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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 is more common in males (ratio 3:1) [3]. 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) [5].

The local or regional incidence of IDU has had an impact on the overall incidence of endocarditis [6,7]. 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 [6].

IE is more common in HIV-infected IDUs than in HIV-uninfected IDUs [4,8,9]. 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) [9]. Lower CD4 counts were associated with a higher risk of IE in IDUs even after controlling for frequency of drug injection.

The incidence of IE in HIV-infected patients has declined with use of antiretroviral therapy. In one cohort of HIV-infected patients, the incidence of IE declined from 20 to 6 per 1000 person-years between the early and late 1990s [10].


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Literature review current through: Sep 2016. | This topic last updated: Jun 24, 2015.
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