Management of Patients with Infective Endocarditis: State of the Art

By Bryant Fisher, MD, and Pyongsoo Yoon, MD

The management of infective endocarditis remains a multifaceted subject that continues to increase in complexity with the rising incidence of injection drug use. A recent statement from the American Heart Association (AHA) titled “Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association” highlights the importance of a multidisciplinary team in the management of this life-threatening illness. The involvement of addiction medicine is described as a key component to prevent complications and morbidity in this vulnerable population through relapse-prevention and treatment of the underlying substance use disorder. Recent evidence is also emerging that shows utilization of a multidisciplinary endocarditis team improves mortality in hospitalized patients with endocarditis and surgical indications.

These data also demonstrate increased rates of surgical intervention in this patient population, suggesting that the implementation of an endocarditis team improves optimization for surgery. Surgically managed patients with substance use disorders have been shown to have higher short and midterm mortality rates compared to those without injection drug use, largely due to overdose deaths and relapse. Due to increased public reporting of surgical outcomes and their impact on hospital rankings, surgeons have developed a risk-averse approach to these patients in recent years to curb the effect of nonsurgical morbidity and mortality. Developing an endocarditis team with the involvement of addiction medicine has the potential to reduce the risks associated with this patient population and, consequently, increase rates of life-saving surgical intervention. While UPMC has been at the forefront of such innovation in endocarditis management, widespread adoption of the endocarditis team method is likely inevitable as it is facilitated by development of guidelines for implementation by expert clinicians.

Given the emerging evidence for such an approach, UPMC developed a multidisciplinary endovascular infection (EVI) team under the Division of Infectious Disease, University of Pittsburgh School of Medicine, in 2019. The team is composed of multiple specialties including cardiology, infectious disease, cardiothoracic surgery, electrophysiology, neurology, neurosurgery, pharmacy, social work, and addiction medicine. The team meets weekly to discuss the management of patient cases from across UPMC. Open communication allows the team to address questions regarding surgical/ medical management, antibiotic regimens, and optimization for surgery. Patient imaging and echocardiograms are reviewed by our expert cardiologists during the meeting. This has allowed for patients from more UPMC hospitals to be reviewed and discussed to arrange for efficient transfer to higher levels of care. The utilization of an endovascular infection team has prompted specialty cooperation and innovation in the care of this patient population.

The Division of Infectious Disease has developed a team of subspecialists devoted to endocarditis treatment. In addition to the usual recommendations for IV antibiotic therapy, they also offer unique alternatives including various oral therapies and long-acting lipoglycopeptides (Dalbavancin). Early involvement of addiction medicine reduces patientdirected discharge and relapse while also enabling initiation of methadone and buprenorphine to mitigate opioid withdrawal. Long-term follow-up with addiction medicine through this established relationship further improves patient adherence to sobriety, reducing relapse infection after surgery.

Follow-up appointments with addiction medicine frequently occur at the patient’s infectious disease visit, further longitudinal care. Given the importance of post-op management, dedicated social workers specialized in addiction management assist with transition to long-term care facilities while also arranging for family meetings. Due to the support from the endovascular infection team and improved patient optimization, more aggressive surgical intervention has been undertaken and unique approaches such as percutaneous vegectomy and vacuum aspiration are increasingly offered. Input from the electrophysiology team improves the care of patients with rhythm disturbances and allows for early referral of patients with lead infections for possible surgical intervention. Topics such as re-operation on patients continuing to inject drugs, optimal timing of transition to oral antibiotic therapy, and risk stratification for surgery will be a focus of discussion to determine optimal care for this patient population. Utilization of the endovascular infection team has become integral to infective endocarditis management at UPMC while promoting continued innovation in patient care.