Best Practice of the Month
Explaining Endocarditis

Endocarditis is an inflammation of the lining of the heart, usually caused by an infection. Its symptoms are vague and include things like joint and muscle pain, fatigue, fever and chills, night sweats, swelling, and painful or difficult breathing. If not treated quickly, it can damage or destroy heart valves. Treatment is typically antibiotics or other medications, though sometimes surgery is necessary.

Does it seem like there are more cases of endocarditis – and maybe even more deaths from it – in your community? Epidemiologic evidence is starting to point to a real increase in both. Up until about 2017, the incidence of endocarditis was stable in North America – although a couple studies had already raised concerns about increasing rates of endocarditis specifically among people who inject drugs (PWID). Subsequent studies by researchers in Virginia and West Virginia clearly document increases in the number of hospital admissions for endocarditis and linked them directly to injection drug use.

This best practice provides strategies you may use in your community to reduce the incidence and mortality of endocarditis.

Why are we talking about endocarditis?

PWID are at high risk for endocarditis, and your current efforts to reduce stigma so that PWID and healthcare providers can communicate effectively and respectfully could make endocarditis easier to spot. Increasing awareness of endocarditis and its symptoms among PWID, their friends, and families is another good strategy.

PWID are at high risk for endocarditis because using drugs by injection can introduce bacteria to the bloodstream, allowing it to reach the heart. However, the increase in risk isn’t all that makes it relevant to RCORP grantees. Because endocarditis is not that common, healthcare providers may not consider it as a possible diagnosis unless they know a patient is at increased risk. If PWID fear disclosing their use, it can delay diagnosis and treatment.

Recently, researchers in West Virginia published a brief report describing increased mortality due to endocarditis among those discharged from infectious endocarditisrelated hospitalization, finding that those deaths had doubled for people who did not inject drugs but was seven times higher among PWID. Tragically, almost 30 percent of the time, the underlying cause of death after hospital discharge was opioid overdose. No one with OUD should leave the hospital without naloxone.

In addition to the issues relating to risk and stigma, the COVID-19 pandemic complicates diagnosis. The symptoms of endocarditis and COVID-19 infection are similar enough that they may have made it even harder to recognize and respond promptly to endocarditis.

Prevention: A new sterile syringe for every injection

It is critical not to share injecting equipment. This is now a well-known fact. What may be less well known is that re-using one’s own equipment also can increase the risk of both abscesses and endocarditis. The infectious organisms that typically cause endocarditis normally live on the skin, so there is always a risk that injecting drugs will introduce these organisms to the blood stream. The risk is even higher when you reuse equipment because once a needle and syringe are used, they are contaminated with organisms from the skin. Used equipment provides a nice, cozy place with some blood and skin cells where the organisms can multiply, and the next use of the syringe introduces this larger dose of bacteria into the blood stream. In addition, a used syringe is duller and more damaging to the skin.

Prevention: Sterile water, clean equipment, clean surface, clean skin

In addition to using a new, sterile syringe for every injection, sterile water, a clean surface, clean equipment, and clean skin are essential to reducing infection risk. Some ways to achieve this include:

  • Boiling water to sterilize it prior to using it for injection is a standard recommendation, but this advice may be especially important for people who live in homes that rely on well water. Wells can become infected with bacteria from the environment, usually from animal fecal material.
  • Preparing the drug on a clean surface can help reduce infection risk. This may not be difficult for people who can use drugs in a home but poses a challenge for people who must inject in public places where there may be few surfaces or none that are clean.
  • If there is no clean place put equipment while preparing to inject, the best option may be covering the surface with an article of clothing or newspaper.
  • Avoid the temptation to hold the syringe (or other equipment) in the mouth to avoid setting it down on a dirty surface. The mouth is full of bacteria that are dangerous if they enter the blood stream.
  • Equipment that will be reused, such as a tourniquet and the spoon or other container in which the drug is liquified, should be washed thoroughly after each use.
  • Clean the skin well with soap and water or an alcohol wipe. Cleaning the skin doesn’t really kill bacteria but moves bacteria away from the planned injection site.

The North Carolina Harm Reduction Coalition has an excellent, short guide to safer injecting.

Prevention: Wound care

PWID may experience a variety of wounds to the skin and soft tissue under it. The two most important kinds of wounds, relative to endocarditis, are cellulitis and abscesses, both of which can be sources of bacteria that go on to infect the heart. Wound care is an important harm reduction service and a way to prevent endocarditis and other serious infections. Wound care “clinics” or services can be offered at a syringe service or other harm reduction program. Wound care is often a nursing intervention and can be provided at a site with other harm reduction services or on a walk-in basis during a regular time at a doctor’s office or clinic in your community.

The Minnesota Department of Health has developed a concise resource on safer injection practices for PWID that also mentions wound care. NEXT Distro has a detailed guide with images that could be helpful to harm reduction and healthcare providers.

Next Steps

  • Increase awareness of endocarditis by distributing the NIDA infographic on endocarditis to consortium members and display it wherever possible.
  • Share the brief report published Clinical Cardiology in February 2022 with public health and healthcare providers in your community and work to make sure that all people with OUD receive naloxone upon hospital discharge.
  • Talk with consortium members, healthcare providers, and harm reductionists in your community about what they are observing and what efforts they might already have in place to identify and reduce endocarditis and how to amplify these efforts.