The Hippo


May 29, 2020








Endocarditis hits plateau?
An update on drug-related heart infections

By Ryan Lessard

 The available data for heart valve infections caused by intravenous drug use in 2017 points to a slowing down in infection rates and possibly mortality rates, though the evidence is mixed and not everyone is optimistic.

What we know
An uptick in cases of endocarditis, a bacterial infection of heart valves, is a secondary effect of a regional opioid addiction epidemic. While it can be caused by other things, frequent use of unsanitary needles can result in an explosion of cases. That’s what happened in New Hampshire in recent years as places like Catholic Medical Center saw their drug-related endocarditis patients jump from five in 2013 to 51 in 2016. 
If left untreated, the infection proves fatal. Deaths resulting from drug-related endocarditis apparently increased, with 11 deaths in 2016. There were only four such deaths in the previous nine years. 
While the public health officials don’t track endocarditis cases statewide, data from CMC, Elliot Hospital, the Medical Examiner’s office and anecdotal information from Dartmouth-Hitchcock can provide a window into the situation. And the picture for 2017 is mixed.
Kim Fallon, the chief forensic investigator at the Medical Examiner’s office, checked their database to see how many deaths were caused by drug-related endocarditis in calendar year 2017. There were seven in the records, though Fallon said this may not present a complete picture since some endocarditis-related deaths could be marked as “natural” or the ME’s office could decline jurisdiction to perform the autopsy. 
In many cases, patients get treated and discharged without proper support systems to treat their addiction. 
“And they immediately relapse, get infected, come back and die. And this is something, unfortunately, we see not uncommonly, said Dr. Bryan Marsh, the chief of the section on infectious diseases at Dartmouth-Hitchcock.
One case from the 2017 death toll demonstrates how complications of endocarditis can haunt addicts even after they enter recovery from their addiction. A teenage girl died from what the certificate states were complications of bacterial endocarditis after a tricuspid valve replacement and after a pacemaker was inserted. While she was documented to have been a chronic heroin user in the past, there were no illicit drugs in her system when she died. The drugs that were found were antidepressants and methadone, since she was in a medication-assisted treatment program.
The numbers from the ME’s office seems to show a slight decline. Data from CMC show a small increase, but at a slower rate than past years. In 2016, the hospital had 87 endocarditis patients, 51 of whom were infected from intravenous drug use. In 2017, it had 55 drug-related cases out of 90.
“Our numbers have plateaued in terms of the … opiate cases that we see,” said Dr. Jonathan Eddinger, a CMC cardiologist. 
Elliot Hospital sees fewer endocarditis patients than CMC, generally, as it doesn’t offer valve replacement surgery. It noted a jump from nine overall cases in fiscal year 2015 to 17 in fiscal year 2016. But in fiscal year 2017, there was a slight drop to 13. 
It’s unclear whether that pattern will continue, however. Six months into fiscal year 2018, Elliot has already recorded nine cases, putting it on track to reach 18 by the end of June.
Marsh said he and the staff who treat endocarditis patients have the strong impression that cases increased significantly in 2017 compared to 2016. And he said drug use is the primary driver of that increase. Dartmouth sees patients from all over New Hampshire and a significant portion of Vermont.
Marsh said the hospital does not track which cases are caused by intravenous drug use and did not have data available by press time for overall cases.
“On any given week we see probably an average of two new patients with several bacterial complications of injecting drug use. And the majority of those are endocarditis,” Marsh said.
At any given time in 2017, there was an average of about half a dozen patients in the hospital getting treated for the condition, which he said is an increase over the previous year.
Treatment involves four to six weeks of intravenous antibiotics. And since addicts are more likely to reinfect themselves or use their antibiotics IV to inject drugs, they are kept at the hospital for the duration of their treatment.
Turning a corner?
Eddinger and Marsh are of two minds when it comes to interpreting the limited data on this issue. 
Eddinger believes the plateauing numbers are likely a sign that things are moving in the right direction. The state’s treatment and recovery infrastructure has improved in recent years, and attitudes have changed around medication-assisted treatment, Eddinger said, which may point to some success at stemming the tide of addiction in small ways. 
One possible sign of this is the projected number of overdose deaths in 2017, which is expected to be the first decrease since the epidemic began, though the death toll will still be in the 400s.
At CMC, a push to ensure patients don’t reinfect themselves after being discharged has led to a stronger partnership with Hope for NH Recovery. Eddinger said peer recovery coaches from the organization will come in and help patients who want treatment navigate the resources available.
“I do think we’re making a dent in it,” Eddinger said.
At CMC, there were six valve replacements due to drug-related endocarditis in 2017, down from 16 in 2016.
While this may be attributable to a slowdown of cases, doctors may also be opting to do fewer surgeries if they think patients are less likely to survive the operation, which Eddinger calls “selection bias.”
“It’s possible there’s less surgeries because of selection bias,” Eddinger said.
While Eddinger is optimistic that we will soon see a future with fewer endocarditis cases, Marsh is less sanguine about that prospect. 
From his perspective, Marsh does not yet see a light at the end of the tunnel.
“It’s not a surprise that the number of cases have gone up [at Dartmouth] in that all the evidence we have in the region is that the opiate epidemic is continuing to worsen. We haven’t done a good job as a society yet in starting to turn that around,” Marsh said.

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