Infective Endocarditis in People Who Inject Drugs: A Call for Patient-Centered, Multidisciplinary Care

Caring for patients with infective endocarditis has always been complex. Key management decisions must be made about antimicrobial choice, often combination therapy, surgery, cardiac care, and the treatment of myriad potential embolic and immunologic consequences, ranging from cerebrovascular complications to glomerulonephritis. All of this is to say that no single provider or discipline can best manage the typical endocarditis patient on their own; it is a condition that inherently indicates multidisciplinary collaboration and a versatile clinical acumen.

Over the past decade, there has been a clear and sharp rise in infective endocarditis among people who inject drugs (PWID).1,2 This phenomenon has paralleled rises in fatal overdoses, acute viral hepatitis and other invasive infections associated with injecting drugs. The change in endocarditis epidemiology has been extreme. Valve surgeries for endocarditis among people using drugs have more than doubled between 2012 and 2017,increasing such that, in certain regions of the country, drug use-related endocarditis comprised 58% of endocarditis surgeries as of 2018.3 Clearly the clinical and demographic profile of the typical endocarditis patient is changing from the historical archetype of an older individual with subacute Streptococcal endocarditis, to a younger person with injection drug-related Staphylococcal endocarditis.

Although many of the details about antimicrobial and surgical management have been previously delineated in AHA guidelines, the clinical needs of the typical endocarditis patient are shifting. Crucial to ensuring optimal outcomes and patient-centered care are considerations that range from addiction treatment and harm reduction education to alternative antimicrobial management strategies in the event of a patient directed discharge (also known as “against medical advice”) to the use of non-stigmatizing language around substance use. To meet these needs, this Scientific Statement was developed to comment on the unique aspects of endocarditis care among PWID.

In the Statement, the authors cover three main domains: addiction medicine, antimicrobial management and surgery. In the sphere of addiction medicine, the authors address the diagnosis and management of substance use disorders. They rightfully highlight the use of language that is person-first (e.g., “person who injects drugs”) as well as non-judgmental (e.g., “urine drug test is positive” rather than “dirty” or “clean” toxicology tests). Likewise, they cover aspects of care that meet addiction needs the way other healthcare needs are typically met, such as treating drug withdrawal, offering standard or care medications for opioid use disorder and responding to in-hospital substance use with patient-centered, non-punitive approaches. The authors recommend inpatient addiction consultation, where available, but also acknowledge that these services are not universally available. Therefore, there are provided references for clinicians to learn about treatment of opioid use disorder, which need not solely be the domain of addiction specialists.

Advocating for these culture shifts is important. Studies over the past decade have demonstrated that addiction needs are not treated nearly as aggressively as infectious diseases care. For example, in one study of injection drug-related bacteremia due to Staphylococcus aureus, 100% of patients underwent a transthoracic echocardiogram to evaluate for endocarditis, yet less than a quarter received buprenorphine or methadone, the standard of care for opioid use disorder treatment.4 PWID often avoid or delay treatment for infections due to concerns of stigmatizing healthcare experiences or worries they will go into opioid withdrawal.5 Therefore, making inpatient care a welcoming and non-judgmental environment for PWID is important to ensure they feel comfortable accessing care for potentially severe infections, such as endocarditis.

PWID with endocarditis typically have long inpatient stays, since they are often not considered candidates for home infusion to complete the typical six weeks of parenteral antibiotics. Understandably, many patients cannot remain in the hospital for these long periods. Rates of patient directed discharge are exceedingly high and rising among PWID with endocarditis, up to 21% in 2015.6 Therefore, in considering the unique concerns around antimicrobial therapy for PWID, this Statement focuses on second-line approaches to complete an antibiotic course, drawing inferences from the POET (Partial Oral Treatment of Endocarditis) study7 and emerging data about long-acting glycopeptides, such as dalbavancin. The authors also provide some guidance in terms of how to consider who, among PWID with endocarditis, may be candidates for home infusion antibiotics (also known as outpatient parenteral antimicrobial therapy, OPAT). One small but impactful clinical trial demonstrated comparable short-term outcomes for OPAT vs. inpatient care for PWID with injection drug-related infections.8 Other observational data has also suggested that certain PWID can have good outcomes on OPAT.9 In the Statement, the authors suggest a number of elements to consider in evaluating PWID for OPAT, although many of the criteria are no different from any other patient being considered for OPAT (e.g. cost, safe housing, transportation).

Lastly, the authors comment on surgical management, underscoring that surgical decisions for PWID should follow those laid out in guidelines for anyone with endocarditis. General guidance is given on the use of aspiration vegectomy for right-side endocarditis, although data to inform optimal use is scant. Nonetheless, surgery is common among PWID. In fact, in certain regions of the US, people who use drugs make up a majority of endocarditis surgeries, as of 2018.3 The number is surely higher now. This growing population requires long-term cardiac care and follow-up, as periodic imaging is recommended for bioprosthetic valve replacements.10 Ensuring post-discharge engagement in cardiac and primary care is paramount.

PWID with endocarditis often have substantial clinical and psychosocial needs. There is far more content in this Statement that covers topics such as harm reduction education and infection prevention. Even beyond the scope of this statement, resources are needed to address housing, insurance and transportation. Therefore, one of the earliest recommendations in the Statement resounds as one of the most salient – the need to develop multidisciplinary teams, or at least, close collaboration. Endocarditis is becoming predominantly an infection of PWID, rather than other risk groups. Optimal management cannot be limited to input from infectious diseases providers, cardiologists and surgeons. Rather, there must be a move to integrate motivated addiction medicine clinicians, social workers and peer support specialists (people with lived experience of substance use disorders) to offer treatment and support for patients.

Patients with substance use disorders are not a niche population that we in healthcare rarely encounter. Rather, they are our day-to-day patients. We must work to ensure that the experience of endocarditis care does not result in a painful and stigmatizing experience. To meet our duty as providers, healers and patient advocates, we must treat PWID with endocarditis the way we aspire to address other serious illnesses: with compassion and holistic patient-centered care.