Infective endocarditis in persons who use drugs: Epidemiology, current management, and emerging treatments PMC

kh.nour 0 Comments November 15, 2021

In IDUs, injection of foreign antigens can precipitate antibody production that leads to immune complex deposition on valvular surfaces, which forms nidi for bacterial adhesion [22]. Inoculations with sterile horse serum or dead streptococci have been shown to cause tricuspid, aortic, or mitral valvulitis in rabbits, which forms a lesion vulnerable for bacterial seeding and endocarditis [11, 67]. Although the valvulitis did not localize specifically to the right side of the heart, one may predict that a predisposing endothelial lesion, as might occur on the right side in IDUs, might cause greater right-side immune complex deposition. Foreign injected materials can also produce reticuloendothelial blockade, prolonging bacteremia by inhibiting pathogen clearance. Prolonged bacteremia is important for reseeding and propagating a developing vegetation. Aureus is the most common pathogen in isolated tricuspid valve endocarditis, accounting for 50%–60% of cases among IDUs [4, 42–44].

Endocarditis in persons who inject drugs

For persistent and invasive infections, refractory heart failure and prosthetic valves, surgical intervention is indicated. However, the high recurrence rate caused by continuing IDU and medical non-compliance inevitably raises the ethical consideration of offering valve surgery iv drug use to this patient population. Due to his non-adherence to treatment and continued use of intravenous drugs, he later developed recurrent AV endocarditis with multiple organisms. Blood cultures isolated include Streptococcus sanguinis, Candida albicans, and Streptococcus mutans.

Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Persons Who Inject Drugs — Six Sites, 2005 … – CDC

Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Persons Who Inject Drugs — Six Sites, 2005 ….

Posted: Fri, 08 Jun 2018 07:00:00 GMT [source]

Heart Valves and Infective Endocarditis

On physical examination, there were bilateral inspiratory crackles over bilateral lung bases. He also had a diastolic murmur over the left lower sternal border. Initial tests were notable for a urine drug screen positive for cocaine, marijuana, methadone, and opioids.

Multidisciplinary Care Is Crucial

  • Surgery may be needed for mechanical complications or resistant organisms.
  • About 10 to 20% of cases are right-sided (tricuspid or pulmonic valve).
  • After phagocytosis of the staphylococci by the endothelium, endothelial cells produce a variety of cytokines, including adhesion molecules such as vascular-cell adhesion molecules (VCAM) and intercellular adhesion molecules (ICAM), and express Fc receptors.
  • Cerebral emboli, which usually affect the middle cerebral artery, result in hemiplegia and sensory dysfunction.
  • Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

Antibiotics should not be initiated before three sets of blood cultures have been taken. However, there are instances where patients present with atypical characteristics. It is in these patients that the majority of the complications occur. A high degree of suspicion and a low threshold for diagnostic investigations is required to diagnose and rule out IE in IVDUs. Here we describe a case of an IVDU patient with atypical presentation of IE who ultimately required multiple revision surgeries for native aortic valve endocarditis.

  • On the fifth day of his hospital stay, transesophageal echocardiography (TEE) was performed, and a 1.5 cm vegetation was found on the aortic valve.
  • So-called “euthermic endocarditis,” could be subject to a delay in diagnosis and initiation of appropriate antimicrobial and/or surgical therapy, resulting in an increased risk of IE-related complications and poorer outcomes [6].
  • The antibiotic regimen was then changed to nafcillin (2 g IV q4h) and gentamicin (3 mg/kg qday for 5 days) for MSSA positive endocarditis.
  • Inoculations with sterile horse serum or dead streptococci have been shown to cause tricuspid, aortic, or mitral valvulitis in rabbits, which forms a lesion vulnerable for bacterial seeding and endocarditis [11, 67].
  • However, bacteria on the skin or in the mouth, throat or gut (intestines) may enter the bloodstream and cause endocarditis under the right circumstances.

Differential Diagnosis

Management of IDU-IE is generally consistent with management of non-IDU-IE, which may include medical or combined medical-surgical therapy. The care of persons with IDU-IE should also include components to address the underlying substance use disorder (SUD). The pathogenesis of bacterial endocarditis has been reviewed exhaustively elsewhere [16–23] and is summarized in table 2. Hypotheses to explain predilection for right-side endocarditis in injection drug users (IDUs). Infective Endocarditis InfographicThis infographic highlights basic information about infective endocarditis alongside an anatomical image of a human heart. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

If you’re at high risk of endocarditis, the American Heart Association recommends taking antibiotics an hour before having any dental work done. In endocarditis, irregular growths made of germs and cell pieces form a mass in the heart. They can break loose and travel to the brain, lungs, kidneys and other organs.

Intravenous Drug Abuse Endocarditis

  • Candida, Aspergillus, Histoplasma, and Brucella infections are rare, but are found, in particular, in IVDAs, alcoholics, and patients with prosthetic heart valves.
  • Also, the possible presence of underlying malignancy was investigated.
  • These candidates include those with isolated TVIE, those without any complications secondary to IE, and those with IE from HACEK organisms.
  • We retrospectively analysed 440 patients admitted to a single surgical centre for definite active IE from January 2012 to December 2020.

The diagnosis of infective endocarditis is usually based on a constellation of clinical findings rather than a single definitive test result. The classic physical findings (Janeway lesions, Osler’s nodes, Roth spots and splinter hemorrhages) are rarely seen, appearing only in 5–15% of IE patients. Instead the more common manifestations are the complications of advanced stage disease, including septic emboli and organ infarction. Physical examination on presentation was significant for temperature of 39.3°C, controlled blood pressure, sinus tachycardia at a rate of 105 beats/min, and a respiratory rate of 28/min.

how does iv drug use cause endocarditis

Formal diagnosis

We seek to provide an update for providers on recent research and published literature on the subject of this type of infection. It is important to address this type of infection with a sensitive and collaborative approach. Second, drug overdose data suggests that persons using drugs are shifting from using opioids only to polysubstance use that includes stimulants (i.e., cocaine and methamphetamine). This evolution poses significant challenges to addressing IDU-IE given that stimulant use disorder lacks effective pharmacotherapies, unlike OUD. Implementation of harm reduction education in the hospital or helping patients to link to syringe service programs (SSPs) at discharge may help reduce the risk of repeat infections and fatal overdoses.

Identification of organisms

Patients in the DU-IE cohort were younger (median age 36 years) and less frequently male (62.2%) compared with patients in the NDU-IE cohort (median age 60 years; 68.9% male). Patients in the DU-IE cohort more commonly smoked cigarettes (74.4% vs. 20.3%), reported more than seven drinks a week (12% vs. 7.6%) and more frequently had liver disease (46.3% vs. 9.4%). VS projected the study, analysed and interpreted the data, and wrote the manuscript.