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Dr. Gosta Pettersson discusses treatment options for infective endocarditis.

Enjoy the full Tall Rounds® & earn free CME

  • Introduction: Gosta Pettersson, MD
  • Case Presentation: Right Sided IE in PWID: Jin Woo Chung, MD
  • Medical management - New Drugs and Oral Rx: Steven Gordon, MD
  • Role of Surgery - When, When Not and How: Shinya Unai, MD
  • Role for Catheter Debulking?: Joseph Campbell, MD
  • The Addiction - MAT, Bundle Care and Peer Support: Matthew McWeeney, CNP
  • HVTI Initiatives: Alice Kim, MD and Betsy Stovsky, RN, MSN
  • A Patient Story

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Talking Tall Rounds®: Lifelong Care for Endocarditis

Podcast Transcript

Announcer:
Welcome to Cleveland Clinic Cardiac Consult brought to you by the Sydell and Arnold Miller Family, Heart, Vascular & Thoracic Institute at Cleveland Clinic. In each podcast, we aim to provide relevant and helpful information for healthcare professionals involved in cardiac, vascular and thoracic specialties. Enjoy.

Gosta Pettersson, MD, PhD:
Hey, good morning. I'm Dr. Pettersson. I'm a staff surgeon at the Department of Cardiovascular Surgery, and we have just completed a very interesting Tall Rounds devoted to treatment of patients with endocarditis and we will focus on patients who inject drugs. We've had the patients who I've been followed since 2013 here. We've been emphasizing the enormous drug epidemic we're in and the crisis. Our attitude to this is that we should not waste this crisis, but do our best to turn things around and to help these poor patients who get into addiction.

Gosta Pettersson, MD, PhD:
Surgery is a small portion of it but the main portion is medical treatment and addiction treatment. At the end, we had the patient Michelle Schindler, the presenter, very touching story, and she is now clean since two years. She's actively participating in helping other patients and taking courses how to be a peer supporter. So please listen to the program. It was very interesting. Thank you.

Jin Woo Chung, MD:
Good morning. I'm going to present about right-sided infective endocarditis in patient with IV drug abuse. This is a 27-year-old female with history of IV drug use, who admitted with infective endocarditis in July 2013.

Jin Woo Chung, MD:
Prior to admission, patient lost 100 pounds over six months, and had multiple melena with admitting hemoglobin in 5.4. Patient was admitted to the Akron General Hospital with fever and extreme lethargy and confusions. Patient was intubated in the ED for respiratory distress and transferred to the Cleveland Clinic for management of MRSA, infective endocarditis, septic pulmonary emboli, and necrotizing pneumonia and septic shock, and also AKI requiring hemodialysis.

Jin Woo Chung, MD:
CT chest showed bilateral air-filled cavities suggesting septic emboli and TT showed moderate RV dysfunctions, and three to four plus PR with a large vegetations and two plus TR with a mildly thickened tricuspid valve.

Jin Woo Chung, MD:
However, patient was considered too sick for surgery so treated medically and eventually discharged to LTACH for rehabilitation.

Jin Woo Chung, MD:
Weeks later, the patient was a readmitted to MICU for management L4 L5 septic arthritis, AKI and septic shock. However, surgery was postponed again because patient was still too deconditioned and patient was eventually discharged to SNF for rehabilitation.

Jin Woo Chung, MD:
February 2014, patient underwent for surgery, primary valve replacement with Biocor 27 and tricuspid repair with CE Classic ring reinserted. Her stay was uncomplicated and the patient was discharged home on post-op day eight.

Jin Woo Chung, MD:
September 2015, unfortunately, substance abuse with the labs and patient was treated for bacteremia at outside hospital.

Jin Woo Chung, MD:
April 2016, patient presented to outside of the hospital with fever, headache, nausea, and night sweats and patient was found to have enterococcus faecalis bacteremia, and also thrombosis on tip of the right IJ catheter. The patient was transported to CCF for further evaluation and management. TT was done here and which showed a normal EF and moderately dilated RV and moderate decreased RV function and questionable small mobile liquid density on tricuspid valve and large vegetations on prosthetic pulmonic valve causing severe pulmonary stenosis. Peak pressure gradient was 64.

Jin Woo Chung, MD:
The patient underwent a second surgery in May 2016. Reentry without issues and we found a large vegetation on pulmonic valve and no vegetations on tricuspid valve. We explanted a previous prosthetic pulmonic valve and reimplanted a new Biocor 27 prosthesis. Hospital course was uncomplicated, but patient left hospital post-op day seven against medical advice.

