1021. Repeat Infective Endocarditis (rIE) in Persons Who Inject Drugs (PWID)

Abstract Background Injection drug use (IDU) is a major risk factor for infective endocarditis (IE). Rates of IE have recently increased in the US concurrent with the opioid crisis. Although IDU-related IE is well described, 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 2004–2017 with an ICD-9 or -10 diagnosis of IE who met Duke criteria for IE and who self-reported IDU in the 3 months prior to admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after the diagnosis of the first episode, was then reviewed. Results Of the 94 PWID with IE, 22 (23.4%) experienced rIE (19 re-infections, three relapses). All patients were Caucasian, 50% were male, and 68.2% lived in rural areas; the median age was 30. All 22 patients resumed IDU after their first episode of IE. The mean duration from completion of antibiotics for the prior IE episode to admission with rIE was 257.5 days; the episode of rIE occurred within 1 year in 17 patients (77.3%). On repeat admission, those with rIE had a Pitt bacteremia score of 3.0 and an APACHE II score of 13.1. Fever and bacteremia persisted for an average of 5.6 days and 2.6 days, respectively. S. aureus was the cause of rIE in 54.5% of patients and the tricuspid valve (TV) was involved in 77.3% of cases. Valve surgery occurred in 22.7% of patients. Mean length of stay was 25.3 days and mean duration of antibiotic therapy was 32.1 days. Seven patients (31.8%) died during the rIE hospitalization and another died within 12 months after discharge resulting in a 1-year mortality of 36.3%. Compared with their first episode of IE, rIE patients had higher admission Pitt bacteremia (3.0 vs. 1.5, P = 0.07) and APACHE II scores (13.1 vs. 9.5, P = 0.18), fewer S. aureus infections (54.5% vs. 95.4%, P = 0.01), similar TV involvement (77.3% vs. 72.7%, P = 1), and less frequent surgery (22.7% vs. 59.1%, P = 0.06). Conclusion rIE is common in PWID with most episodes occurring within 1 year of the initial episode. Reinfection is more frequent than relapse. The microbiology of rIE is more varied than first episode IE in PWID with S. aureus being less frequently isolated. Illness severity is high, hospitalizations are prolonged, and 1-year mortality is significant. More effective strategies for preventing rIE in PWID are needed. Disclosures J. Peacock, Pfizer: Shareholder, Owns common stock in Pfizer which was inherited and held in a trust.

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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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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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Clinical Characteristics and Factors Associated With Mortality in First-Episode Infective Endocarditis Among Persons Who Inject Drugs

JAMA Network Open ◽

10.1001/jamanetworkopen.2018.5220 ◽

2018 ◽

Vol 1 (7) ◽

pp. e185220 ◽

Cited By ~ 40

Author(s):

Laura Rodger ◽

Stephannie Dresden Glockler-Lauf ◽

Esfandiar Shojaei ◽

Adeel Sherazi ◽

Brian Hallam ◽

...

Keyword(s):

Infective Endocarditis ◽

Clinical Characteristics ◽

First Episode ◽

Persons Who Inject Drugs ◽

Factors Associated

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1024. First Episode Infective Endocarditis in Persons Who Inject Drugs (PWIDs); A Retrospective Cohort Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.861 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S305-S305

Author(s):

Laura Rodger ◽

Dresden GlockerLauf ◽

Esfandiar Shojaei ◽

Adeel Sherazi ◽

Brian Hallam ◽

...

Keyword(s):

Cohort Study ◽

Infective Endocarditis ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Cox Regression ◽

First Episode ◽

Persons Who Inject Drugs ◽

Cox Regression Analysis ◽

Lower Survival ◽

Valvular Surgery

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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170. Predictors of Recurrent Infective Endocarditis in Intravenous Drug Users

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.245 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S109-S109

Author(s):

Kullatham Kongpakpaisarn ◽

Sadaf Aslam ◽

Musaab Tariq ◽

Rahul Mhaskar ◽

Doosup Shin ◽

...

Keyword(s):

