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

Rodger, Laura; Glockler-Lauf, S. Dresden; Shojaei, Esfandiar; Sherazi, Adeel; Hallam, Brian; Koivu, Sharon; Gupta, Kaveri; Hosseini-Moghaddam, Seyed M; Silverman, Michael

doi:10.1001/jamanetworkopen.2018.5220

Cited by 114 publications

(111 citation statements)

References 59 publications

(165 reference statements)

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“…Other predictors of inpatient mortality described in our report included patients older than 40 years of age, severe sepsis or shock on presentation; these predictors are similar to previously described literature emphasizing the importance of initial presentation with multiorgan dysfunction and risk of systemic embolization [15][16][17][18][19][20]. In a study by Ferrera et al, IE patients presenting with atrial fibrillation had higher in-hospital mortality independently from other relevant clinical variables [21].…”

Section: Discussionsupporting

confidence: 87%

Elevated troponin level as a predictor of inpatient mortality in patients with infective endocarditis in the Southeast United States

et al. 2020

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Background: Despite recent improvement in management, infective endocarditis (IE) continues to be associated with considerable risk of morbidity and mortality. Early identification of predictors of inpatient mortality is key in improving patient outcomes in IE. The aim of our study was to evaluate the role of serum troponin levels measurements as a marker of increased mortality. Methods: A case-control study included adult patients with IE admitted to a tertiary care hospital in east Tennessee between December 2012 and July 2017. Cases were defined as patients with definitive IE who died in-hospital; controls were patients who did not die in hospital. First patient admission was included only. Data collected included the patients' demographic and baseline clinical information, microbiological data, injection drug use status, elevated serum troponins levels. Results: Two hundred eighty three patients with definitive IE were included; median (IQR) age was 41 (30-57) years, and 153 (54%) patients were men. One-hundred sixty-four (58%) were injection drug users. The most frequent IE type was: 167 (59%) right-sided, 86 (30%) left-sided, 24 (9%) both left and right-sided, and 10 (4%) device related. The most commonly isolated organism was Staphylococcus aureus (n = 141), and 64% were methicillin-resistant. Two-hundred twelve (75%) patients had a troponin level obtained, and 57 (27%) had an elevated troponin value. Thirty-six (13%) patients died in-hospital; in-hospital mortality was associated elevated troponin values (adjusted odds ratio [adjOR], 7.3; 95%CI, 3.3-15.9), and methicillin-resistant S. aureus IE (adjOR 2.6; 95%CI, 1.2-5.8). Forty-four (16%) patients received IE valve surgery, and none of these patients died in the hospital. Conclusion: Inpatient mortality was higher in patients with IE and elevated cardiac troponin levels compared to patients with normal levels.

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Section: Discussionsupporting

confidence: 87%

Elevated troponin level as a predictor of inpatient mortality in patients with infective endocarditis in the Southeast United States

et al. 2020

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“…8,13,17 Opioid agonist therapy (buprenorphine and methadone) to prevent withdrawal should be routinely offered to all patients with OUD including those with infectious complications of OUD to facilitate appropriate medical treatment and engage patients in long-term addiction treatment. Referral to addiction treatment has been associated with improved IDU-associated endocarditis mortality, 18 and initiation of medications for OUD (MOUD) can be achieved successfully in the emergency department, inpatient wards, and specifically in patients admitted with IDU-associated endocarditis. [19][20][21] Protocols and resources for inpatient management of withdrawal and…”

Section: Key Management Questions In the Inpatient Management Of Infementioning

confidence: 99%

“…In contrast, another study found that surgery was the strongest predictor of survival among patients with IDU-associated endocarditis after a median of 3.6 years follow-up. 18 Another consideration is that patients with IDU-associated infection tend to be younger, and despite advancements, many modern prostheses have a finite lifespan. When multiple surgical options exist, a procedure that avoids prosthetic material is preferred.…”

Section: Is Surgical Placement Of Prosthetic Materials Safe In Patientmentioning

confidence: 99%

New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use

Serota

Vettese

2019

Journal of Hospital Medicine

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A s a result of the epidemic of opioid use disorder (OUD), there has been a secondary surge in hospitalizations for infectious complications of injection drug use (IDU). 1,2 In the previous 10 years, there have been significant increases in IDU-associated human immunodeficiency virus (HIV) 3 and hepatitis C virus (HCV) 4 infection as well as increased hospitalizations from IDU-associated skin and soft tissue infections, osteomyelitis, septic arthritis, bacteremia, fungemia, and infective endocarditis in the United States. 2,[5][6][7] Patients admitted with IDU-associated infections have long lengths of stay, high rates of leaving against medical advice (AMA), readmission, and mortality. [8][9][10][11][12][13] In a British cohort (median age 36 years), five-year mortality after an episode of IDU-associated endocarditis was 42%. 14 Admissions for IDU-associated infections can be a troubling experience for both patients and providers alike. 15 While management decisions of IDU-associated infectious syndromes have sometimes been based on emotion, dogma, and an often-stigmatizing approach toward people suffering from addiction, 16 with a better understanding of addiction and effective treatments, as well as accumulating data in both addiction and infectious disease fields, it is an appropriate time to reevaluate the approach to treatment.The goal of this review is to examine recent evidence and attempt to answer questions that frequently arise in the management of hospitalized patients with IDU-associated infections. The questions addressed in this review primarily stem from the discussion of Schranz and colleagues in their description of increasing hospitalizations for IDU-associated endocarditis. 7 Additionally, questions were developed from discussions with practicing academic hospitalists. For each question, a review of the published literature was performed, with a focus on articles published between 2014 and 2019. Finally, a framework for how to approach patients with infectious complications of IDU is presented. As a comprehensive review of infectious complications of OUD would be difficult to cover in one review, this review will focus on eight questions that frequently arise in the care of inpatients.

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“…There has been a rising incidence of infective endocarditis (IE) among people who inject drugs (PWID), paralleling the opioid epidemic in North America (1)(2)(3)(4)(5)(6). This infectious complication of intravenous drug use (IVDU) is associated with significant morbidity and mortality requiring extensive and costly(1,2) multidisciplinary care (7). PWID are at risk of IE due to: comorbidities of HIV, hepatitis C and skin and soft tissue infections; non-sterile injection practices; and the reuse of injection drug preparation equipment (IDPE) (2,4,(8)(9)(10)(11)(12).…”

Section: Introductionmentioning

confidence: 99%

“…Furthermore, the components of hydromorphone-CR capsules that provide the controlled release, increase survival of HIV (19) and Staphylococcus aureus (12), which cause the vast majority of IE cases (7). Moreover, residual drug remains in cookers and filters after an initial injection, allowing PWID to resolubilize the remaining drug and conduct multiple injections (11,14,16,19,20) (Fig.…”

Section: Introductionmentioning

confidence: 99%

Risk Factors Of Infective Endocarditis In Persons Who Inject Drugs

Shah

Wong

Ball

et al. 2020

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

Cited by 114 publications

References 59 publications

Elevated troponin level as a predictor of inpatient mortality in patients with infective endocarditis in the Southeast United States

Elevated troponin level as a predictor of inpatient mortality in patients with infective endocarditis in the Southeast United States

New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use

Risk Factors Of Infective Endocarditis In Persons Who Inject Drugs

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