Current Management of Infective Endocarditis in Injection Drug Users in Tennessee

Overview

A survey of 17 Tennessee healthcare facilities revealed that while most screen for substance use disorders in patients with infective endocarditis who inject drugs, few provide addiction consultation services. Antibiotic therapy is predominantly completed inpatient or at skilled nursing facilities, with less frequent use of oral antibiotics, long-acting agents, or outpatient parenteral therapy. Cardiac surgical interventions are limited to fewer than half of the facilities.

Background

Infective endocarditis is a serious infection with increasing hospitalizations over the past two decades, particularly among people who inject drugs (PWID). PWID are at higher risk for methicillin-resistant Staphylococcus aureus infections and longer hospital stays. Tennessee, a state heavily impacted by the opioid crisis, has seen rising endocarditis mortality rates in young adults with substance use disorders. Treatment complexity is compounded by challenges such as limited addiction services, provider stigma, and logistical barriers.

Data Highlights

Key Findings

• 88% of facilities screen for substance use disorders on admission, but only 24% provide addiction consultation services.
• Most facilities (94%) complete intravenous antibiotic therapy during inpatient stay; 75% also utilize skilled nursing facilities for antibiotic completion.
• Alternative antibiotic strategies such as oral antibiotics (56%), long-acting lipoglycopeptides (50%), and outpatient parenteral therapy (25%) are less commonly employed.
• Less than half of the surveyed facilities perform cardiac surgery (44%) or catheter-based interventions (38%) for endocarditis in PWID.
• There is a notable gap between screening for addiction and providing comprehensive addiction management services.

Clinical Implications

Healthcare facilities treating infective endocarditis in PWID should consider expanding addiction consultation services to address underlying substance use disorders effectively. Incorporating alternative antibiotic regimens, including oral and long-acting agents, may improve treatment flexibility and patient adherence. Enhancing access to surgical interventions and outpatient therapies could optimize outcomes in this complex patient population.

Conclusion

Current management of infective endocarditis in PWID in Tennessee is characterized by routine addiction screening and inpatient antibiotic completion but limited addiction services and alternative treatment modalities. Opportunities exist to improve care through integrated addiction management and diversified antibiotic strategies.

References

1. Parikh et al. 2015-2017 -- MRSA bloodstream infections attributed to PWID in Tennessee
2. Tennessee Department of Health Antibiotic Steward Call Survey 2022-2023