Key Points Question In first-episode infective endocarditis in persons who inject drugs, what are the clinical differences between patients who receive surgery vs those who are medically treated, and which factors are associated with mortality? Findings In this case series of 370 first-episode cases of infective endocarditis, the main significant differences between persons who inject drugs who received surgery and those who did not were the site of infection and cardiac complications. Decreased mortality was associated with surgery and referral to addiction treatment services, while higher mortality was associated with left-sided and bilateral infections. Meaning In selected persons who inject drugs with first-episode endocarditis, surgical management and referral to addiction treatment were associated with reduced mortality.

to address the emerging public health emergency in persons who inject drugs in Middlesex-London, with further details on strategy and resources to come to the Board of Health in September. Key Points  Rates of HIV, Hepatitis C, Invasive Group A Streptococcal Disease, and infective endocarditis have all been increasing in persons who inject drugs in Middlesex-London.  Rates are being driven by several intersecting factors, including underlying mental health and addictions issues, and changes in prescription opioid drug practices.  Stakeholders will continue to be engaged at the local and provincial levels to ensure an integrated and coordinated response to this emerging public health issue.

Background Injection drug use-associated endocarditis (IDUaIE) incidence in Ontario has recently been associated with hydromorphone prescribing rates. Staphylococcus aureus causes the majority of cases of IDUaIE in Ontario and across North America. Hydromorphone controlled-release (Hydromorphone-CR) requires a complex technique for injection and therefore provides multiple opportunities for contamination. Hydromorphone-CR contains several excipients, which could enhance staphylococcal survival and increase risk of contaminating the injectate. Methods Used injection drug preparation equipment (cookers/filters) was collected from persons who inject drugs (PWID), rinsed with water, and plated on Mannitol salt agar. Bacterial isolates from bacteremic PWID were used to assess the survival of S . aureus and Streptococcus pyogenes on cookers/filters with Hydromorphone-CR, hydromorphone immediate-release (Hydromorphone-IR) or oxycodone controlled-release (Oxycodone-CR). The solutions spiked with S . aureus were heated and the remaining viable bacteria enumerated. Results S . aureus was detected in 12/87 (14%, 95%CI 8–23%) cookers/filters samples used for injection of Hydromorphone-CR. Hydromorphone-CR was the only opioid associated with greater survival of methicillin-sensitive S . aureus (MSSA) and methicillin-resistant S . aureus (MRSA) on cookers/filters when compared to sterile water vehicle control. There was a ~2 log reduction in the number of S . aureus that survived when cookers/filters were heated. Conclusion 14% of all cookers/filters used in the preparation of Hydromorphone-CR were contaminated with S . aureus . Hydromorphone-CR prolongs the survival of MRSA and MSSA in cookers/filters. Heating cookers/filters may be a harm-reduction strategy.

BackgroundPersons 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.MethodsRetrospective 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.ResultsIn 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.ConclusionThis 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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