Infective Endocarditis: A New Consequence of the Opioid Epidemic

December 04, 2018

A "staggering increase" in the occurrence of drug use–associated infective endocarditis appears to be a consequence of the current opioid epidemic, a new study suggests.

"Our results show that infective endocarditis is a severe and largely underdiscussed consequence of the opioid crisis and that a sharp increase of cases in drug users is fundamentally reshaping the landscape of this condition," lead author Asher Schranz, MD, University of North Carolina at Chapel Hill, told Medscape Medical News.

For the study, Schranz and colleagues examined hospitalization trends for drug use–associated infective endocarditis during the past 10 years in 100 hospitals in North Carolina.

They found that the rate of drug use–associated infective endocarditis hospitalizations with valve surgery rose 13-fold in that state from 2007 to 2017. In the final study year, 42% of all infective endocarditis surgeries were performed in patients who were drug users.

This indicates "a dramatic shift in the demographic and clinical profile of patients undergoing infective endocarditis surgery," Schranz said.

"While there is a high awareness of the risk of HIV, hepatitis C, and overdose with drug use, infective endocarditis is not thought of as a major issue. However, our results suggest that it is not an uncommon consequence," he noted.

"These patients tend to have lengthy hospital stays, as infective endocarditis requires 6 weeks of parenteral IV antibiotics, and it is often not thought appropriate to send patients with a history of drug use home with an intravenous catheter," he said. "This leads to high hospital costs and — as many of the patients are uninsured — then these costs are falling to the hospitals."

Schranz also points out that more could be done to help patients withdraw from drug use while in hospital.

"The long hospital stays necessary for these patients gives a fantastic opportunity to engage in addiction care, but I'm not sure we are doing the best in this regard at present because of inadequate infrastructure," he said. "We need to embrace inpatient and outpatient addiction treatment programs."

He noted that the average cost for a hospital stay for drug use–associated infective endocarditis in this study was $250,000. "This drastically outweighs the costs of treating opioid use disorder even over several years," he said.

The study was published online December 4 in the Annals of Internal Medicine.

The author of an accompanying editorial, Alysse Wurcel, MD, Tufts Medical Center, Boston, Massachusetts, told Medscape Medical News: "The sharp increase in drug user–associated infective endocarditis parallels the increase in opioid use we are currently seeing. The infection is likely derived from Staph aureus or Streptococcus bacteria on the skin, which enters the blood stream when drugs are injected."

Infective endocarditis is an acute condition that, although very serious, can be treated. The underlying problem, however, is the growing epidemic of opioid use disorder, Wurcel noted.

She agrees with Schranz that more needs to be done to treat the addiction while these patients are receiving treatment for infective endocarditis in hospital. "In many centers, they don't have addiction specialists on staff. This is a wasted opportunity," she said. "When these patients are discharged, they are generally not handed over to an addiction care team, so they usually go back on the drugs again.

"When a patient who is a drug user is hospitalized for a serious infection like this, in addition to the acute treatment for the infection, they should receive wraparound care in the same way that patients with cancer or heart failure do, with prevention programs in both the inpatient and outpatient settings," she added.

For the study, the reseachers analyzed data from the North Carolina Hospital Discharge Database, which includes demographic, diagnostic, procedural, and billing information from all short-term, nonfederal, acute care hospitals in the state. The data represent roughly 1 million hospitalizations yearly. The study population consisted of all North Carolina residents older than 18 years who were hospitalized for infective endocarditis from 2007 to 2017.

Results showed that there were 22,825 hospitalizations for infective endocarditis during the 10-year period; 2602 (11%) were associated with drug use. Valve surgery was performed for 1655 patients with infective endocarditis (7%); 285 (17%) of these cases were associated with drug use.

Annual drug use–associated infective endocarditis hospitalizations increased from 0.92 to 10.95 per 100,000 persons from 2007 to 2017, and drug use–associated infective endocarditis hospitalizations with surgery increased from 0.10 to 1.38 per 100,000 persons.

In the final year, 42% of infective endocarditis valve surgeries were performed in patients who were drug users.

Compared with other surgical patients with infective endocarditis, those with drug user–associated infective endocarditis were younger (median age, 33 years vs 56 years), were more commonly women (47% vs 33%), were more commonly white (89% vs. 63%), and were primarily insured by Medicaid (38%) or were uninsured (35%).

Hospital stays for drug user associated–infective endocarditis were longer (median, 27 days vs 17 days), and median charges were higher ($250,994 vs $198,764). Charges for the 282 drug user–associated infective endocarditis cases during the 10-year period exceeded $78 million.

The authors note that such patients are often young and that many will require repeat surgery for prosthetic valve degeneration. "The anticipated need for future surgeries, whether for reinfection or structural degeneration, and long-term cardiac follow-up care is substantial and must be considered in assessing total downstream costs," they state.

The researchers also found that 13% of patients with drug user–associated infective endocarditis were discharged against medical advice, which they say is "a dangerous outcome that puts patients at risk for an inadequately treated, potentially life-threatening infection and is linked to increased mortality and readmissions."

They suggest that discharge against medical advice may represent a symptom of the absence or inadequacy of addiction care and may be associated with untreated drug withdrawal.

In her editorial, Wurcel notes that new data indicate that for patients who are hospitalized for infections and who receive addiction medicine counseling, there are fewer discharges against medical advice and fewer readmissions.

"Clinicians trained in addiction medicine are key partners in treating DUA-IE [drug use–associated infective endocarditis] and need to be involved soon after infected patients are admitted. Initiating medical treatment for substance use disorder during hospitalization is acceptable, feasible, and sustainable after discharge," Wurcel writes.

She also points out that use of long-acting injectable antibiotics is another strategy for these patients. This approach is being used increasingly in situations in which outpatient intravenous treatment is not considered desirable.

"The field is open for innovative patient-centered research on how to prevent endocarditis and provide equitable, evidence-based treatment focusing not only on the microbe but on the underlying substance use disorder," Wurcel concludes. "Action is urgently needed to understand and improve the cascade of care" for persons with drug use–associated infective endocarditis.

Ann Intern Med. Published online December 4, 2018. Abstract, Editorial

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