(89) Infective Endocarditis in People Who Use Drugs: A Critical Review of Guidelines

Introduction: The incidence of infective endocarditis (IE) among people who use drugs (PWUD) is rising. There are multiple but differing guidelines on management of this condition. To date, a comprehensive comparison of guidelines has yet to be published. Our objective was to perform a critical review that identifies key differences in guideline recommendations for treating IE among PWUD, clarifies the prevailing disease/population definitions, determines the presence of stigmatizing language, and assesses whether substance use disorder treatment is included as a recommendation.

Methods: In line with Arksey and O’Malley’s framework, a scoping review was performed using Joanna Briggs Institute and PRISMA-ScR guidelines. Three electronic databases (PubMed, CINAHL Plus, and Google Scholar) were queried between 2015 and 2020. English-language, society-developed guidelines for the treatment of IE in PWUD were included. Data items included guidelines for surgical candidacy and antimicrobial management, terminology used to define IE in PWUD, the presence of stigmatizing language, and if opioid use disorder treatment was mentioned.

Results: Four guidelines from the following organizations were included: American Heart Association (2015), American College of Cardiology (2020), American Association for Thoracic Surgery (2016), and European Society of Cardiology (2015). Some societies propose non-standard care in PWUD (e.g. avoiding surgery, avoiding placement of a prosthetic valve, and considering oral antibiotics over intravenous antibiotics) due to concern for disease recidivism. Medical terminology for this patient population is not standardized and all of the guidelines employ some stigmatizing language (e.g. “addict”, “drug abuse”, “drug users”). Two guidelines describe “drug use associated endocarditis” as well as “injection drug use-related IE” without clear distinction between the two potentially distinct (albeit, overlapping) populations. Three guidelines include reference to addiction treatment, but only one specifies the use of opioid agonist therapy for treating opioid use disorder.

Conclusions: Current guidelines for treatment of IE among PWUD frequently use stigmatizing language and do not consistently incorporate substance use disorder treatment into their recommendations. Future updates should address these deficiencies.

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