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Drug-associated infective endocarditis increased more than 10-fold from 2007 to 2017 in step with the opioid crisis in one state, researchers reported.

Annual hospitalizations related to the infection went from 0.92 to 10.95 per 100,000 persons during this time period in North Carolina. Admissions involving valve surgery also grew, from 0.10 to 1.38 per 100,000 persons per year.

In the last year of the study, people who used drugs accounted for 42% of all endocarditis valve surgeries performed in the state, according to a group led by Asher Schranz, MD, of the University of North Carolina in Chapel Hill, in a paper published online in . The data had been previously presented at IDWeek in October.

The increase in drug-associated infective endocarditis is "largely attributable to opioids" and "aligns with the growing number of deaths from heroin and synthetic narcotic use in North Carolina, which began an acute upward trajectory in 2014," the authors noted.

Given that each case of hospitalization and surgery for infective endocarditis costs more than $250,000, it is "almost certainly" cheaper to approach the problem with comprehensive outpatient treatment programs employing pharmacotherapy for opioid use, Schranz and colleagues said.

"A rational public health approach would prioritize funding of inpatient and outpatient drug use disorder treatment, harm reduction, and other activities to prevent infective endocarditis," they argued.

Their study based on the North Carolina Hospital Discharge Database included 22,825 adults with a hospitalization for infective endocarditis, of which 11% could be tied to the patient's drug use.

Surgery was performed in 7% of infective endocarditis hospitalizations and 17% for drug-associated infective endocarditis ones. The tricuspid was involved much more often in surgery for the latter (39% vs 11%), the investigators found.

Valve surgeries for drug-related infections tended to be on younger patients than other infective endocarditis procedures (median age 33 vs 56) and in more women (47% vs 33%) and white individuals (89% vs 63%). Most of the drug-related infection surgeries were in patients with Medicaid for their primary insurance (38%) or no insurance at all (35%).

Among the limitations of using the state database was the lack of granular clinical information for the study and the unknown generalizability to other states, Schranz's group noted.

"Further studies are needed to characterize long-term outcomes for patients with DUA-IE [drug use-associated infective endocarditis] after discharge, including reinfection, reoperation, and mortality, and to understand the role of addiction treatment, harm reduction, and other interventions in improving DUA-IE outcomes," they said.

The current situation can be likened to a 1930s malaria epidemic among New York heroin users, which led to the population at risk to start cutting heroin with quinine to prevent malaria infection.

"They saw a threat and developed a strategy to effectively reduce it," wrote Alysse Wurcel, MD, of Tufts Medical Center in Boston, in an accompanying editorial. Similarly, the field today could also use "innovative patient-centered research on how to prevent endocarditis and provide equitable, evidence-based treatment focusing not only on the microbe but on the underlying substance use disorder."

"Action is urgently needed to understand and improve the cascade of care for persons with DUA-IE," she emphasized.

When these individuals are admitted, early involvement of clinicians trained in addiction medicine may be a good idea, the editorialist suggested.

A rethinking of the traditional 6 weeks of IV antibiotic treatment also makes sense given the potential for discharge against medical advice and "suboptimal" post hospitalization treatment options of people who inject drugs, she added.

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