Septic Shock ◽

Infective Endocarditis ◽

Drug Use ◽

Kidney Diseases ◽

Medical Center ◽

First Episode ◽

Demographic Information ◽

Contributing Factors ◽

Significant Difference ◽

Iv Drug Use

Abstract Background Caring for hospitalized patients with infective endocarditis (IE) can be challenging due to the nature of the disease and its complications, underlying medical and psychiatric problems, socioeconomic status and environmental factors.Some of these patients develop recurrent IE after the first episode treated. On-going intravenous (IV) drug use after hospital discharge is the highest predictive factor for recurrent IE. Besides IV drug use, there are limited data of other contributing factors to recurrent IE. Those factors may be modifiable during the first hospitalization to reduce the incidence of recurrent IE. Methods A retrospective cohort study was conducted at a large tertiary acute care medical center in Tampa, Florida. All consecutive patients with IE with history of IV drug use from January, 2011 to December, 2017 were included. Basic demographic information, co-morbidities (diabetes, hypertension, chronic lung and kidney diseases, HIV, Hepatitis B and C status, coronary artery diseases), valves involved, length of stay, complications at their first IE episode such as septic shock and stroke were included. Groups were identified based on the first episode, first recurrence and second or more recurrences of IE. Results A total of 106 patients were identified based on the inclusion criteria. The association between the type of valve infection (right side and left side) and IE recurrence was found to be statistically significant. (P = 0.003). Right side valves are prone to have recurrent IE episodes. People with recurrent IE were more likely to have septic shock (P = 0.02) and requiring intensive care unit (ICU) admissions (P < 0.001) during their first episode There was no statistically significant difference between other demographic information and recurrent endocarditis as well as other parameters such as organisms or type of substance used. (Table 1) Conclusion Right-sided IE and presence of septic shock during their first episode of IE may be the predictors for recurrent IE. Interventions including closer follow-up, more aggressive septic shock recognition and management, socioeconomic assessment in addition to substance abuse treatments after discharge should be considered to prevent recurrent IE. Disclosures All authors: No reported disclosures.

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Dialysis access as a source of infective endocarditis in dialysis patients

Monaldi Archives for Chest Disease ◽

10.4081/monaldi.2020.1505 ◽

2020 ◽

Vol 90 (4) ◽

Author(s):

Hee D. Jeon ◽

Kevin B. Lo ◽

Eduardo E. Quintero ◽

Byeori Lee ◽

Asma Gulab ◽

...

Keyword(s):

Infective Endocarditis ◽

Vascular Access ◽

Medical Center ◽

Bacterial Invasion ◽

Dialysis Access ◽

Dialysis Patients ◽

Access Site ◽

Source Of Infection ◽

Duke Criteria ◽

Increased Risk

The incidence of Infective Endocarditis (IE) is higher in dialysis patients compared to the general population. A major risk factor for IE in this group stems from bacterial invasion during repeated vascular access. Previous studies have shown increased risk of bacteremia in patients with indwelling dialysis catheters compared to permanent vascular access. However, association between the development of IE and the type of dialysis access is unclear. We aimed to examine the associated types of intravascular access and route of infection in dialysis patients who were admitted with infective endocarditis at our center. All patients admitted to Albert Einstein Medical Center in Philadelphia with a diagnosis of infective endocarditis who were on chronic hemodialysis were identified from the hospital database for the period of 1/1/07 to 12/31/18. Modified Duke criteria was used to confirm the diagnosis of infective endocarditis. A total of 96 cases were identified. Of those, 57 patients had an indwelling dialysis catheter while the other 39 had permanent dialysis access. In 82% of patients with dialysis catheters, their dialysis access site was identified as the primary source of infection compared to 30% in those with permanent dialysis access (p<0.001). The number of dialysis catheters placed in the preceding 6 months was strongly associated with endocarditis resulting from the dialysis access site (OR = 3.202, p=0.025). Dialysis catheters are more likely to serve as the source of infection in dialysis patients developing IE compared to permanent dialysis access. Increased awareness of risk of IE associated with dialysis catheters is warranted.

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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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Assessing the in-hospital survival benefits of intensive care

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462305050087 ◽

2005 ◽

Vol 21 (1) ◽

pp. 66-72 ◽

Cited By ~ 21

Author(s):

Amir Shmueli ◽

Charles L. Sprung

Keyword(s):

Intensive Care ◽

Potential Benefit ◽

Medical Center ◽

Probit Model ◽

Apache Ii ◽

Apache Ii Score ◽

Differential Survival ◽

Hospital Survival ◽

Average Potential ◽

Admission Policies

Objectives:For an efficient and fair allocation of medical resources, one must know which patients benefit more from medical care. The objective of this study is to assess the differential survival benefits of a general intensive care unit (ICU) by acute diagnoses and by Acute Physiological and Chronic Health Evaluation (APACHE II) scores.Methods:The sample included all patients triaged for admission to the Hadassah-Hebrew University Medical Center ICU during a 7-month period (n = 381). The potential effect of ICU on in-hospital survival was estimated by a bivariate (admission–survival) probit model, using crowding in the unit as the identifying variable, controlling for observable patients characteristics: age, sex, acute diagnoses, and APACHE II score. Using the estimates, the differential predicted survival benefits of ICU were calculated for selected general acute diagnoses and for different APACHE II scores.Results:Adjusting for age, sex, and general acute diagnoses, the average potential survival benefit of ICU is 17 percentage points (pts). The benefit of ICU for patients with central nervous system problems, with sepsis, or with respiratory failure are higher than average (23 pts). Adjusting for APACHE II scores as well increases the estimated average potential benefit to 21 pts. Over the range of APACHE II scores, the highest benefit (38 pts of potential benefit) is attained for patients with scores around 22.Conclusions:Survival benefits differ across diagnoses and APACHE II scores. Facing limited resources, admission policies should distinguish between survival probabilities (and survival maximization) and survival benefits (and maximization of ICU benefits). Actual referral and admission policies to the present ICU do not maximize the potential survival benefits of ICU resources.

