Long term surgical outcomes for infective endocarditis in people who inject drugs: a systematic review and meta-analysis.
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SUBMITTER: Goodman-Meza D
PROVIDER: S-EPMC6839097 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ImportancePeople who inject drugs (PWID) who are being treated for infective endocarditis remain at risk of new bloodstream infections (BSIs) due to ongoing intravenous drug use (IVDU).ObjectivesTo characterize new BSIs in PWID receiving treatment for infective endocarditis, to determine the clinical factors associated with their development, and to determine whether new BSIs and treatment setting are associated with mortality.Design, setting, and participantsThis retrospective cohort study was performed at 3 tertiary care hospitals in London, Ontario, Canada, from April 1, 2007, to March 31, 2018. Participants included a consecutive sample of all PWID 18 years or older admitted with infective endocarditis. Data were analyzed from April 1, 2007, to June 29, 2018.Main outcomes and measuresNew BSIs and factors associated with their development, treatment setting of infective endocarditis episodes (ie, inpatient vs outpatient), and 90-day mortality.ResultsThe analysis identified 420 unique episodes of infective endocarditis in 309 PWID (mean [SD] patient age, 35.7 [9.7] years; 213 episodes [50.7%] involving male patients), with 82 (19.5%) complicated by new BSIs. There were 138 independent new BSIs, of which 68 (49.3%) were polymicrobial and 266 were unique isolates. Aerobic gram-negative bacilli (143 of 266 [53.8%]) and Candida species (75 of 266 [28.2%]) were the most common microorganisms. Ongoing inpatient IVDU was documented by a physician in 194 infective endocarditis episodes (46.2%), and 127 of these (65.5%) were confirmed by urine toxicology results. Multivariable time-dependent Cox regression demonstrated that previous infective endocarditis (hazard ratio [HR], 1.89; 95% CI, 1.20-2.98), inpatient treatment (HR, 4.49; 95% CI, 2.30-8.76), and physician-documented inpatient IVDU (HR, 5.07; 95% CI, 2.68-9.60) were associated with a significantly higher rate of new BSIs, whereas inpatient addiction treatment was associated with a significantly lower rate (HR, 0.53; 95% CI, 0.32-0.88). New BSIs were not significantly associated with 90-day mortality (HR, 1.76; 95% CI, 0.78-4.02); significant factors associated with mortality included inpatient infective endocarditis treatment (HR, 3.39; 95% CI, 1.53-7.53), intensive care unit admission (HR, 9.51; 95% CI, 4.91-18.42), and methicillin-resistant Staphylococcus aureus infective endocarditis (HR, 1.77; 95% CI, 1.03-3.03), whereas right-sided infective endocarditis was associated with a significantly lower mortality rate (HR, 0.41; 95% CI, 0.25-0.67).Conclusions and relevanceIn this study, new BSIs were common in PWID receiving parenteral treatment for infective endocarditis. Discharging patients to outpatient treatment was not associated with an increase in new BSI incidence or mortality; carefully selected PWID may therefore be considered for such treatment.
| S-EPMC7424403 | biostudies-literature
Project description:BACKGROUND:The rising incidence of infective endocarditis (IE) among people who inject drugs (PWID) has been a major concern across North America. The coincident rise in IE and change of drug preference to hydromorphone controlled-release (CR) among our PWID population in London, Ontario intrigued us to study the details of injection practices leading to IE, which have not been well characterized in literature. METHODS:A case-control study, using one-on-one interviews to understand risk factors and injection practices associated with IE among PWID was conducted. Eligible participants included those who had injected drugs within the last 3?months, were >?18??years old and either never had or were currently admitted for an IE episode. Cases were recruited from the tertiary care centers and controls without IE were recruited from outpatient clinics and addiction clinics in London, Ontario. RESULTS:Thirty three cases (PWID IE+) and 102 controls (PWID but IE-) were interviewed. Multivariable logistic regressions showed that the odds of having IE were 4.65 times higher among females (95% CI 1.85, 12.28; p?=?0.001) and 5.76 times higher among PWID who did not use clean injection equipment from the provincial distribution networks (95% CI 2.37, 14.91; p?<?0.001). Injecting into multiple sites and heating hydromorphone-CR prior to injection were not found to be significantly associated with IE. Hydromorphone-CR was the most commonly injected drug in both groups (90.9% cases; 81.4% controls; p?=?0.197). DISCUSSION:Our study highlights the importance of distributing clean injection materials for IE prevention. Furthermore, our study showcases that females are at higher risk of IE, which is contrary to the reported literature. Gender differences in injection techniques, which may place women at higher risk of IE, require further study. We suspect that the very high prevalence of hydromorphone-CR use made our sample size too small to identify a significant association between its use and IE, which has been established in the literature.
