Surgical treatment of infective endocarditis in intravenous drug abusers

Abstract

Background Despite current progress in antibiotic therapy and medical management, infective endocarditis remains a serious condition presenting with high mortality rates. It also is a life-threatening complication in patients with a history of chronic intravenous drug abuse. In this study, we analyzed our institutional experience on the surgical therapy of infective endocarditis in patients with active intravenous drug abuse. The aim of the study is to identify the predictive factors of mortality and morbidity in this subgroup of patients. Methods Between 2007 and 2020, a total of 24 patients (7 female, mean age 38.5 ± 8.7) presenting with active intravenous drug abuse underwent a surgical treatment for the infective endocarditis at out center. The primary endpoint was survival at 30th day after the surgery. The secondary composite endpoint included freedom from death, recurrent endocarditis, re-do surgery, and postoperative stroke during the follow-up period. Mean follow-up was 4.2 ± 4.3 years. Results Staphylococcus species was the most common pathogen detected in the preoperative blood cultures. Infection caused by Enterococcus species as well as liver function impairment were identified as mortality predictor factors. Logistic EuroSCORE and EusoSCORE-II were also predictive factors for mortality in univariate analysis. Survival at 1 and 3 years was 78 and 72% respectively. Thirty-day survival was 88%. 30-day freedom from combined endpoint was 83% and after 1 and 3 years, 69 and 58% of the patients respectively were free from combined endpoint. Five patients (20.8%) were readmitted with recurrent infective endocarditis. Conclusion In patients presenting with active intravenous drug abuse, treatment of infective endocarditis should be performed as aggressively as possible and should be followed by antibiotic therapy to avoid high mortality rates and recurrent endocarditis. Early intervention is advisable in patients with an infective endocarditis and enterococcus species in the preoperative blood cultures, liver function deterioration as well as cardiac function impairment. Attention should be also payed to addiction treatment, due to the elevated relapse rate in patients who actively inject drugs. However, larger prospective studies are necessary to support our results. As septic shock is the most frequent cause of death, new treatment options, e.g. blood purification should be evaluated.

The Surgical Treatment of Infective Endocarditis: A Comprehensive Review

“…Between 2007 and 2020, Zubarevich et al [ 71 ] evaluated 24 consecutive IVDU patients who underwent valve surgery for IE, with a mean follow-up of 4.2 years, and reported a 30-day survival of 88% and 72% at three years from surgery. The rate of readmission due to recurrent IE was 20.8%, while only 58% remained free from a composite endpoint of freedom from mortality, recurrent endocarditis, re-do surgery, and postoperative stroke.…”

Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association

“…Recurrent IE and death after valve surgery have been prevalent in this population, however, especially in the setting of untreated substance use disorder. 90–92 Among PWID who were included in the Society of Thoracic Surgeons Adult Cardiac Surgery database, 16.1% of patients underwent a repeat valve surgical procedure. 88 Outcomes after reoperative valve surgery in patients with IE, including mortality, have been worse in PWID than in those who do not inject drugs in some studies, although it is not clear how often addiction treatment was included in those cohorts.…”

Infective endocarditis in people who inject drugs: A scoping review of clinical guidelines

“…For this population, treatment of the underlying substance use disorder (SUD) is integral for optimal outcomes 4 . Part of this approach includes prevention of premature patient‐directed discharge, a common but potentially avoidable outcome for PWID presenting to the hospital 5 .…”

“…For this population, treatment of the underlying substance use disorder (SUD) is integral for optimal outcomes. 4 Part of this approach includes prevention of premature patient-directed discharge, a common but potentially avoidable outcome for PWID presenting to the hospital. 5 Medical management of withdrawal and initiation of available Federal Drug Administration-approved therapy for treatment of the primary SUD are important components of the IE treatment plan in this population.…”