Original Research
4 December 2018

Trends in Drug Use–Associated Infective Endocarditis and Heart Valve Surgery, 2007 to 2017: A Study of Statewide Discharge Data

Publication: Annals of Internal Medicine
Volume 170, Number 1



Drug use–associated infective endocarditis (DUA-IE) is increasing as a result of the opioid epidemic. Infective endocarditis may require valve surgery, but surgical treatment of DUA-IE has invoked controversy, and the extent of its use is unknown.


To examine hospitalization trends for DUA-IE, the proportion of hospitalizations with surgery, patient characteristics, length of stay, and charges.


10-year analysis of a statewide hospital discharge database.


North Carolina hospitals, 2007 to 2017.


All patients aged 18 years or older hospitalized for IE.


Annual trends in all IE admissions and in IE hospitalizations with valve surgery, stratified by patients' drug use status. Characteristics of DUA-IE surgical hospitalizations, including patient demographic characteristics, length of stay, disposition, and charges.


Of 22 825 IE hospitalizations, 2602 (11%) were for DUA-IE. Valve surgery was performed in 1655 IE hospitalizations (7%), including 285 (17%) for DUA-IE. Annual DUA-IE hospitalizations increased from 0.92 to 10.95 and DUA-IE hospitalizations with surgery from 0.10 to 1.38 per 100 000 persons. In the final year, 42% of IE valve surgeries were performed in patients with DUA-IE. Compared with other surgical patients with IE, those with DUA-IE were younger (median age, 33 vs. 56 years), were more commonly female (47% vs. 33%) and white (89% vs. 63%), and were primarily insured by Medicaid (38%) or uninsured (35%). Hospital stays for DUA-IE were longer (median, 27 vs. 17 days), with higher median charges ($250 994 vs. $198 764). Charges for 282 DUA-IE hospitalizations exceeded $78 million.


Reliance on administrative data and billing codes.


DUA-IE hospitalizations and valve surgeries increased more than 12-fold, and nearly half of all IE valve surgeries were performed in patients with DUA-IE. The swell of patients with DUA-IE is reshaping the scope, type, and financing of health care resources needed to effectively treat IE.

Primary Funding Source:

National Institutes of Health.