| S-EPMC7275611 | biostudies-literature
Project description:BackgroundInjection drug use (IDU) associated infective endocarditis (IE) is clinically challenging due to social issues this population endures. Rates of IDU are rising globally, however, there is a lack of clear guidelines for IDU associated IE. The aim of this study is to assess the epidemiology of the IDU and non-IDU populations and compare their long-term outcomes to help guide future management.MethodsAn observational cohort study was conducted on all 350 patients treated for IE at St Vincent's Hospital Melbourne between 1999 and 2015. Follow up was performed until death or January 2021. Primary outcome was all-cause mortality.ResultsIDU patients are younger (p<0.001), more likely to have concurrent infections (p<0.001), and other addiction disorders (p<0.001), while non-IDU patients are older with a higher level of comorbid illnesses (p<0.001). IDU and non-IDU patients received similar management during their admissions and experienced similar levels of in-hospital outcomes, except for non-IDU patient being more likely to develop pneumonia post-surgery (p = 0.03). IDU patients are more likely to become reinfected (p = 0.034) but have better long-term survival, with survival estimates at 15-years being 64.98% (95%CI: 50.94-75.92%) for IDU patients compared to 26.67% (95%CI: 19.76-34.05%) for non-IDU patients (p<0.001).ConclusionDespite having higher levels of reinfection, IDU patients have better long-term survival compared to non-IDU patients. Therefore, we suggest IDU patients should not have blanket restrictions on the management they are offered unless at the individual level there is a contraindication to therapy.
| S-EPMC9417006 | biostudies-literature
Project description:IntroductionInfective endocarditis (IE) is a severe and highly prevalent infection among people who inject drugs (PWID). While short-term (30-day) outcomes are similar between PWID and non-PWID, the long-term outcomes among PWID after IE are poor, with 1-year mortality rates in excess of 25%. Novel clinical interventions are needed to address the unique needs of PWID with IE, including increasing access to substance use treatment and addressing structural barriers and social determinants of health.Methods and analysisPWID with IE will be connected to a multidisciplinary team that will transition with them from hospital to the community. The six components of the Second Heart Team are: (1) peer support worker with lived experience, (2) systems navigator, (3) addiction medicine physician, (4) primary care physician, (5) infectious diseases specialist, (6) cardiovascular surgeon. A convergent mixed-methods study design will be used to test the feasibility of this intervention. We will concurrently collect quantitative and qualitative data and 'mix' at the interpretation stage of the study to answer our research questions.Ethics and disseminationThis study has been approved by the Hamilton Integrated Research Ethics Board (Project No. 7012). Results will be presented at national and international conferences and submitted for publication in a scientific journal.Clinical trail registrarionTrial registration number: ISRCTN14968657 https://www.isrctn.com/ISRCTN14968657.
