Abstract: Background: The United States’ opioid epidemic has led to an increase in people who inject drugs (PWID) and opioid-associated infections, including infectious endocarditis (IE). Cardiac surgery is often indicated in IE to improve outcomes but is controversial in PWID due to the concerns about continued injection drug use leading to risk for reinfection and decreased survival. In response, we assessed the long-term survival after cardiac valve surgery in PWID compared with people who do not inject drugs (non-PWID) in the published literature. Methods: We performed a systematic review and meta-analysis (MA) of studies that reported survival data after surgery for IE in PWID. We searched PUBMED up to April 2018. We extracted Kaplan–Meier (KM) curves from included studies. From the KM curves, we used an algorithm to estimate individual participant data (eIPD). In a one-step approach, we ran a Cox proportional hazards (CPH) model analysis of the eIPD with study random effects. In a two-step approach, we fitted CPH models by individual study; then, we ran a mixed-effects MA model of the log hazard ratios (HR) and standard errors. Results: We identified 11 retrospective studies. Of these, six reported comparisons of PWID vs. non-PWID, and five reported results for PWID only. Based on eIPD, we included 407 PWID and 1,877 non-PWID. Mean age for PWID was 36.7 years (95% CI 34.4–39.1) and for non-PWID was 52.0 years (95% CI 45.3–59.4). There were 144 deaths (35.3%) in PWID and 559 (29.8%) deaths in non-PWID. We present by study and by group KM curves of eIPD (Figures 1 and 2). In one-step MA (included all 11 studies), the HR for PWID was 1.13 (95% CI 0.92–1.39). In two-step MA (included six comparison studies), heterogeneity was high (I2 = 72%); and there was no significant between-group difference (HR 1.29, 95% CI 0.80–2.07) (Figure 3). Conclusion: Survival time post-surgery of PWID was similar to that of non-PWID. These estimates are concerning, as PWID on average are much younger than non-PWID with IE. Future studies should explore interventions to improve outcomes in PWID after surgery, including treatment of addiction during and after the index hospitalization and provision of naloxone at the time of discharge. Disclosures: All authors: No reported disclosures.

Abstract

Background

The United States’ opioid epidemic has led to an increase in people who inject drugs (PWID) and opioid-associated infections, including infectious endocarditis (IE). Cardiac surgery is often indicated in IE to improve outcomes but is controversial in PWID due to the concerns about continued injection drug use leading to risk for reinfection and decreased survival. In response, we assessed the long-term survival after cardiac valve surgery in PWID compared with people who do not inject drugs (non-PWID) in the published literature.

Methods

We performed a systematic review and meta-analysis (MA) of studies that reported survival data after surgery for IE in PWID. We searched PUBMED up to April 2018. We extracted Kaplan–Meier (KM) curves from included studies. From the KM curves, we used an algorithm to estimate individual participant data (eIPD). In a one-step approach, we ran a Cox proportional hazards (CPH) model analysis of the eIPD with study random effects. In a two-step approach, we fitted CPH models by individual study; then, we ran a mixed-effects MA model of the log hazard ratios (HR) and standard errors.

Results

We identified 11 retrospective studies. Of these, six reported comparisons of PWID vs. non-PWID, and five reported results for PWID only. Based on eIPD, we included 407 PWID and 1,877 non-PWID. Mean age for PWID was 36.7 years (95% CI 34.4–39.1) and for non-PWID was 52.0 years (95% CI 45.3–59.4). There were 144 deaths (35.3%) in PWID and 559 (29.8%) deaths in non-PWID. We present by study and by group KM curves of eIPD (Figures 1 and 2). In one-step MA (included all 11 studies), the HR for PWID was 1.13 (95% CI 0.92–1.39). In two-step MA (included six comparison studies), heterogeneity was high (I2 = 72%); and there was no significant between-group difference (HR 1.29, 95% CI 0.80–2.07) (Figure 3).

Conclusion

Survival time post-surgery of PWID was similar to that of non-PWID. These estimates are concerning, as PWID on average are much younger than non-PWID with IE. Future studies should explore interventions to improve outcomes in PWID after surgery, including treatment of addiction during and after the index hospitalization and provision of naloxone at the time of discharge.

Disclosures

All authors: No reported disclosures.

Background

In recent years, the number of infective endocarditis (IE) cases associated with injection drug use has increased. Clinical guidelines suggest deferring surgery for IE in people who inject drugs (PWID) due to a concern for worse outcomes in comparison to non-injectors (non-PWID). We performed a systematic review and meta-analysis of long-term outcomes in PWID who underwent cardiac surgery and compared these outcomes to non-PWID.

Methods

We systematically searched for studies reported between 1965 and 2018. We used an algorithm to estimate individual patient data (eIPD) from Kaplan-Meier (KM) curves and combined it with published individual patient data (IPD) to analyze long-term outcomes after cardiac surgery for IE in PWID. Our primary outcome was survival. Secondary outcomes were reoperation and mortality at 30-days, one-, five-, and 10-years. Random effects Cox regression was used for estimating survival.

Results

We included 27 studies in the systematic review and 19 provided data (KM or IPD) for the meta-analysis. PWID were younger and more likely to have S. aureus than non-PWID. Survival at 30-days, one-, five-, and 10-years was 94.3, 81.0, 62.1, and 56.6% in PWID, respectively; and 96.4, 85.0, 70.3, and 63.4% in non-PWID. PWID had 47% greater hazard of death (HR 1.47, 95% CI, 1.05-2.05) and more than twice the hazard of reoperation (HR 2.37, 95% CI, 1.25-4.50) than non-PWID.

Conclusion

PWID had shorter survival that non-PWID. Implementing evidence-based interventions and testing new modalities are urgently needed to improve outcomes in PWID after cardiac surgery.