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Wurcel AGAnderson JEChui KKSkinner SKnox TASnydman DRet al. Increasing infectious endocarditis admissions among young people who inject drugs. Open Forum Infect Dis. 2016;3:ofw157. [PMID: 27800528]
Ronan MVHerzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections increased sharply, 2002-12. Health Aff (Millwood). 2016;35:832-7. [PMID: 27140989]  doi: 10.1377/hlthaff.2015.1424
Zibbell JEAsher AKPatel RCKupronis BIqbal KWard JWet al. Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014. Am J Public Health. 2018;108:175-81. [PMID: 29267061]  doi: 10.2105/AJPH.2017.304132
Rudd RASeth PDavid FScholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65:1445-52. [PMID: 28033313]  doi: 10.15585/mmwr.mm655051e1
Deo SVRaza SKalra ADeo VSAltarabsheh SEZia Aet al. Admissions for infective endocarditis in intravenous drug users [Letter]. J Am Coll Cardiol. 2018;71:1596-7. [PMID: 29622169]  doi: 10.1016/j.jacc.2018.02.011
Njoroge LWAl-Kindi SGKoromia GAElAmm CAOliveira GH. Changes in the association of rising infective endocarditis with mortality in people who inject drugs. JAMA Cardiol. 2018;3:779-80. [PMID: 29926083]  doi: 10.1001/jamacardio.2018.1602
Fleischauer ATRuhl LRhea SBarnes E. Hospitalizations for endocarditis and associated health care costs among persons with diagnosed drug dependence—North Carolina, 2010-2015. MMWR Morb Mortal Wkly Rep. 2017;66:569-73. [PMID: 28594786]  doi: 10.15585/mmwr.mm6622a1
Rosenthal ESKarchmer AWTheisen-Toupal JCastillo RARowley CF. Suboptimal addiction interventions for patients hospitalized with injection drug use-associated infective endocarditis. Am J Med. 2016;129:481-5. [PMID: 26597670]  doi: 10.1016/j.amjmed.2015.09.024
Jones CMCampopiano MBaldwin GMcCance-Katz E. National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health. 2015;105:e55-63. [PMID: 26066931]  doi: 10.2105/AJPH.2015.302664
Vlahakes GJ. “Consensus guidelines for the surgical treatment of infective endocarditis”: The surgeon must lead the team [Editorial]. J Thorac Cardiovasc Surg. 2017;153:1259-60. [PMID: 28024806]  doi: 10.1016/j.jtcvs.2016.10.041
Wurcel AGYu SPacheco MWarner K. Contracts with people who inject drugs following valve surgery: unrealistic and misguided expectations [Letter]. J Thorac Cardiovasc Surg. 2017;154:2002. [PMID: 29132892]  doi: 10.1016/j.jtcvs.2017.07.020
DiMaio JMSalerno TABernstein RAraujo KRicci MSade RM. Ethical obligation of surgeons to noncompliant patients: can a surgeon refuse to operate on an intravenous drug-abusing patient with recurrent aortic valve prosthesis infection? Ann Thorac Surg. 2009;88:1-8. [PMID: 19559179]  doi: 10.1016/j.athoracsur.2009.03.088
How many chances should a drug user get? [Letter]. The New York Times. 6 May 2018. Accessed at www.nytimes.com/2018/05/06/opinion/drug-user-heart.html on 21 June 2018.
Kansagra SMCohen MK. The opioid epidemic in NC: progress, challenges, and opportunities. N C Med J. 2018;79:157-62. [PMID: 29735617]  doi: 10.18043/ncm.79.3.157
Gunn AHBartlett BFeng GGayed MKanter KOnuoha Eet al. Running the numbers: county level dynamics of heroin mortality in North Carolina. N C Med J. 2018;79:195-200. [PMID: 29735630]  doi: 10.18043/ncm.79.3.195
Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health: 2015-2016 state-specific tables of model-based estimates (totals and percentages). Accessed at www.samhsa.gov/data/sites/default/files/NSDUHsaeSpecificStates2016A/NSDUHsaeSpecificStates2016.htm on 15 May 2018.
Seth PScholl LRudd RABacon S. Overdose deaths involving opioids, cocaine, and psychostimulants—United States, 2015-2016. MMWR Morb Mortal Wkly Rep. 2018;67:349-58. [PMID: 29596405]  doi: 10.15585/mmwr.mm6712a1
Worth SHouse K. Opioid use disorder: treatment & recovery. N C Med J. 2018;79:185-7. [PMID: 29735626]  doi: 10.18043/ncm.79.3.185
Canary LHariri SCampbell CYoung RWhitcomb JKaufman Het al. Geographic disparities in access to syringe services programs among young persons with hepatitis C virus infection in the United States. Clin Infect Dis. 2017;65:514-7. [PMID: 28402431]  doi: 10.1093/cid/cix333