| S-EPMC8553071 | biostudies-literature
Project description:Background:Injection drug use (IDU) is a major risk factor for infective endocarditis (IE). Few data exist on repeat IE (rIE) in persons who inject drugs (PWID). Methods:Patients ?18 years old seen at Wake Forest Baptist Medical Center from 2004 to 2017 who met Duke criteria for IE and who self-reported IDU in the 3 months before admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after diagnosis of the first episode, was then reviewed. Results:Of the 87 PWID who survived their first episode of IE, 22 (25.3%) experienced rIE and 77.3% had rIE within a year of the first episode. All patients who experienced rIE resumed IDU between episodes of IE. Of the patients with rIE, 54.5% had an infection caused by S. aureus and 22.7% required surgical intervention. Mortality at 1 year was 36.3%. Compared with their first IE episode, patients with rIE had fewer S. aureus infections (P = .01). Compared with PWID who experienced single-episode IE, intravenous prescription opioid use (P = .01), surgery (P < .01), tricuspid valve involvement (P = .02), and polymicrobial infection (P = .03) occurred more often during first episodes of IE in individuals who then developed rIE. Conclusions:rIE is common among IDU-related IE and confers a high 1-year mortality rate. The microbiology of rIE is varied, with S. aureus being less frequently isolated. More studies on modification of social and clinical risk factors are needed to prevent rIE.
| S-EPMC6288769 | biostudies-literature
Project description:Severe neurological complications following infective endocarditis remain a major problem with high mortality rate. The long-term neurological consequences following infective endocarditis remain uncertain. Otherwise, neurosurgeries could be performed after these complications; however, few clinical series have reported the results. Therefore, we utilized a large, nationwide database to unveil the long-term mortality and neurosurgical outcome following infective endocarditis. We included patients with a first-time discharge diagnosis of infective endocarditis between January 2001 and December 2013 during hospitalization. Patients were further divided into subgroups consisting of neurological complications under neurosurgical treatment and complications under non-neurosurgical treatment. Long-term result of symptomatic neurological complications after infective endocarditis and all-cause mortality after different kinds of neurosurgeries were analyzed. There were 16,495 patients with infective endocarditis included in this study. Symptomatic neurological complications occurred in 1,035 (6.27%) patients, of which 279 (26.96%) accepted neurosurgical procedures. Annual incidence of neurological complications gradually increased from 3.6% to 7.4% (P?<?0.001). The mortality rate among these patients was higher than that among patients without complications (48.5% vs. 46.1%, P?=?0.012, increased from 20% initially to nearly 50% over the 5-year follow-up). However, neurosurgery had no effect on the long-term mortality rate (50.9% vs. 47.6%, P?=?0.451). Incidence of neurological complications post-infective endocarditis is increasing, and patients with these complications have higher mortality rates than patients without. Neurosurgery in these populations was not associated with higher long-term mortality. Therefore, it should not be ruled out as an option for those with neurological complications.
| S-EPMC7055329 | biostudies-literature
Project description:People who inject drugs (PWID) are a population exposed to many genotoxicants and with a high prevalence of HCV infection. Direct-acting antiviral (DAA) regimens are now widely used to treat chronic HCV infection. Although side effects to treatment are currently rare, the long-term effects such as suspicions of de novo hepatocellular carcinoma (HCC) occurrence or HCC recurrence and cardiac defects are still up for debate. Given the structure of DAAs, the molecules have a potential mitochondrial DNA (mtDNA) genotoxicity. We have previously reported acute mtDNA toxicity of three DAA regimens among PWID with a strong impact on the rate of mtDNA deletion, less on the quantity of mtDNA copy per cell at sustained viral response at 12 weeks (SVR12). Herein, we report the mtDNA parameters nine months after drug discontinuation. We observed that the percentage of the deleted mtDNA genome increased over time. No exposure to any other genotoxicants during this period was associated with a high deletion percentage, suggesting that the replicative advantage of the deleted molecules outweighed their elimination processes. Such observation calls for longer-term follow-up and may contribute to the molecular basis of subclinical side effects of DAA treatments.
