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Infective endocarditis in injection drug users

Daniel J Sexton, MD
Vivian H Chu, MD, MHS
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Infective endocarditis (IE) was initially recognized to be a complication of injection drug use in the 1950s [1]. Aspects of IE that are unique to or characteristic of injection drug users will be reviewed here. Diagnostic criteria, complications, and general management of IE are discussed separately. (See "Clinical manifestations and evaluation of adults with suspected native valve endocarditis" and "Complications and outcome of infective endocarditis" and "Antimicrobial therapy of native valve endocarditis".)


Estimates of the incidence of infective endocarditis (IE) in injection drug users (IDUs) have been hampered by the lack of reliable data; approximately 2 to 4 cases per 1000 years of IDU have been described [2-4]. IE among IDUs has historically been more common in males (ratio 3:1) [3]; however, data from the United States suggest an increasing proportion of females, with a similar proportion of males and females in the 15- to 24-year-old age category [5]. The average age of patients with IE and IDU is generally younger than for the age of patients with IE and no history of IDU (31 versus 42 years in one study) [6].

In the United States, use of heroin nearly doubled between 2006 and 2013 [7]. The rate of IDU-related IE has increased concomitantly from 6 to 8 percent of hospitalizations (between 2000 and 2008) to 12 percent (in 2013). Over this interval, IDU-related IE has trended toward younger patients, a higher proportion of whites, and a more similar distribution of males versus females [5]. In one report of hospitalizations for endocarditis in North Carolina between 2010 and 2015, the number of cases increased 12-fold, from 0.2 to 2.7 per 100,000 persons per year [8].

The local or regional incidence of IDU has also had an impact on the overall incidence of endocarditis [9,10]. As an example, the incidence of IE in IDU in Philadelphia was estimated to be 5.3 cases/100,000 person-years, accounting for nearly one-half of all IE cases [9].

IE is more common in HIV-infected IDUs than in HIV-uninfected IDUs [4,11,12]. One case-control study among IDUs in Baltimore noted a fourfold higher incidence of IE in HIV-infected IDUs (13.8 versus 3.3 cases per 1000 person-years) [12]. Lower CD4 counts were associated with a higher risk of IE in IDUs even after controlling for frequency of drug injection.

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Literature review current through: Nov 2017. | This topic last updated: Aug 28, 2017.
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