Background: Intravenous drug use is an increasingly common condition predisposing to infective endocarditis. Data on infective endocarditis in intravenous drug users are limited. Objective: To determine the clinical features, bacteriologic findings, site of involvement, complications, and mortality associated with infective endocarditis in intravenous drug users. Methods: Cohort study of intravenous drug users with native valve infective endocarditis. Results: A total of 125 cases of infective endocarditis occurred in 114 patients (84 cases [67%] in men and 41 cases [32%] in women) with a mean (±SD) age of 37±7 years. The tricuspid valve was involved in 58 cases (46%), the mitral valve in 40 cases (32%), and the aortic valve in 24 cases (19%). The microorganisms identified included Staphylococcus in 82 cases (65.6%) and Streptococcus in 32 cases (25.6%). Twenty-three patients (18%) underwent surgery, and two (9%) of them died. One hundred two patients (82%) were treated medically, and nine (9%) of them died. Fifteen patients (63%) with aortic valve involvement vs 17 patients (17%) without aortic valve involvement underwent surgery or died without surgery (odds ratio, 8.24; 95% confidence interval, 3.1 to 21.8). Among the survivors, at least one major cardiovascular complication occurred in 79 cases (69.3%). Conclusions: Infective endocarditis in intravenous drug users affects the right and left sides of the heart with approximately equal frequency. At present, more than 90% of cases of infective endocarditis in intravenous drug users in Chicago are caused by staphylococci or streptococci. Involvement of the aortic valve is predictive of increased morbidity and mortality in intravenous drug users with infective endocarditis. With medical treatment, and surgery when medical treatment fails, intravenous drug users with infective endocarditis have an in-hospital survival rate of 91%. (Arch Intern Med. 1995;155:1641-1648)

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Clinical Features, Site of Involvement, Bacteriologic Findings, and Outcome of Infective Endocarditis in Intravenous Drug Users

Infective endocarditis in the narcotic addict.

Infective endocarditis caused by gram-negative bacteria: A review of the literature, 1945–1977

One hundred samples of heroin and 100 of injection paraphernalia were cultured. A wide variety of microorganisms were found. The heroin contained Bacillus species, Staphylococcus albus, fungi, Clostridium perfringens, and (rarely) gramnegative bacilli. The same organisms were recovered from the injection paraphernalia, along with a variety of gram-negative bacilli among which Escherichia coli predominated. Not one coagulase-positive Staphylococcus was isolated, despite the fact that this organism is the most common cause of infections in our addict population; thus, the addicts themselves are probably the source of Staphylococcus

Microbiologic Study of Street Heroin and Injection Paraphernalia

From 1969 to 1974, 19 cases of Serratia marcescens endocarditis were observed in the San Francisco Bay Area. Seventeen patients were intravenous drug users, and Serratia caused 14% of all addict-associated endocarditis in San Francisco. Serratia strains were nonpigmented and had typical antibiotic sensitivities, except that 9 of the isolates exhibited colonial variation, with each variant having different antibiotic sensitivities. Aortic or mitral valves were involved in 13 patients, and heart failure developed in 9 of these. Twelve patients had embolic episodes to brain, iliofemoral arteries, or lung. Five of 6 patients with tricuspid valvulitis were cured by antibiotics either with (1) or without excision of the valve. All 12 patients with aortic or mitral valvulitis treated medically died; 11 had unremitting sepsis. Aortic valve replacement and antibiotics were effective in 1. Gentamicin combined with either carbenicillin or chloramphenicol was the most effective treatment regimen.

M A Feinstein

Papers

Infective endocarditis in drug addicts.