| S-EPMC9599189 | biostudies-literature
Project description:Locally destructive infective endocarditis (IE) of the aortic valve complicated by abscess formation in the aortic root may seriously affect patients' outcomes. Surgical repair of such conditions is often challenging. This is a single-center observational analysis of consecutive patients treated surgically for IE between 2009 and 2019. We divided the cohort into two groups considering the presence of an aortic root abscess and compared the characteristics and postoperative outcomes of patients accordingly. Moreover, we examined three different procedures performed in abscess patients regarding operative data and postoperative results: an isolated surgical aortic valve replacement (AVR), AVR with patch reconstruction of the aortic root (AVR + RR) or the Bentall procedure. The whole cohort comprised 665 patients, including 140 (21.0%) patients with an aortic root abscess and 525 (78.9%) as the control group. The abscess group of patients received either AVR (66.4%), AVR + RR (17.8%), or the Bentall procedure (15.7%). The mean age in the whole cohort was 62.1 ± 14.8. The mean EuroSCORE II was 8.0 ± 3.5 in the abscess group and 8.4 ± 3.7 in the control group (p = 0.259). The 30-day and 1-year mortality rates were 19.6% vs. 11.3% (p = 0.009) and 40.1% vs. 29.6% (p = 0.016) in the abscess compared to the control group. The multivariable regression analysis did not reveal aortic root abscess as an independent predictor of mortality. Rather, age > 60 correlated with 30-day mortality and infection with Streptococcus spp. correlated with 1-year mortality. In the analysis according to the performed procedures, KM estimates exhibited comparable long-term survival (log-rank p = 0.325). IE recurrence was noticed in 12.3% of patients after AVR, 26.7% after AVR + RR and none after Bentall (p = 0.069). We concluded that patients with an aortic root abscess suffer worse short and long-term outcomes compared to other IE patients. The post-procedural survival among ARA patients did not significantly vary based on the procedures performed.
| S-EPMC10820780 | biostudies-literature
Project description:ImportancePersons 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.ObjectivesTo 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 participantsThis 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 measuresSurvival among PWID; the causative organisms, site of infection, and cardiac as well as noncardiac complications; referral to addiction services; and surgical vs medical management.ResultsOf 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 relevanceThis 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.
| S-EPMC6324402 | biostudies-literature
Project description:BackgroundInfective endocarditis (IE) is increasing among persons who inject drugs (PWID) and has high morbidity and mortality. Recurrent IE in PWID is not well described.MethodsThis was a retrospective cohort study conducted between February 2007 and March 2016. It included adult inpatients (≥18) at any of 3 tertiary care centers in London, Ontario, with definite IE based on the Modified Duke's Criteria. The objectives were to characterize recurrent IE in PWID, identify risk factors for recurrent IE, identify the frequency of fungal endocarditis, and establish whether fungal infection was associated with higher mortality.ResultsThree hundred ninety patients had endocarditis, with 212/390 in PWID. Sixty-eight of 212 (32%) PWID had a second episode, with 28/212 (12%) having additional recurrences. Second-episode IE was more common in PWID (11/178 [6.2%] vs 68/212 [32.1%]; P < .001). Peripherally inserted central catheter (PICC) line abuse was associated with increased risk of recurrent endocarditis (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.01-3.87; P = .04). In PWID, fungal IE was more common in second episodes than first episodes (1/212 [0.5%] vs 5/68 [7.4%]; P = .004). Additionally, fungal infections were associated with mortality in second-episode IE in PWID with an adjusted OR of 16.49 (95% CI, 1.12-243.17; P = .041). Despite recurrent infection, likely due to continued drug use, there was a low rate of referral to addiction treatment (14/68 [20.6%]).ConclusionsPWID have a high risk of recurrent endocarditis, particularly in patients who abuse PICC lines. Fungal endocarditis is more common in second-episode endocarditis and is associated with increased mortality. Consideration of empiric antifungal therapy in PWID with IE history and suspected IE should be considered.
| S-EPMC6796994 | biostudies-literature