Photo: American Heart Association

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Managing a potentially deadly heart infection is complex in people who inject drugs, including opioids, stimulants, and others, and requires a unique approach to care including consultation with an addiction specialist, according to a new American Heart Association Scientific Statement published today in the Association’s flagship journal Circulation. 

Infective endocarditis is caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel. In this new scientific statement, “Management of Infective Endocarditis in People Who Inject Drugs,” the American Heart Association highlights the need for specialized care in people who inject drugs, a population that has not been addressed in detail in previous guidance from the Association.

“Advances in our understanding of the unique challenges to treating infective endocarditis in people who inject drugs compared to those who develop the infection due to other health conditions prompted this statement,” said Daniel C. DeSimone, M.D., chair of the scientific writing committee for the statement and a consultant in infectious diseases and an associate professor of medicine at the Mayo Clinic in Rochester, Minn. “More people who inject drugs are having this potentially deadly heart infection, therefore, this statement is focused on highlighting the primary issue of addiction. Effective treatment of infective endocarditis in people with injection drug use should also include treatment for substance use disorder. Without a multi-disciplinary approach, these individuals are not only more likely to develop infective endocarditis and other serious infections but also to have infection relapses.”

About infective endocarditis:

• There are more than 35,000 cases of infective endocarditis per year in the U.S.
• About one in five people with infective endocarditis die from the infection.
• Heart valves do not have a direct blood supply, so the body’s immune response can’t reach them, making valve infections difficult to treat.
• The infection can come from many sources, including poor dental hygiene, implanted medical devices, chronic skin disorders, burns, injection drug use and more.
• A study of U.S. health information from 2002 to 2016 found that the proportion of patients hospitalized with infective endocarditis related to injection drug use doubled from 8% to about 16%. 
• People with infective endocarditis related to injection drug use are younger, with an average age of 38 years, compared to those who do not inject drugs. Most people with non-drug related infective endocarditis are older than age 45 years, with one-third older than the age of 69 years.

A comprehensive approach to care:

DeSimone and the writing group noted that a multi-disciplinary team approach is advised to improve the long-term prognosis for this population, “which is currently dismal for this relatively young group of individuals,” he said.

The standard treatment for infective endocarditis is six weeks of intravenous antibiotics. This treatment protocol is often not possible in people who inject drugs because they are more likely to leave the hospital before treatment is completed. Recent research indicates other treatment options, including shorter intravenous antibiotic regimens followed by oral antibiotics, or using only oral antibiotics, may help complete treatment in this population.

The writing group also emphasizes the importance of early management for substance use disorder started at the time of hospitalization for infective endocarditis, including FDA-approved medications to help reduce opioid-related withdrawal symptoms, to minimize chances of discontinuing treatment early.

Screening people for injection drug use should promote a wholistic approach to medical care without judgement. The statement advises support for improved public education about safer injection practices and a list of items for a harm reduction kit (tourniquet, bandages, sterile water, etc.) to provide to people who inject drugs.

The multidisciplinary care team should include cardiologists, cardiac surgeons and infectious diseases specialists, as well as addiction medicine or addiction psychiatry specialists, pharmacists, social workers and nurse specialists. The nurse specialists may provide coordinated care from the initial hospitalization for infective endocarditis to outpatient and community care to support substance use disorder.

Individuals with endocarditis due to injection drug use may experience financial challenges to access treatment if they do not have health insurance or have housing instability including homelessness. They may also have underlying mental health conditions that may contribute to their addiction and treatment for both substance use disorder and infective endocarditis.

The writing group also stresses that people with infective endocarditis who inject drugs should be considered for heart valve repair or replacement surgery regardless of current drug use if they have indications for valve surgery.

“There’s no evidence that indications for valve surgery are different for people who inject drugs compared to those who don’t, however, some treatment centers don’t offer surgery, especially if the patient currently injects drugs or has had a previous valve surgery,” DeSimone said. “Those who develop infective endocarditis require complex care delivered by professionals who look beyond stigma and bias to provide optimal and equitable care.” He adds that more studies are needed to evaluate the safety and effectiveness of medications used to treat injection drug use-related infective endocarditis.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Rheumatic Fever, Endocarditis and Kawasaki Disease Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiovascular and Stroke Nursing; the Council on Clinical Cardiology; and the Council on Peripheral Vascular Disease. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association’s official clinical practice recommendations.