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Canadian Journal of Cardiology

Dealing With the Epidemic of Endocarditis in People Who Inject Drugs

      Abstract

      North America is facing an opioid epidemic and growing illicit drug supply, contributing to growing numbers of injection drug use–related infective endocarditis (IDU-IE). Patients with IDU-IE have high early and late mortality. Patients with IDU-IE more commonly present with right-side IE compared with those with non-IDU IE, and a majority are a result of Streptococcus aureus. Although most patients can be successfully managed with intravenous antibiotic treatment, surgery is often required in part owing to high relapse rates, potential treatment biases, and more aggressive pathophysiology in some. Multidisciplinary management as endocarditis teams, including not only cardiologists and cardiac surgeons, but also infectious disease specialists, drug addiction experts, social workers, neurologists, and neurosurgeons, is essential to best manage substance use disorder and facilitate safe discharge to home and society. Structural and population-level interventions, such as harm-reduction programs, are necessary to reduce IDU-IE relapse rates in the community and other IDU-related health concerns, such as overdoses. In this review, we describe the pathophysiologic, clinical, surgical, social, and ethical characteristics of IDU-IE and their management. We present the most recent clinical guidelines for this condition and discuss existing gaps in knowledge to guide future research, practice changes, and policy interventions.

      Résumé

      La crise des opioïdes qui sévit actuellement en Amérique du Nord est amplifiée par la présence accrue de drogues illicites sur le marché, ce qui contribue à l’augmentation du nombre d’endocardites infectieuses dans le contexte de consommation de drogues injectables (EI-CDI). Les patients atteints d’EI-CDI, principalement causées par Streptococcus aureus, présentent des taux élevés de mortalité précoce et tardive, ainsi qu’une atteinte plus fréquente du cœur droit que chez les autres patients. Même si la prise en charge par des antibiotiques intraveineux donne de bons résultats dans la plupart des cas, un traitement chirurgical est souvent nécessaire en raison du taux élevé de rechutes, d’une possible subjectivité dans le choix du traitement et d’une pathophysiologie parfois plus agressive de la maladie. La prise en charge de l’endocardite par une équipe multidisciplinaire (formée non seulement de cardiologues et de chirurgiens cardiaques, mais aussi d’infectiologues, d’experts en toxicomanie, de travailleurs sociaux, de neurologues et de neurochirurgiens) est essentielle pour traiter adéquatement le trouble de l’usage d’une substance et pour faciliter la réinsertion sociale. Des interventions structurelles et populationnelles, comme des programmes de réduction des préjudices liés à la toxicomanie, sont nécessaires pour réduire les taux de rechute d’EI-CDI dans le milieu de vie et les autres problèmes de santé liés à la consommation de drogues injectables, tels que les surdoses. Nous décrivons ici les caractéristiques pathophysiologiques, cliniques, chirurgicales, sociales et éthiques liées aux EI-CDI, ainsi que leur prise en charge. Nous présentons les plus récentes recommandations cliniques au sujet de cette affection et nous mettons en lumière les lacunes dans les connaissances, afin d’orienter la recherche, le choix des changements à apporter dans la pratique et la mise en place d’outils d’intervention.

      Graphical abstract

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