Jin Woo Chung, MD:
Follow up until now, the last TT was done January 2019, which showed a normal EF and normal size RV and normal function RV and no tricuspid vegetations. No pulmonic valve regurgitations and peak pressure gradient was 22. The patient was seen last time, August 2019, and she's doing well and free of drugs.

Steven Gordon, MD:
I just want to frame this is that we are in a huge crisis. If you look at this graph here, if you look at the number of people who have died in this past decade, which is reaching out over 700,000 and that's up to 60 to 70,000 a year. We are in a huge epidemic crisis that far exceeds my experience with HIV.

Steven Gordon, MD:
Much has been written and much is uncovering. This is a good book that I found, which gives a nice summary, but remember too, we are also downtown right now Judge Posner is actually head of all the litigation in terms of the non-criminal and we're beginning to see activity on that. Actually under Freedom of Information Act, what was able to be obtained by the Washington Post was actually the pill distribution that is legal pill distribution in America, which tells a different story. This is a story I say of a failure.

Steven Gordon, MD:
If you look at those numbers, there were about 76 billion legal opioid pills manufactured and distributed over a six year period and just do the math. Obviously in some cities and areas, the number of pills per capita far exceeded what could be taken. What you have here is primarily the manufacturers of which there's more, but there are big three here. This is Purdue, Mallinckrodt, Octavius. You've got the distributors who received those pills. This includes a Ohio company, as we know, but Walgreens, Cardinal Health, CVS, these are companies we're all known to. You have pill mills and diversions. Some of that blame is on physicians. You've got OxyContin introduced in 1996. At the same time you have Joint Commission taking up pain is the fifth vital sign, which reinforces the issue we're under treating pain and there we have the losses.

Steven Gordon, MD:
From a quality point of view, we view this as a series of things that happen, that create huge amount of loss. Now we're in a big hole here, but all of us can look in a mirror and there's blame to be shared by all.

Steven Gordon, MD:
I'm going to pivot to infections and endocarditis is at the tip of the iceberg. Most of the infections that we see in people who inject drugs are going to be skin and soft tissue. A lot of the pneumonias is a nice case that was presented can be septic emboli.

Steven Gordon, MD:
In a recent study, looking in patients in New York and the MMWR, endocarditis of patients presenting to the ER is about 14% of cases and most of those are going to be staph aureus. This comes from our own institution, but no surprise. Again, the endocarditis associated with people who inject drugs is a lagging indicator, but this has been seen something that has increased all across the country. Again, as a heart center, we have felt this and have continued to deal with this over the past few years.

Steven Gordon, MD:
We have our own lessons learned as presented in this case. You can see some of the numbers at the clinic. This represents about maybe 20 to 15% of all patients operated on at the clinic each year. Our numbers are increasing. My colleagues here are the big driver of that and so this is something that we are in medias res, I would say.

Steven Gordon, MD:
Our lessons learned. Nabin Shrestha published this paper a few years ago, which actually showed something that was paradoxical. People who are operated on with endocarditis, who inject drugs actually do better in the first 90 days than people who don't inject drugs with endocarditis. A lot of reasons for that they're younger, less comorbidities, but as Nabin's paper showed you go beyond 90 days, the hazard ratio of that cohort for readmission, reinfection or death is 10 times that of the people who don't inject drugs with endocarditis that are operated. This was a big wake up call for us in terms of here.

Steven Gordon, MD:
When we look at what we call the failure mode analysis, this is going to be presented next month by one of our residents. But what we call the cascade of care for treatment of addiction, we fell down and if standard of care, which it is for opioid use disorder is medication assisted treatment, you can see less than 3% of our patients were discharged on documented medication assisted treatment. It's not that we didn't know about the addiction, but at that point it was, here's a phone number to call or get yourself involved in treating the addiction. This is a big miss and a big opportunity that we're going to hear about.

Steven Gordon, MD:
I know we're going to be talking about, what's been done Dr. Kim and McWeeney, will go ahead and do that.

Steven Gordon, MD:
Now, what about treating patients from an ID perspective? In our society, it's interesting if you pool most ID people, we tend to look at this as it's not our problem, but it's, but we don't want to let patients go out with IV antibiotics with cath in their arms, because we were fearful of intentional misuse. We're fearful of decreased ability of these patients to come back and there is stigma, which we'll talk about.

Steven Gordon, MD:
Now, I would ask any patient with an opioid use disorder, "Is the presence of a catheter are not going to be the trigger for you to use?" The answer to that in every single patient that we've seen is obviously no. In fact, one could argue it's a harm reduction situation. Catheters don't cause the addiction and they don't facilitate the addiction.

