Drug-associated endocarditis on the rise

Hospitals face consequences of opioid addiction and difficult choices about treating endocarditis.

Viral infections such as hepatitis C (HCV) and HIV are well-known complications of injection drug use. However, cases of drug-associated endocarditis are also rising rapidly across the country—and hospitalists are on the front lines of this aspect of the opioid crisis.

While national figures are not available, a recent Morbidity and Mortality Weekly Report (MMWR) study found that hospitalizations for drug-associated endocarditis rose 12-fold in North Carolina between 2010 and 2015, while hospital expenses increased 18-fold. The bulk of those costs fell on public payers, the authors noted, as 42% of those hospitalized were uninsured or covered under Medicaid.

Photo by Thinkstock
Photo by Thinkstock.

“Bacterial infections are more complicated in cause and effect compared with HIV and HCV,” said the report's coauthor, Erin Barnes, MD, a hospitalist at Wake Forest Baptist Medical Center in Winston-Salem, N.C. “Hospitalists are struggling with how to deal with this population that often needs very long courses of antibiotics and surgery as well as resources to treat addiction.”

The postacute period may be the most challenging component of treatment, added William Goodman, MD, MPH, chief medical officer at Catholic Medical Center in Manchester, N.H. In 2015, his hospital had the second-highest overdose-related death rate in the nation. Last year, surgeons there performed 24 valve replacements in IV drug users, up from eight in 2012.

“The hardest part is keeping people sober and helping prevent relapse once they're back in the community,” he said. “Drug-associated endocarditis is not just about a patient with an infection; it's really about what we can do to help this patient have the best chance of staying in recovery.”

No quick fix

Treating drug-associated endocarditis is medically complex and often expensive due to the need for long hospital stays and complex surgeries, hospitalists say. Patients are often young and at high risk for readmission for recurrent infections because many resume injecting drugs after discharge.

One recent study looked retrospectively at patients admitted for drug-associated endocarditis at Beth Israel Deaconess Medical Center in Boston between 2004 and 2014. Over the study period, 50 out of 102 patients were readmitted, 28 had ongoing injection drug use at readmission, and 26 died before age 50. The findings were published in the May 2016 American Journal of Medicine.

Opioid users also tend to be white and living in rural or suburban communities—demographics that have not historically been associated with high incidences of HIV, according to the MMWR study. As a result, patients admitted for endocarditis in rural areas may be underscreened for HIV and other common complications of IV drug use.

In one retrospective study of admissions for endocarditis over 10 years at the University of Cincinnati Medical Center, the authors concluded that a sharp increase in endocarditis cases was a marker for a hidden outbreak of injection drug use. The study, published in the American Journal of the Medical Sciences, found that only 25% of patients with drug-associated endocarditis were tested for HIV, 32% were tested for HCV, and 20% were tested for opioid use.

“Endocarditis is a window into other serious infectious disease problems,” said Judith Feinberg, MD, FACP, professor of behavioral medicine and psychiatry at West Virginia University in Morgantown, W.V., who is known for her research on HIV/AIDS. “Everyone who is admitted for endocarditis should be tested for hepatitis B, C, and HIV. These infections may be lurking under the surface and are important to diagnose as early as possible for effective treatment.”

Due to the nature of their addiction, patients with drug-associated endocarditis tend to require more resources than similarly sick patients, noted Dr. Goodman. For example, patients with no history of injection drug use can usually be discharged home to continue IV therapy, but patients addicted to opioids require close monitoring to prevent them from obtaining and injecting illicit drugs during their hospitalization, he explained. Dr. Goodman and other experts reported anecdotes of patients trying to fish used syringes out of sharps disposal containers or inject opioids through peripherally inserted central catheters.

To help prevent such occurrences, Catholic Medical Center has such protocols as making security personnel aware of admissions of injection drug users and placing patients close to nursing stations where they can be more easily observed.

Cases become even more complex when patients require surgery to replace infected heart valves, said Dr. Barnes. Although most patients are young and healthy enough to tolerate valve replacement, the risks mount with repeated surgeries and there are very little data on long-term outcomes after surgery to weigh the potential risks and benefits of the procedure.

“Injection drug users are very hard to study or follow after discharge as many are uninsured or don't want to make contact,” Dr. Barnes said. “We have to rely on guidelines and expert opinion based on what qualifies as a need for surgery in the general population.”

Drug-associated endocarditis has traditionally been associated with right-sided disease, but there has been a recent increase in left-sided infections, which tend to be more severe and more likely to require surgery, she added.

Another concern is re-infection of prosthetic valves. “The complications of repeat infections in the same valve can be very severe,” said Dr. Barnes. “Patients can develop a pus pocket around the valve or other life-threatening complications that require more complex surgeries.”

The decision about whether to perform repeat surgery for endocarditis can be extremely hard, especially since many patients are in their 20s or 30s, she added. In some cases, the risks may be too high based on a patient's physical condition and the number of previous procedures he or she has undergone.

“I've seen a number of 20-year-old patients die, which is very difficult,” Dr. Barnes said. “Everyone wants to do as much as they can to see them move forward with their lives, but we can't always succeed.”

Treating addiction

Despite the high rates of repeat infections and mortality associated with drug-associated endocarditis, hospitals historically have done little to address the root problem of addiction.

In the American Journal of Medicine study, for example, fewer than 25% of the patients admitted had addiction or psychiatric consultations and fewer than 8% left the hospital with a plan for medication-assisted treatment. In addition, the hospital did not provide overdose education or naloxone.

Part of the problem is a tendency to view addiction as a social issue rather than a medical illness, said Christopher Rowley, MD, MPH, an infectious disease specialist at Beth Israel Deaconess Medical Center in Boston and the study's senior author. Another issue is that most physicians received very little education about how to treat addiction during medical school and residency.

As a result, despite extensive evidence that medication-assisted treatment is effective in reducing cravings and dependence, it has not been a routine part of care, said Dr. Rowley. However, his and other hospitals are starting to change their approach to patients with drug-associated endocarditis.

“We've recognized that if we don't try to address patients' opioid use disorder during their hospitalization we very likely are going to see them back in the hospital,” said Dr. Rowley. “We're now being proactive to do what we can while they are hospitalized.”

At Beth Israel Deaconess, patients are started on medication-assisted treatment and seen by psychiatric addiction nurses and case workers during their hospital stay, he said. Some may be transferred to addiction programs at state facilities before transitioning back to the community. The hospital also connects them with outpatient clinicians and resources for ongoing management of addiction.

At Catholic Medical Center in New Hampshire, physicians at the hospital have partnered with emergency medical services and treatment centers throughout the city to help deal with the crisis in their state, where overdoses have surpassed car crashes as the leading cause of death.

Ideally, every hospital would offer addiction treatment “on demand” and coordinate with outpatient primary care physicians and rehabilitation specialists, said Dr. Feinberg. However, most hospitals are struggling with inadequate resources to deal with the growing opioid epidemic.

“Often, patients seeking addiction treatment are put on waiting lists for weeks or months,” she said. “Some overdose and die before they get into treatment, and many never get the help they need.”

Considering that treating endocarditis with antibiotics and surgery costs about $250,000 per admission, helping patients battle their addiction seems like the most cost-effective—as well as ethical—approach to care, noted Dr. Goodman.

“There's a practical aspect to what we're doing for these patients—we had to rise up and respond to a crisis that was beginning to overwhelm our hospital medicine service,” said Dr. Goodman. “Even if you don't agree it's the right thing to do, it's far more efficient and effective to help someone stay sober, stable, and treated than for them to end up in the hospital.”