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

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

Abstract

Importance: Persons who inject drugs (PWID) represent a distinct demographic of patients with infective endocarditis. Many centers do not perform valvular surgery on these patients owing to concerns about poor outcomes. Addiction services are underused in hospitals.

Objectives: To compare clinical characteristics in first-episode infective endocarditis in PWID who are surgically vs medically managed and to identify variables associated with mortality.

Design, setting, and participants: This case series studied PWID treated for a first episode of infective endocarditis between April 1, 2007, and March 30, 2016. Participants were adult patients (aged ≥18 years) admitted to any of 3 hospitals in London, Ontario, Canada. Analysis occurred between July 2016 and November 2017.

Main outcomes and measures: Survival among PWID; the causative organisms, site of infection, and cardiac as well as noncardiac complications; referral to addiction services; and surgical vs medical management.

Results: Of 370 total first-episode cases of infective endocarditis, 202 (54.6%) were in PWID. Among PWID, 105 (52%) were male, the median (interquartile range) age was 34 (28-42) years, and patients were predominantly positive for the hepatitis C virus (69.8% [141 of 202]). Right-sided infection was more common (61.4% [124 of 202]), and most infections were caused by Staphylococcus aureus (77.2% [156 of 202]). Surgery occurred in 19.3% of patients (39 of 202). The all-cause mortality rate was 33.7% (68 of 202). Adjusting for age and sex, survival analysis demonstrated that surgery was associated with lower mortality (hazard ratio [HR], 0.44; 95% CI, 0.23-0.84; P = .01), as was referral to addiction treatment (HR, 0.29; 95% CI, 0.12-0.73; P = .008). Higher mortality was associated with left-sided infection (HR, 3.26; 95% CI, 1.82-5.84; P < .001) and bilateral involvement (HR, 4.51; 95% CI, 2.01-10.1; P < .001).

Conclusions and relevance: This study presents the demographic characteristics of first-episode infective endocarditis in PWID. Results highlight the potentially important role of addictions treatment in this population. Further study to optimize selection criteria for surgery in PWID is warranted.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure.. Survival Curves for Persons Who Inject…
Figure.. Survival Curves for Persons Who Inject Drugs (PWID) With First-Episode Infective Endocarditis (IE)
Survival curves are shown for PWID with IE who underwent surgery vs those who did not. Survival was not significantly different at any time point.

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