Comment; Improved survival with surgical approaches and referral to addiction treatment during the inpatient setting.  Good to know

Laura Rodger, MD1Stephannie Dresden Glockler-Lauf, MPH1Esfandiar Shojaei, MD2; et alAdeel Sherazi, MD1Brian Hallam, BA2Sharon Koivu, MD2Kaveri Gupta, MD, FRCP3Seyed M. Hosseini-Moghaddam, MD3Michael Silverman, MD, FRCP3

Author Affiliations Article Information

JAMA Netw Open. 2018;1(7):e185220. doi:10.1001/jamanetworkopen.2018.5220

Key Points

Question In first-episode infective endocarditis in persons who inject drugs, what are the clinical differences between patients who receive surgery vs those who are medically treated, and which factors are associated with mortality?

Findings In this case series of 370 first-episode cases of infective endocarditis, the main significant differences between persons who inject drugs who received surgery and those who did not were the site of infection and cardiac complications. Decreased mortality was associated with surgery and referral to addiction treatment services, while higher mortality was associated with left-sided and bilateral infections.

Meaning In selected persons who inject drugs with first-episode endocarditis, surgical management and referral to addiction treatment were associated with reduced mortality.


Importance Persons 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.

Objectives To 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 Participants This 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 Measures Survival among PWID; the causative organisms, site of infection, and cardiac as well as noncardiac complications; referral to addiction services; and surgical vs medical management.

Results Of 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 Relevance This 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.

Dr. Raymond Oenbrink
Latest posts by Dr. Raymond Oenbrink (see all)