Commentary: When is repeated cardiac valve surgery justified during drug-associated infective endocarditis?

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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Outcome of dialysis-requiring acute kidney injury in patients with infective endocarditis: A nationwide study

Clinical Infectious Diseases ◽

10.1093/cid/ciaa1017 ◽

2020 ◽

Author(s):

Jeppe Kofoed Petersen ◽

Andreas Dalsgaard Jensen ◽

Niels Eske Bruun ◽

Anne-Lise Kamper ◽

Jawad Haider Butt ◽

...

Keyword(s):

Acute Kidney Injury ◽

Infective Endocarditis ◽

Hospital Mortality ◽

Kidney Injury ◽

Valve Surgery ◽

Cardiac Valve ◽

Post Discharge ◽

Dialysis Treatment ◽

Cardiac Valve Surgery ◽

One Year

Abstract Background Infective endocarditis (IE) may be complicated by acute kidney injury, yet data on the use of dialysis and subsequent reversibility are sparse. Methods Using Danish nationwide registries, we identified patients with first-time IE from 2000 to 2017. Dialysis naïve patients were grouped into: those with and those without dialysis during admission with IE. Continuation of dialysis was followed one year post-discharge. Multivariable adjusted Cox proportional hazard analysis was used to examine one-year mortality for patients surviving IE according to use of dialysis. Results We included 7,307 patients with IE; 416 patients (5.7%) initiated dialysis treatment during admission with IE and these were younger, had more comorbidities and more often underwent cardiac valve surgery compared with non-dialysis patients (47.4% vs. 20.9%). In patients with both cardiac valve surgery and dialysis treatment (n=197), 153 (77.7%) initiated dialysis on- or after the date of surgery. The in-hospital mortality was 40.4% and 19.0% for patients with and without dialysis, respectively (p<0.0001). Of those who started dialysis and survived hospitalization, 21.6% continued dialysis treatment within one year after discharge. In multivariable adjusted analysis, dialysis during admission with IE was associated with an increased one-year mortality from IE discharge, HR=1.64 (95% CI: 1.21-2.23). Conclusion In dialysis-naïve patients with IE, approximately 1 in 20 patients initiated dialysis treatment during admission with IE. Dialysis identified a high-risk group with an in-hospital mortality of 40% and an approximately 20% risk of continued dialysis. Those with dialysis during admission with IE showed worse long-term outcomes than those without.

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