Bixler DCorby-Lee GProescholdbell SRamirez TKilkenny MELaRocco Met al. Access to syringe services programs—Kentucky, North Carolina, and West Virginia, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018;67:529-32. [PMID: 29746453]  doi: 10.15585/mmwr.mm6718a5
Ball LJSherazi ALaczko DGupta KKoivu SWeir MAet al. Validation of an algorithm to identify infective endocarditis in people who inject drugs. Med Care. 2018;56:e70-5. [PMID: 29200131]  doi: 10.1097/MLR.0000000000000838
Fung KWRichesson RSmerek MPereira KCGreen BBPatkar Aet al. Preparing for the ICD-10-CM transition: automated methods for translating ICD codes in clinical phenotype definitions. EGEMS (Wash DC). 2016;4:1211. [PMID: 27195309]  doi: 10.13063/2327-9214.1211
Centers for Medicare & Medicaid Services. 2018 ICD-10 CM and GEMs. Updated 11 August 2017. Accessed at www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html on 12 June 2018.
Centers for Medicare & Medicaid Services. 2018 ICD-10 PCS and GEMs. Updated 26 July 2017. Accessed at www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html on 12 June 2018.
Kim JBEjiofor JIYammine MAndo MCamuso JMYoungster Iet al. Surgical outcomes of infective endocarditis among intravenous drug users. J Thorac Cardiovasc Surg. 2016;152:832-41. [PMID: 27068439]  doi: 10.1016/j.jtcvs.2016.02.072
State of North Carolina. North Carolina's opioid action plan 2017-2021. 2017. Accessed at https://drive.google.com/file/d/0B9NAvIvnEGfGMnM4Qjl4ck5WV2M/view on 20 February 2018.
Rabkin DGMokadam NAMiller DWGoetz RRVerrier EDAldea GS. Long-term outcome for the surgical treatment of infective endocarditis with a focus on intravenous drug users. Ann Thorac Surg. 2012;93:51-7. [PMID: 22054655]  doi: 10.1016/j.athoracsur.2011.08.016
Østerdal OBSalminen PRJordal SSjursen HWendelbo ØHaaverstad R. Cardiac surgery for infective endocarditis in patients with intravenous drug use. Interact Cardiovasc Thorac Surg. 2016;22:633-40. [PMID: 26826713]  doi: 10.1093/icvts/ivv397
Gossop MGreen LPhillips GBradley B. Lapse, relapse and survival among opiate addicts after treatment. A prospective follow-up study. Br J Psychiatry. 1989;154:348-53. [PMID: 2597836]
Broers BGiner FDumont PMino A. Inpatient opiate detoxification in Geneva: follow-up at 1 and 6 months. Drug Alcohol Depend. 2000;58:85-92. [PMID: 10669058]
Gossop MStewart DBrowne NMarsden J. Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses. Addiction. 2002;97:1259-67. [PMID: 12359030]
Englander HWeimer MSolotaroff RNicolaidis CChan BVelez Cet al. Planning and designing the Improving Addiction Care Team (IMPACT) for hospitalized adults with substance use disorder. J Hosp Med. 2017;12:339-42. [PMID: 28459904]  doi: 10.12788/jhm.2736
Trowbridge PWeinstein ZMKerensky TRoy PRegan DSamet JHet al. Addiction consultation services—linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat. 2017;79:1-5. [PMID: 28673521]  doi: 10.1016/j.jsat.2017.05.007
Ti LTi L. Leaving the hospital against medical advice among people who use illicit drugs: a systematic review. Am J Public Health. 2015;105:e53-9. [PMID: 26469651]  doi: 10.2105/AJPH.2015.302885
Spooner KKSalemi JLSalihu HMZoorob RJ. Discharge against medical advice in the United States, 2002-2011. Mayo Clin Proc. 2017;92:525-35. [PMID: 28291588]  doi: 10.1016/j.mayocp.2016.12.022
Saitz R. Discharges against medical advice: time to address the causes. CMAJ. 2002;167:647-8. [PMID: 12358198]
Zhu HWu LT. National trends and characteristics of inpatient detoxification for drug use disorders in the United States. BMC Public Health. 2018;18:1073. [PMID: 30157815]  doi: 10.1186/s12889-018-5982-8
Chan ACPalepu AGuh DPSun HSchechter MTO'Shaughnessy MVet al. HIV-positive injection drug users who leave the hospital against medical advice: the mitigating role of methadone and social support. J Acquir Immune Defic Syndr. 2004;35:56-9. [PMID: 14707793]