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Vancomycin AUC24/MIC Ratio in Patients with Complicated Bacteremia and Infective Endocarditis Due to Methicillin-Resistant Staphylococcus aureus and Its Association with Attributable Mortality during Hospitalization

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.05609-11 ◽

2011 ◽

Vol 56 (2) ◽

pp. 634-638 ◽

Cited By ~ 71

Author(s):

Jack Brown ◽

Kristen Brown ◽

Alan Forrest

Keyword(s):

Staphylococcus Aureus ◽

Infective Endocarditis ◽

Odds Ratio ◽

Univariate Analysis ◽

Apache Ii ◽

Bayesian Estimator ◽

Attributable Mortality ◽

Apache Ii Score ◽

Main Diagnosis ◽

Methicillin Resistant

ABSTRACTMethicillin-resistantStaphylococcus aureus(MRSA) is a common cause of complicated bacteremia (CB) and infective endocarditis (IE). The gold standard treatment for these infections is vancomycin. A vancomycin area under the concentration-time curve from 0 to 24 h (AUC24)/MIC ratio of >400 has been suggested as a target to achieve clinical effectiveness, and yet to date no study has quantitatively investigated the AUC24/MIC ratio and its association with attributable mortality (AM). We performed a review of patients treated for MRSA CB and IE from 1 July 2006 to 30 June 2008. AM was defined as deaths where CB or IE was documented as the main cause or was mentioned as the main diagnosis. Classification and regression tree analysis (CART) was used to identify the AUC24/MIC ratio associated with AM. Mann-Whitney and Fisher exact tests were used for univariate analysis, and logistic regression was used for multivariate modeling. The MICs were determined by Etest, and the AUC24was determined using a maximuma posterioriprobability-Bayesian estimator. A total of 32 CB and 18 IE patients were enrolled. The overall crude mortality and AM were 24 and 16%, respectively. The CART-derived partition for the AUC24/MIC ratio and AM was <211. Patients with an AUC24/MIC ratio of <211 had a >4-fold increase in AM than patients who received vancomycin doses that achieved an AUC24/MIC ratio of ≥211 (38 and 8%, respectively;P= 0.02). In bivariate analysis the APACHE-II score and an AUC24/MIC ratio of <211 were significantly associated with AM. In the multivariate model, the APACHE-II score (odds ratio, 1.24;P= 0.04) and a vancomycin AUC/MIC ratio of <211 (odds ratio, 10.4;P= 0.01) were independent predictors of AM. In our analysis, independent predictors of AM were the APACHE-II score and an AUC24/MIC ratio of <211. We believe further investigations are warranted.

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Das rupturierte infrarenale Aortenaneurysma – eine kritische Analyse

VASA ◽

10.1024/0301-1526.28.1.30 ◽

1999 ◽

Vol 28 (1) ◽

pp. 30-33 ◽

Cited By ~ 9

Author(s):

Bürger ◽

Meyer ◽

Tautenhahn ◽

Halloul

Keyword(s):

Aortic Aneurysm ◽

Aortic Rupture ◽

Anesthetic Management ◽

Objective Evaluation ◽

Left Ventricular ◽

Apache Ii ◽

Apache Ii Score ◽

Infrarenal Aortic Aneurysm ◽

Emergency Situations ◽

Probability Of Death

Background: Objective evaluation of the management of patients with ruptured infrarenal aortic aneurysm in emergency situations has been described rarely. Patients and methods: Fifty-two consecutive patients with ruptured infrarenal aortic aneurysm (mean age, 70.3 years; range, 56–89 years; SD 7.8) were admitted between January 1993 and March 1998. Emergency protocols, final reports, and follow-up data were analyzed retrospectively. APACHE II scores at admission and fifth postoperative day were assessed. Results: The time between the appearance of first symptoms and the referral of patients to the hospital was more than 5 hours in 37 patients (71%). Thirty-eight patients (71%) had signs of shock at time of admission. Ultrasound was performed in 81% of patients as the first diagnostic procedure. The most frequent site of aortic rupture was the left retroperitoneum (87%). Intraoperatively, acute left ventricular failure occurred in four patients, and cardiac arrest in two others. The postoperative course was complicated significantly in 34 patients. The overall mortality rate was 36.5% (n = 19). In 35 patients, APACHE II score was assessed, showing a probability of death of more than 40% in five patients and lower than 30% in 17 others. No patient showing probability of death of above 75% at the fifth postoperative day survived (n = 7). Conclusions: Ruptured aortic aneurysm demands surgical intervention. Clinical outcome is also influenced by preclinical and anesthetic management. The severity of disease as well as the patient’s prognosis can be approximated using APACHE II score. Treatment results of heterogenous patient groups can be compared.

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