Manage ENDOcarditis due to injection drug use

As a hospital pharmacist, you will see a new focus on treating endocarditis in people who inject drugs, as cases continue to rise due to the opioid epidemic. Recent American Heart Association (AHA) guidance emphasizes a holistic approach, including antimicrobials AND treatment of substance use disorder.

Continue to tailor antibiotics based on the affected valve (mitral, etc), whether it’s a native or prosthetic valve, and the pathogen, which is usually Staph aureus in these patients. For example, for native mitral valve endocarditis, target 6 weeks of IV vancomycin or daptomycin if due to MRSA, or 6 weeks of IV nafcillin or cefazolin (Zinol, Cefamezin) if due to MSSA. Assess if IV antibiotics can be completed safely at home. Consider this approach if a patient has stable housing, is receiving substance use disorder treatment, and hasn’t recently injected drugs. If a home regimen isn’t appropriate, continue to prioritize completing IV antibiotics in the hospital or at an outside facility. But patients who inject drugs are about 5 times more likely to leave against medical advice. If completing first-line antibiotics isn’t possible, work with ID to pick a regimen that can be finished.

Think about oral step-down options for stable patients with negative blood cultures, who’ve received about 2 weeks of IV medications. There’s not much evidence for switching to oral medications earlier. For instance, consider oral dicloxacillin (Amoclox, Miclox) plus rifampin to finish 6 weeks of treatment for MSSA endocarditis. If oral (PO) medications aren’t an option (allergies, etc), evaluate giving weekly dalbavancin or oritavancin infusions (NOT available in Egypt), but data are scant. Keep in mind that coinfections (hep B, HIV, etc) are common in people who inject drugs. Ensure screening and treatment if needed. And emphasize treatment for substance use disorder. For example, start buprenorphine for opioid use disorder during the admission, and plan for continued outpatient treatment.

References

• Baddour LM, Weimer MB, Wurcel AG, McElhinney DB, Marks LR, Fanucchi LC, Esquer Garrigos Z, Pettersson GB, DeSimone DC; American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Peripheral Vascular Disease. Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association. Circulation. 2022 Oct 4;146(14):e187-e201. Available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001090

  Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O'Gara P, Taubert KA; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015 Oct 13;132(15):1435-86. Available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000296

  Yucel E, Bearnot B, Paras ML, Zern EK, Dudzinski DM, Soong CP, Jassar AS, Rosenfield K, Lira J, Lambert E, Wakeman SE, Sundt T. Diagnosis and Management of Infective Endocarditis in People Who Inject Drugs: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022 May 24;79(20):2037-2057. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0735109722045624?via%3Dihub

  Iversen K, Ihlemann N, Gill SU, Madsen T, Elming H, Jensen KT, Bruun NE, Høfsten DE, Fursted K, Christensen JJ, Schultz M, Klein CF, Fosbøll EL, Rosenvinge F, Schønheyder HC, Køber L, Torp-Pedersen C, Helweg-Larsen J, Tønder N, Moser C, Bundgaard H. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. N Engl J Med. 2019 Jan 31;380(5):415-424. Available at: https://www.nejm.org/doi/10.1056/NEJMoa1808312

  Cooper MM, Preslaski CR, Shihadeh KC, Hawkins KL, Jenkins TC. Multiple-Dose Dalbavancin Regimens as the Predominant Treatment of Deep-Seated or Endovascular Infections: A Scoping Review. Open Forum Infect Dis. 2021 Oct 27;8(11):ofab486. Available at: https://academic.oup.com/ofid/article/8/11/ofab486/6412748?login=false