Ti LMilloy MJBuxton JMcNeil RDobrer SHayashi Ket al. Factors associated with leaving hospital against medical advice among people who use illicit drugs in Vancouver, Canada. PLoS One. 2015;10:e0141594. [PMID: 26509447]  doi: 10.1371/journal.pone.0141594
Bourguignon TBouquiaux-Stablo ALLoardi CMirza ACandolfi PMarchand Met al. Very late outcomes for mitral valve replacement with the Carpentier-Edwards pericardial bioprosthesis: 25-year follow-up of 450 implantations. J Thorac Cardiovasc Surg. 2014;148:2004-11. [PMID: 24667021]  doi: 10.1016/j.jtcvs.2014.02.050
Nishimura RAOtto CMBonow ROCarabello BAErwin JP 3rdFleisher LAet al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;70:252-89. [PMID: 28315732]  doi: 10.1016/j.jacc.2017.03.011
Baddour LMWilson WRBayer ASFowler VG JrTleyjeh IMRybak MJet alAmerican Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132:1435-86. [PMID: 26373316]  doi: 10.1161/CIR.0000000000000296
Libertin CRCamsari UMHellinger WCSchneekloth TDRummans TA. The cost of a recalcitrant intravenous drug user with serial cases of endocarditis: need for guidelines to improve the continuum of care. IDCases. 2017;8:3-5. [PMID: 28239556]  doi: 10.1016/j.idcr.2017.02.001
Ho JArchuleta SSulaiman ZFisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65:2641-4. [PMID: 20864497]  doi: 10.1093/jac/dkq355
Dobson PMLoewenthal MRSchneider KLai K. Comparing injecting drug users with others receiving outpatient parenteral antibiotic therapy. Open Forum Infect Dis. 2017;4:ofx183. [PMID: 29026870]  doi: 10.1093/ofid/ofx183
Suzuki JJohnson JMontgomery MHayden MPrice C. Outpatient parenteral antimicrobial therapy among people who inject drugs: a review of the literature. Open Forum Infect Dis. 2018;5:ofy194. [PMID: 30211247]  doi: 10.1093/ofid/ofy194
D'Couto HTRobbins GKArd KLWakeman SEAlves JNelson SB. Outcomes according to discharge location for persons who inject drugs receiving outpatient parenteral antimicrobial therapy. Open Forum Infect Dis. 2018;5:ofy056. [PMID: 29766017]  doi: 10.1093/ofid/ofy056
Hartman LBarnes EBachmann LSchafer KLovato JFiles DC. Opiate injection-associated infective endocarditis in the southeastern United States. Am J Med Sci. 2016;352:603-8. [PMID: 27916215]  doi: 10.1016/j.amjms.2016.08.010
Shrestha NKJue JHussain STJerry JMPettersson GBMenon Vet al. Injection drug use and outcomes after surgical intervention for infective endocarditis. Ann Thorac Surg. 2015;100:875-82. [PMID: 26095108]  doi: 10.1016/j.athoracsur.2015.03.019
Medicaid.gov. Medicaid Disproportionate Share Hospital (DSH) payments. 2018. Accessed at www.medicaid.gov/medicaid/finance/dsh/index.html on 10 July 2018.
Office of the Secretary, Department of Defense (DoD). TRICARE; mental health and substance use disorder treatment. Final rule. Fed Regist. 2016;81:61067-98. [PMID: 27592499]
Bin Abdulhak AABaddour LMErwin PJHoen BChu VHMensah GAet al. Global and regional burden of infective endocarditis, 1990-2010: a systematic review of the literature. Glob Heart. 2014;9:131-43. [PMID: 25432123]  doi: 10.1016/j.gheart.2014.01.002
Chu VHPark LPAthan EDelahaye FFreiberger TLamas CInternational Collaboration on Endocarditis (ICE) Investigators. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation. 2015;131:131-40. [PMID: 25480814]  doi: 10.1161/CIRCULATIONAHA.114.012461
Healthcare Cost and Utilization Project. HCUP partners in the SID. 2018. Accessed at www.hcup-us.ahrq.gov/partners.jsp?SID on 24 September 2018.
Pemberton MR, Forman-Hoffman VL, Lipari RN, Ashley OS, Heller DC, Williams MR. Prevalence of past year substance use and mental illness by veteran status in a nationally representative sample. CBHSQ Data Review. November 2016. Accessed at www.samhsa.gov/data/sites/default/files/NSDUH-DR-VeteranTrends-2016/NSDUH-DR-VeteranTrends-2016.pdf on 22 September 2018.
Naeger SMutter RAli MMMark THughey L. Post-discharge treatment engagement among patients with an opioid-use disorder. J Subst Abuse Treat. 2016;69:64-71. [PMID: 27568512]  doi: 10.1016/j.jsat.2016.07.004

