Treatment and Outcome

As mentioned before, many IVDU with infective endocarditis have right-sided endocarditis. This prompted researchers to assess the feasibility of shorter antibiotic courses in this population, as right-sided endocarditis has a better prognosis than left -sided infection. This approach is particularly attractive as the compliance of IVDU to prolonged hospitalization or home care is low. Chambers [30] in 1988 published a report confirming the possibility to treat right-sided endocarditis in IVDU with as two-week course of antibiotics. Fortun [31] confirmed these results by performing a prospective, randomized clinical trial among drug abusers to assess the efficacy and safety of a short course of a combination of a glycopeptide (vancomycin or teicoplanin) and gentamicin compared with a combination of cloxacillin and gentamicin for treatment of right-side endocarditis caused by S. aureus. Therapeutic success was significantly more frequent with cloxacillin than with a gly-copeptide. No adverse effects were noted among patients in the cloxacillin group. Ribera et al. showed similar results [32]. Thus, a shortened course of penicilliase-resistant penicillin with or without the addition of an aminoglycoside for right-sided infective endocarditis in IVDU infected with S. aureus sensitive to methicillin seems and acceptable alternative.

Another issue is the best surgical approach for IVDU with endocarditis. To determine the early and late results of surgical treatment for infective endocarditis in IVDU, Mathew et al. [33] observed IVDU undergoing surgical treatment for infective endocarditis. Eighty patients underwent cardiac surgery for the following indications: acute congestive heart failure in 44 (56%) patients, persistent sepsis in 21 (26%) patients and multiple systemic embolization in 15 (19%) patients. Six patients (7.5%) died within 30 days of surgery and 13 of 69 patients (17.6%) died during the follow-up from cardiovascular causes. The probability of survival at 36 months and at 60 months was 0.74 and 0.70, respectively. Seventeen (30%) of the survivors had at least one major cardiovascular event, 6 (8.8%) patients had recurrent endocarditis, 10 (14.6%) patients experienced central nervous system complications and 3 (4.4%) patients required repeated valve replacement. Probability of event-free survival at 36 months and 60 months was 0.65 and 0.52, respectively. These authors conclude that since the expected mortality without surgery in patients with infective endocarditis in whom medical treatment fails is almost 100%, surgical treatment should be advised liberally as it substantially improves the outlook for early and late survival of IVDU with endocarditis.

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