclosures All authors: No reported disclosures.

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138. Prognosis Following Valve Replacement Surgery for Infective Endocarditis Among Persons Who Inject Drugs

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.213 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S97-S97

Author(s):

Sean Bullis ◽

Krystine Spiess ◽

W Kemper Alston

Keyword(s):

Infective Endocarditis ◽

Length Of Stay ◽

Valve Replacement ◽

High Mortality ◽

Medical Center ◽

Academic Medical Center ◽

Persons Who Inject Drugs ◽

Replacement Surgery ◽

Valve Replacement Surgery

Abstract Background Infective endocarditis (IE) is a major cause of morbidity and mortality among persons who inject drugs (PWID) and rates have increased during the current opioid epidemic. Severe cases may require valve replacement surgery (VRS). These patients are typically younger with fewer comorbidities than those who undergo VRS for other indications. This study was designed to examine the prognosis for these cases. Methods The University of Vermont Medical Center is a 562-bed academic medical center. A retrospective cohort included all cases of IE among PWID who underwent VRS between November, 2009 and December, 2015. The cohort intentionally included surgeries performed prior to 2016 in order to provide sufficient follow-up time. Outcomes included survival, readmission, complications, adherence to follow-up, length of stay, rate of repeat VRS, microbiology, and recurrent bloodstream infections. Results The cohort included 31 patients. 80% were male and the median age was 31. The valves replaced or repaired included 18 aortic, 10 mitral, 9 tricuspid, and 1 pulmonic (7 patients had two valves involved). Organisms included Staphylococcus aureus (48%), Streptococcus spp. (22%), and Enterococcus (13%). The median length of stay for the index admission was 35 days. To date, at least 38% of the cohort has died. The median survival for those who died was 337 days (0–2,224). Adherence with initial outpatient follow-up visit was only 50%, with others either canceling or missing appointments. 39% followed up with infectious diseases and 39% with cardiothoracic surgery. 29% never followed up. The readmission rate was 51%, and 22% of the cohort was readmitted more than three times. 48% had a repeat bloodstream infection, 73% of which were with a different organism than the index infection. The rate of repeat VRS was 31%. Conclusion Our observational data reveal a high mortality rate with poor adherence to follow-up and a high rate of readmission among this rural cohort of PWID who have VRS for IE. The major limitation of this work is the passive follow-up from the medical record. The high mortality and morbidity of this disease suggests that more intensive, multispecialty post-operative care is needed for PWID who are treated surgically. Disclosures All authors: No reported disclosures.

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Bacterial Endocarditis of Anatomically Normal Native Pulmonic Valve with No Predisposing Risk Factors: Case Report and Review

Case Reports in Infectious Diseases ◽

10.1155/2020/1453126 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Muhannad Antoun ◽

John Deel ◽

Dermot Halpin ◽

Fadi Al-Akhrass

Keyword(s):

Risk Factors ◽

Case Report ◽

Infective Endocarditis ◽

Electronic Device ◽

Bacterial Endocarditis ◽

Cardiac Implantable Electronic Device ◽

Native Valve ◽

Persons Who Inject Drugs ◽

Pulmonic Valve ◽

Common Risk Factors

Right-sided native valve infective endocarditis (IE) includes tricuspid valve (TV) and pulmonic valve (PV). It represents 10% of all cases. However, it is more common in persons who inject drugs or in presence of cardiac implantable electronic device (CIED). Pulmonic valve endocarditis is a rare infection and represents ∼1% of all cases. Our case represents a patient with large pulmonic valve vegetation with no known common risk factors for right-sided IE.

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Risk factors of infective endocarditis in persons who inject drugs

Harm Reduction Journal ◽

10.1186/s12954-020-00378-z ◽

2020 ◽

Vol 17 (1) ◽

Author(s):

Meera Shah ◽

Ryan Wong ◽

Laura Ball ◽

Klajdi Puka ◽

Charlie Tan ◽

...

Keyword(s):

Risk Factors ◽

Infective Endocarditis ◽

Persons Who Inject Drugs

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