Information & Authors


Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 170Number 11 January 2019
Pages: 31 - 40


Published online: 4 December 2018
Published in issue: 1 January 2019




Asher J. Schranz, MD
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (A.J.S., D.L.R.)
Aaron Fleischauer, PhD
Centers for Disease Control and Prevention, Atlanta, Georgia (A.F.)
Vivian H. Chu, MD, MHS
Duke University School of Medicine, Durham, North Carolina (V.H.C.)
Li-Tzy Wu, RN, ScD, MA
Duke University School of Medicine, Duke University Medical Center, and Duke University, Durham, North Carolina (L.W.)
David L. Rosen, MD, PhD
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (A.J.S., D.L.R.)
Presented in part at IDWeek, San Francisco, California, 4 October 2018.
Acknowledgment: The authors thank Myron Cohen, MD (University of North Carolina) for manuscript review, Farnaz Chowdhury (North Carolina State Center for Health Statistics) for discharge data expertise, and Elizabeth Suarez (University of North Carolina) for assistance in identifying diagnostic codes.
Grant Support: By grants 5 T32 AI 070114-12 from the National Institute of Allergy and Infectious Diseases (Dr. Schranz); 1 R34 AI 122958-01, 4 UL1 TR 001117-04, 4 R25 HD 076475-04, R01 DE 023375, and 1 R25 HL 135304-01A1 from the National Institutes of Health (NIH) (Dr. Chu); UG1 DA 040317, R01 MD 007658, and K12 HL 138030-02 from NIH (Dr. Wu); and R25 DA 013582 from the Clinical Addiction Research and Education Program of the National Institute on Drug Abuse. Dr. Wu is also supported by the Patient-Centered Outcomes Research Institute (PCORI).
Disclosures: Dr. Schranz reports grants from National Institute of Allergy and Infectious Diseases and National Institute on Drug Abuse and data support from North Carolina State Center for Health Statistics during the conduct of the study. Dr. Chu reports personal fees from UpToDate and Theravance outside the submitted work. Dr. Wu reports grants from NIH and research support from PCORI and Alkermes outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2124.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement: Study protocol and data set: Not available. Statistical code: Available from Dr. Schranz (e-mail, [email protected]).
Corresponding Author: Asher J. Schranz, MD, 130 Mason Farm Road (Bioinformatics), CB #7030, Chapel Hill, NC 27599; e-mail, [email protected].
Current Author Addresses: Drs. Schranz and Rosen: 130 Mason Farm Road (Bioinformatics), CB #7030, Chapel Hill, NC 27599.
Dr. Fleischauer: 1902 Mail Service Center, Raleigh, NC 27699.
Dr. Chu: Duke University Medical Center, Box 102359, Durham NC 27710.
Dr. Wu: Duke South Hospital, Room 3521, Psychiatry Box 3903, Durham, NC 27710.
Author Contributions: Conception and design: A.J. Schranz, A. Fleischauer, L.T. Wu.
Analysis and interpretation of the data: A.J. Schranz, A. Fleischauer, V.H. Chu, L.T. Wu, D.L. Rosen.
Drafting of the article: A.J. Schranz, D.L. Rosen.
Critical revision for important intellectual content: A.J. Schranz, A. Fleischauer, V.H. Chu, L.T. Wu, D.L. Rosen.
Final approval of the article: A.J. Schranz, A. Fleischauer, V.H. Chu, L.T. Wu, D.L. Rosen.
Statistical expertise: A. Fleischauer, L.T. Wu, D.L. Rosen.
Administrative, technical, or logistic support: A.J. Schranz, A. Fleischauer.
This article was published at Annals.org on 4 December 2018.

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