Infective endocarditis related to IV drug use increasing hospital admissions, changing treatment paradigm
NEW ORLEANS — Hospital admissions for infective endocarditis related to IV drug use increased by 436% from 2012 to 2017 at Ohio State University Wexner Medical Center, researchers reported at the American College of Cardiology Scientific Session.
In 2012, there were 196 cases of infective endocarditis at the center, 33 of which were related to IV drug use. The number of overall cases climbed to 395 in 2017, with 177 related to IV drug use, according to data presented here.
Further, 1 in 4 patients admitted for drug-related infective endocarditis died in the hospital in 2017.
Serena Day, MD, cardiology fellow at The Ohio State University, told Cardiology Today the most striking finding from the study is the “sheer increase in volume of IV drug use-related infective endocarditis just in [Ohio State University Wexner Medical Center] alone.”
“I had certainly, as we all have, seen the trends increasing anecdotally over the recent years, but to see the actual [increase] — 436% — was shocking,” she said.
Infective endocarditis generally occurs in individuals with certain congenital heart defects, those with prosthetic heart valves and those with abnormal heart valves after a heart transplant, according to the American Heart Association. However, as observed in this study — and others — infective endocarditis is becoming more common in younger patients, with a link to IV drug use. Risk for infective endocarditis increases in IV drug users because contaminated needles can introduce bacteria into the bloodstream.
In the current study, most patients admitted for drug-related infective endocarditis reported using heroin. The researchers noted that this study looked only at IV drug use; it did not evaluate other forms of drug abuse.
Day and fellow researchers also looked at treatment in these patients with drug-related infective endocarditis. Antibiotics without surgery were used to treat 55% of patients in 2012 and increased to 82% of patients in 2017. The low use of surgery in this population is due to greater risk for reinfection if a patient continues to inject drugs, Day said. According to the CDC, drug users with infective endocarditis are 10 times more likely than other patients to die or require a second valve-repair surgery months after initial discharge.
“There’s been a paradigm shift in how we treat these patients at our institution,” Day said. “Many of these patients continue to use, they continue to relapse and they come back even sicker than they were before. This study underscores the fact that, without treating the addiction, these patients aren’t going to get better. There has to be a comprehensive approach to treating this disease.”
In other findings, infective endocarditis was similarly distributed across the tricuspid, mitral and aortic valves. There was no difference in distribution of embolism outcomes in the lung, brain, bone/joint or heart. The researchers also observed a spike in the prevalence of MRSA endocarditis, from 15% in 2012 to 38% in 2017 (P = .0099).
Nearly all patients with drug-related infective endocarditis in this study were insured by Medicaid or a Medicaid subsidiary.
Speaking with Cardiology Today, Day said this preliminary research raises questions and areas for future investigation.
“One of the things that would be an area to look at would be to assess whether medical or surgical management makes a difference with outcomes. Previously, this condition was treated surgically about 50% of the time; now, we are doing primarily medical treatment due to repeat reinfection rates being high,” she said. “Additionally, evaluating the impact of drug counseling as a comprehensive approach and evaluating those outcomes such as recidivism and mortality [are important].”
The drug crisis continues to be a public health issue throughout the United States. Although this study focused only on cases of drug-related infective endocarditis at a single Ohio center, similar findings have been reported in other studies. As Healio Internal Medicine previously reported, a recent study highlighted a 12-fold annual increase in drug-related infective endocarditis hospitalization in North Carolina in the past decade. Other research presented at the Society for Cardiovascular and Interventions Scientific Sessions focusing on hospitalizations in West Virginia revealed a similar increase in infective endocarditis admissions in the past decade, in a pattern that mirrors the increase in IV drug use.
A comprehensive approach — involving addiction medicine, cardiology, infectious disease and surgery, to name a few — is key to treat this population, Day said.
However, “I don’t think we are quite there yet,” she said. “Cardiologists are not supposed to be experts in addiction and addiction management, and we do what we can for symptom control, but we need more ancillary staff and more physicians who can be an equal part of the treatment plan for these patients.
“My hope is that awareness of this study helps to start the national conversation and bring attention to the issue,” Day said. – by Katie Kalvaitis
Day S, et al. Abstract 19-A-13409-ACC. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.
Disclosure: Day reports no relevant financial disclosures.