Addiction care urged for people who inject drugs and develop dangerous heart infection

People who inject opioids or other drugs and develop a potentially deadly heart infection require a unique approach to care that should include consultation with an addiction specialist, according to a new report from the American Heart Association.

Previous AHA guidance on the condition, called infective endocarditis, did not provide detailed information on how people who inject drugs are affected or how their care might differ from other people with the infection. The new scientific statement, published Wednesday in the AHA journal Circulation, addresses the gap.

Infective endocarditis occurs when bacteria enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel, causing inflammation. Of the more than 35,000 cases a year in the U.S., about 1 in 5 people die.

People who inject drugs are at higher risk for infective endocarditis if they are exposed to bacteria by re-using needles or from other injection practices that aren't sterile. Infections also may arise from other sources, such as poor dental hygiene, implanted medical devices, chronic skin disorders or burns.

The new statement was prompted by advances in understanding the unique challenges of treating heart infections in people who inject drugs, Dr. Daniel C. DeSimone said in a news release. He's chair of the writing committee for the statement and an associate professor of medicine at the Mayo Clinic in Rochester, Minnesota.

"More people who inject drugs are having this potentially deadly heart infection," he said. The proportion of people in the U.S. hospitalized with infective endocarditis related to injection drug use doubled from 2002 to 2016, from 8% to about 16%, research shows.

People hospitalized for infective endocarditis should be screened for substance use and those found to inject drugs should be treated for that condition immediately, the statement advises. Such treatment should include medications approved by the Food and Drug Administration to reduce opioid-related withdrawal symptoms to improve the chances of the patient completing treatment for endocarditis.

DeSimone said the statement writing committee agreed a multidisciplinary team approach for people who inject drugs could improve their long-term prognosis, "which is currently dismal for this relatively young group of individuals." Their average age is 38 years old.

Such a multidisciplinary team can include cardiologists, cardiac surgeons and infectious disease specialists, as well as addiction medicine or addiction psychiatry specialists, pharmacists, social workers and nurse specialists, the statement said. The nurse specialists can help coordinate care as the patient moves from hospitalization to outpatient and community care.

"Without a multidisciplinary approach, these individuals are not only more likely to develop infective endocarditis and other serious infections, but also to have infection relapses," DeSimone said.

People who inject drugs should be considered for heart valve repair or replacement surgery whether they continue to inject drugs or not, the statement said.

"There's no evidence that indications for valve surgery are different for people who inject drugs compared to those who don't," DeSimone said. "However, some treatment centers don't offer surgery, especially if the patient currently injects drugs or has had a previous valve surgery. Those who develop infective endocarditis require complex care delivered by professionals who look beyond stigma and bias to provide optimal and equitable care."

He added that more studies are needed to evaluate the safety and effectiveness of medications used to treat infective endocarditis related to injection drug use.

The standard treatment for infective endocarditis – six weeks of intravenous antibiotics – is not always possible for people who inject drugs because they often leave the hospital before treatment is completed. Research suggests other options, such as shorter intravenous antibiotic regimens followed by oral antibiotics, or just oral antibiotics, might help these patients complete treatment.

The statement also calls for better public education about safer injection practices and for providing people who inject drugs with supplies to reduce potential harm, such as tourniquets, bandages and sterile water.

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