Most Current Guidelines for the Treatment of Infective Endocarditis Fall Short of Evidence-based Treatment for Opioid Use Disorder

Infective Endocarditis (IE) is common among people who inject drugs (PWID), and rates of IE in this population are increasing. Many guidelines outline duration of IV antibiotic treatment and patients’ appropriateness for surgery. Researchers reviewed and compared 10 medical guidelines published 2007–2020 for management of IE in PWID.

• Six of the 10 guidelines include considerations for reduced treatment intensity among PWID, including a shortened course of antibiotics or the use of oral antibiotics.
• Five of the 10 guidelines discuss the increased risk of reinfection among PWID, and 2 guidelines (including those of the American Heart Association [AHA]*) recommend avoiding surgery among PWID.
• Only 1 guideline specifically mentions the prescribing of medication for OUD, and only 3 mention treatment of OUD or an addiction medicine consult.
• All guidelines use some stigmatizing language (e.g., “abuser,” “addict”).
• Management of withdrawal is not addressed in any guidelines.**

* In 2021, the AHA assembled an expert writing group that issued a scientific statement (2022) on the management of IE among PWID endorsing evidence-based treatment, harm-reduction measures, and thorough considerations for surgery in this population (“Indications for surgery in PWID with IE are the same as in patients with IE who do not inject drugs”).

** The 2022 AHA statement recommends using medication for the treatment of withdrawal (buprenorphine and methadone).

Comments: Many guidelines include considerations about reducing standards of care for the treatment of IE among PWID, while few include recommendations about how to address the underlying substance use disorder that led to IE and which increases the risk of recurrence. This orientation—along with the prevalent use of stigmatizing language—reflects a relative lack of substance use expertise and perspective in the formulation of IE guidelines (a gap that the AHA has taken steps to remedy). Evidence-based recommendations about how to address substance use disorder among PWID could facilitate more effective treatment of IE and reduce the risk of recurrence.

Corey McBrayer, DO, MPH** & Timothy S. Naimi, MD, MPH

** Rich Saitz Editorial Intern & Grant Medical Center Addiction Medicine Fellow, OhioHealth.

References: Selitsky L, Racha S, Rastegar D, Olsen Y. Infective endocarditis in people who inject drugs: a scoping review of clinical guidelines. J Hosp Med. 2023;18(2):169–176.

Baddour LM, Weimer MB, Wurcel AG, et al. Management of infective endocarditis in people who inject drugs: a scientific statement from the American Heart Association. Circulation. 2022;146(14):e187–e201.