Infective endocarditis in intravenous drug abusers: clinical challenges emerging from a single-centre experience

Valentina Scheggi; Stefano Del Pace; Nicole Ceschia; Francesco Vanni; Irene Merilli; Edoardo Sottili; Leonardo Salcuni; Nicola Zoppetti; Bruno Alterini; Alfredo Cerillo; Niccolò Marchionni; Pier Luigi Stefàno

doi:10.1186/s12879-021-06697-1

Infective endocarditis in intravenous drug abusers: clinical challenges emerging from a single-centre experience

BMC Infect Dis. 2021 Sep 27;21(1):1010. doi: 10.1186/s12879-021-06697-1.

Authors

Affiliations

¹ Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Largo Brambilla 3, 50134, Florence, Italy. scheggiv@aou-careggi.toscana.it.
² Division of General Cardiology, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
³ Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
⁴ Institute of Applied Physics "Nello Carrara" (IFAC), National Research Council, Sesto Fiorentino, Italy.
⁵ Division of Cardiac Surgery, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
⁶ Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.

Abstract

Background: Intravenous drug abuse (IDA) is a known risk factor for infective endocarditis (IE) and is associated with frequent relapses, but its prognostic impact is still debated. The potential futility of surgery in this population is a further issue under discussion. We aimed to describe the clinical characteristics, the therapeutic strategy, and the prognosis associated with IDA in IE.

Methods: We retrospectively analysed 440 patients admitted to a single surgical centre for definite active IE from January 2012 to December 2020.

Results: Patients reporting IDA (N = 54; 12.2%) were significantly younger (p < 0.001) and presented fewer comorbidities (p < 0.001). IDA was associated with a higher proportion of relapses (27.8 vs. 3.3%, p < 0.001) and, at multivariable analysis, was an independent predictor of long-term mortality (HR 2.3, 95%CI 1.1-4.7, p = 0.015). We did not register multiple relapses in non-IDA patients. Among IDA patients, we observed 1 relapse after discharge in 9 patients, 2 relapses in 5 patients and 3 relapses in 1 patient. In IDA patients, neither clinical and laboratory variables nor the occurrence of even multiple relapses emerged as indicators of an adverse risk-benefit ratio of surgery in patients with surgical indication.

Conclusions: IE secondary to IDA affects younger patients than those with IE not associated with IDA. Probably due to this difference, IE secondary to IDA is not associated with significantly higher mortality, whereas the negative, long-term prognostic impact of IDA emerges in multivariate analysis. Considering the good prognosis of patients with uncomplicated IE treated medically, surgery should be reserved to patients with a strict- guidelines-based indication. However, since there are no clear predictors of an unfavourable risk-benefit ratio of surgery in patients with surgical indication, all patients with a complicated IE should be operated, irrespective of a history of IDA.

Keywords: Cardiac surgery; Infective endocarditis; Intravenous drug abuse; Prognosis.

MeSH terms

Drug Users*
Endocarditis* / drug therapy
Endocarditis* / epidemiology
Endocarditis, Bacterial*
Humans
Neoplasm Recurrence, Local
Retrospective Studies
Risk Factors
Substance Abuse, Intravenous* / complications