Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis.

BACKGROUND: Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. METHODS: Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. RESULTS: We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. CONCLUSIONS: Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.

Epidemiology, Microbiology, and Clinical Outcomes Among Patients With Intravenous Drug Use-Associated Infective Endocarditis in New Brunswick.

BACKGROUND: Within the context of Canada's opioid crisis, medical complications associated with intravenous drug use (IVDU) are increasing. Infective endocarditis (IE) is a serious complication of IVDU, and understanding the characteristics of these patients could aid health systems, clinicians, and patients in the optimization of treatment and prevention of IVDU-IE. METHODS: At a tertiary care hospital in southern New Brunswick, we conducted a retrospective chart review to identify patients with IVDU-IE admitted between January 1, 2013, and December 31, 2017. We collected data related to the epidemiology, microbiology, clinical manifestations, echocardiography, complications during hospital admission, and outcomes. RESULTS: Forty-two cases of IVDU-IE met inclusion criteria. The rate of IVDU-IE increased from 2.28 per 100,000 population in 2014 to 4.00 in 2017, which, although not statistically significant, reflects patterns in other jurisdictions. Most patients (72.4%) were male, and the mean age was 38.3 (±11.5) years. Most patients (79.3%) injected opioids. The most common clinical sign was fever (90.5%), and Staphylococcus aureus (61.9%) was the most common microorganism. The tricuspid valve was most commonly infected (58.5%), 50% of cases had heart failure as a complication during admission, and 45.2% of cases required valve replacement or repair. The 2-year survival rate after admission for initial IVDU-IE episode was 62.0% (95% confidence interval: 36.5-79.7). CONCLUSION: IVDU-IE is common in New Brunswick and may be increasing. Despite the relatively young age of this patient population, IVDU-IE is associated with significant morbidity and mortality. Expanding effective harm reduction and addiction treatment strategies for this cohort is recommended.

CONTEXTE: Dans le contexte de la crise des opioïdes au Canada, les complications médicales liées à l'utilisation de drogues par voie intraveineuse (UDIV) sont en augmentation. L'endocardite infectieuse (EI) est une complication grave de l'UDIV, et la compréhension des caractéristiques de ces patients pourrait aider les systèmes de santé, les cliniciens et les patients à optimiser le traitement et la prévention de l'EI liée à l'UDIV (EI-UDIV). MÉTHODES: Dans un hôpital de soins tertiaires du sud du Nouveau-Brunswick, nous avons effectué un examen rétrospectif des dossiers afin d'identifier les patients atteints de l'EI-UDIV admis entre le 1er janvier 2013 et le 31 décembre 2017. Nous avons recueilli des données relatives à l'épidémiologie, la microbiologie, les manifestations cliniques, l'échocardiographie, les complications lors de l'admission à l'hôpital et les bilans. RÉSULTATS: Quarante-deux cas d'EI-UDIV ont répondu aux critères d'inclusion. Le taux d'EI-UDIV est passé de 2,28 pour 100 000 habitants en 2014 à 4,00 en 2017, ce qui, bien que non significatif statistiquement, reflète les tendances observées dans d'autres juridictions. La plupart des patients (72,4 %) étaient des hommes, et l'âge moyen était de 38,3 ans (±11,5). La plupart des patients (79,3 %) s'injectaient des opioïdes. Le signe clinique le plus fréquent était la fièvre (90,5 %), et le Staphylococcus aureus (61,9 %) était le micro-organisme le plus couramment observé. La valve tricuspide était le plus souvent infectée (58,5 %), 50 % des cas avaient une insuffisance cardiaque en tant que complication lors de l'admission, et 45,2 % des cas ont nécessité un remplacement ou une réparation de la valve. Le taux de survie à deux ans après l'admission pour l'épisode initial d'EI-UDIV était de 62,0 % (intervalle de confiance à 95 % : 36,5-79,7). CONCLUSION: L'EI-UDIV est fréquent au Nouveau-Brunswick et pourrait être en augmentation. Malgré l'âge relativement jeune de cette population de patients, l'UDIV-IE est associée à une morbidité et une mortalité importantes. Il est recommandé d'étendre les stratégies efficaces de réduction des risques et de traitement des dépendances pour cette cohorte.