Steven Gordon, MD:
Now again, what are our own guidelines? Again, you'll see the second author here at Dr. Shrestha. I know most of you are asking why isn't Nabin up here? But that's okay.

Steven Gordon, MD:
In the review, there's only one paper that actually is cited and actually comes from our institution and it's not a great paper. I can say that because we're on it, but it didn't show no signal to noise in terms of bad outcomes in people discharged with opioid use disorder on CoPAC.

Steven Gordon, MD:
We really no formal recommendations. There's not a lot of evidence here, but we do know obviously treating the addiction is critical here no matter what happens.

Steven Gordon, MD:
The other strategies that we're beginning to look at or we're going to be seeing things are either avoiding IV antibiotics, which are not just for patients who inject drugs, the POET study and things is looking at antibiotics in oral antibiotics for endocarditis is out there either going IV or sequential IV to oral or what we call lineless CoPAC. These are the long acting glycopeptides that can be dosed once a week. Theoretically patients could come in once a week, get infusion and pull the line out.

Steven Gordon, MD:
What's the data on that? This is again from the POET trial out of Denmark, very good outcomes, actually surprisingly outcomes, even in prosthetic valve endocarditis. In terms of us, again, this was randomized controlled trial non-inferiority. Again, if you dig down and look at opioid use disorder, less than 2% of these patients where people were injected drugs or with opioid use disorder so hard to generalize that as a way forward, yet.

Steven Gordon, MD:
Same thing in terms of lineless. This was a study published again, coming from Europe, 27 patients with endocarditis also PVE sequential strategy and again, long acting antibiotics, actually very good clinical success. But in this cohort, again, nobody with opioid use disorder or people who inject drugs.

Steven Gordon, MD:
Now I want to talk about stigma because I think this is something I'm old enough to grow up with stigma in the HIV era and there are so many parallels. This is an excellent book in talking about the stigma of addiction. But if we look at the definition of stigma, a mark of disgrace or infamy, a stain or reproach on one's reputation. This is prevalent in these patients' experience and many medical community view these patients as not only dangerous, but also blameworthy. Of course, that is not what we believe.

Steven Gordon, MD:
In last week's New England Journal of Medicine, it was interesting. They talked about a medical student that died of overdose with opioid use disorder, and then it also looked at how physicians aren't very good at policing ourselves or treating ourselves. In fact, the state of Ohio, if a physician's on Suboxone, they cannot practice. They, Ohio, believes in abstinence only for substance abuse disorder in physicians.

Steven Gordon, MD:
If you go back and look when ID Doc Abraham Verghese, who's a very good author, but wrote about this himself in terms of medical student at Texas, who was, who also died of opioid use disorder. A lot of issues there. What we're moving toward what we're teaching our residents and the students is actually patient-centered language in terms of as we talk to these patients. We don't talk about the moralistic aspect. These are not bad people turning good. We don't like using the terms addict, junkie. We don't like saying clean urine. These are very loaded terms. These are people with opioid use disorder. People who inject drugs, the P is upfront and center. Patients with the disease, sharing the concerns in trying to get the good histories and meeting these patients where they are, not judging.

Steven Gordon, MD:
All right, what about the way forward? As we all know, there is no easy way forward. This is what the Australians would say is a wicked problem and there's been a failure in a business in terms of rehab, which maybe we'll get into a little bit. Actually The Goldfinch, which I know the movie's bombing, but actually it's a very good book, a modern day story in my assessment about addiction.

Steven Gordon, MD:
In summary, I think treatment of endocarditis and people who inject drugs with, with substance use disorder and opioid use disorder is challenging. We make our decisions on OPAC on a case-by-case basis. We're going to talk about the bundle of care, antimicrobials, surgery when indicated and of course addiction treatment, the Cascade of Care Model, we're here more about, we have to improve our cascade of care in terms of keeping patients on addiction treatment once they're here, once they leave, and afterwards.

Steven Gordon, MD:
We want to mitigate stigma of people who inject drugs with substance use disorder with more education role monitoring in how the language that we talk about patients and more research. Addiction to treatments, nonpharmacological registries on patients and moving away from this war on drugs, to more of a issue about law enforcement diversion in terms of how we treat these patients.

Steven Gordon, MD:
I do want to give a big shout out. All this work is done by not by me, but by partners in terms of this nature in getting national attention and so my hats off to the whole team here. And thank you.

Announcer:
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