Prospective Cohort Study of Infective Endocarditis in People Who Inject Drugs

International Collaboration on Endocarditis (ICE) Investigators

Research output: Contribution to journalArticlepeer-review

36 Scopus citations


Background: Infective endocarditis (IE) in people who inject drugs (PWID) is an emergent public health problem. Objectives: The purpose of this study was to investigate IE in PWID and compare it with IE in non-PWID patients. Methods: Two prospective cohort studies (ICE-PCS and ICE-Plus databases, encompassing 8,112 IE episodes from 2000 to 2006 and 2008 to 2012, with 64 and 34 sites and 28 and 18 countries, respectively). Outcomes were compared between PWID and non-PWID patients with IE. Logistic regression analyses were performed to investigate risk factors for 6-month mortality and relapses amongst PWID. Results: A total of 7,616 patients (591 PWID and 7,025 non-PWID) were included. PWID patients were significantly younger (median 37.0 years [interquartile range: 29.5 to 44.2 years] vs. 63.3 years [interquartile range: 49.3 to 74.0 years]; p < 0.001), male (72.5% vs. 67.4%; p = 0.007), and presented lower rates of comorbidities except for human immunodeficiency virus, liver disease, and higher rates of prior IE. Amongst IE cases in PWID, 313 (53%) episodes involved left-side valves and 204 (34.5%) were purely left-sided IE. PWID presented a larger proportion of native IE (90.2% vs. 64.4%; p < 0.001), whereas prosthetic-IE and cardiovascular implantable electronic device-IE were more frequent in non-PWID (9.3% vs. 27.0% and 0.5% vs. 8.6%; both p < 0.001). Staphylococcus aureus caused 65.9% and 26.8% of cases in PWID and non-PWID, respectively (p < 0.001). PWID presented higher rates of systemic emboli (51.1% vs. 22.5%; p < 0.001) and persistent bacteremia (14.7% vs. 9.3%; p < 0.001). Cardiac surgery was less frequently performed (39.5% vs. 47.8%; p < 0.001), and in-hospital and 6-month mortality were lower in PWID (10.8% vs. 18.2% and 14.4% vs. 22.2%; both p < 0.001), whereas relapses were more frequent in PWID (9.5% vs. 2.8%; p < 0.001). Prior IE, left-sided IE, polymicrobial etiology, intracardiac complications, and stroke were risk factors for 6-month mortality, whereas cardiac surgery was associated with lower mortality in the PWID population. Conclusions: A notable proportion of cases in PWID involve left-sided valves, prosthetic valves, or are caused by microorganisms other than S. aureus.

Original languageAmerican English
Pages (from-to)544-555
Number of pages12
JournalJournal of the American College of Cardiology
Issue number5
StatePublished - 9 Feb 2021

Bibliographical note

Funding Information:
This study was supported by the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (# E26/202.782/2015 to Dr. Lamas), Red Española de Investigación en Patología Infecciosa (V-2003-REDC14A-O), and Fondo de Investigaciones Sanitarias de la Seguridad Social (FIS 00-0475) (Dr. Miro). Dr. Miro has received a personal 80:20 research grant from the Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, for 2017 to 2021. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Publisher Copyright:
© 2021 American College of Cardiology Foundation


  • HIV
  • Staphylococcus aureus
  • cardiac surgery
  • infective endocarditis
  • opioid crisis
  • people who inject drugs


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