Atypical Infective Endocarditis Presenting With Euthermia and Right Lower Quadrant Abdominal Pain.

Infectious endocarditis (IE) is an infection of the heart's endothelial lining, often stemming from an underlying bacteremia. High-risk populations include intravenous substance users, individuals with structural heart disease, those with intravascular devices, and those with prosthetic heart valves. In the emergency department, IE is often suspected in patients with a fever, known risk factors, and unexplained systemic symptoms due to systemic thromboemboli. We present a case of atypical IE occurring in an afebrile 38-year-old woman with a remote history of intravenous drug use. The patient's clinical presentation was characterized by systemic inflammatory response syndrome, stabbing-like right lower quadrant abdominal pain radiating to the right lower back and the rest of the abdomen, malaise, fatigue, and an absence of a fever. A CT scan revealed a right renal embolism and an infarcted right kidney, prompting a bedside point-of-care echocardiogram that showed a large vegetation on the mitral valve, suggestive of IE with systemic thromboembolic disease. The patient received broad-spectrum antibiotics and antipyretics and ultimately underwent mitral valve replacement, with good recovery upon discharge. Patients with IE are at high risk for life-threatening complications due to tissue damage from systemic microemboli and sepsis. It is important to identify IE's atypical presentation and risk factors for early recognition, prompt point-of-care echocardiogram, and initiation of treatment. This is particularly important in the era of increased opioid use among our patient population which could potentially conceal an underlying fever.

Pre- and Post-Exposure Prophylaxis for HIV in Patients Taking Anti-Seizure Medications.

The prevention of human immunodeficiency virus (HIV) infection has recently emphasized the use of pre- and post-exposure prophylaxis (PrEP and PEP), both of which were highly effective in prevention of HIV infection. Since the last published guidance regarding the cotreatment of people with anti-seizure medications (ASM) and antiretroviral treatments (ARTs) in 2012, both fields have numerous new medication options. Historically, cotreatment of HIV and seizures could be challenging with increased risk of virologic failure and barriers in access to health care due to global availability, social determinants of health, and stigma of both HIV and seizures. In this narrative review, we describe the data-driven and expected bidirectional pharmacokinetic (PK) interactions between guideline-based PrEP and PEP treatment and ASM, as well as overlapping side effects. There are many ASMs with no known interaction with PrEP or PEP regimens. The interactions focus on enzyme inducing ASMs, valproate, and lamotrigine. Most prominently, enzyme inducing ASMs lower serum levels of tenofovir-containing PrEP regimens and elements of PEP (dolutegravir, raltegravir, and ritonavir), which increased risk of virologic treatment failure in people with HIV but have unclear clinical significance on the effectiveness of PrEP and PEP. In addition, ritonavir treatment in PEP may significantly lower lamotrigine serum levels even during the 4 weeks of treatment, which may increase risk for breakthrough seizures during PEP and skin reactions after discontinuation of ritonavir. In addition to PK interactions, overlapping side effects are common including osteopenia, hepatic toxicity, and other gastrointestinal effects. This narrative review aims to be a resource for all clinicians prescribing ASMs so that they can create a welcoming environment to enable successful treatment of seizures and reduce the risk of HIV infection in people at risk. In addition, we highlight knowledge gaps and areas of unmet need that can be addressed with future studies.

Health service utilization, substance use treatment response, and death in patients with opioid use disorder and comorbid hepatitis C findings from prospective cohort study with administrative database linkage.

BACKGROUND: Among patients with opioid use disorder (OUD), high rates of overdose and death have been reported in subgroups with Hepatitis C Virus (HCV). Evidence on the comorbid effect of HCV on clinical and substance use trajectories has been limited by small sample sizes, short follow-up, and heavy reliance on administrative data which lacks granularity on important prognostic factors. Additionally, few studies include populations on substance use treatment. AIM: To establish the impact of HCV exposure (antibody positivity) on health care utilization patterns, substance use treatment response, and death in a cohort of patients with OUD on opioid agonist therapy (OAT). METHODS: This multi-center prospective cohort study recruited adult patients with OUD on OAT from 57 substance use treatment centers in Ontario, Canada. The study collected substance use outcomes, and classified patients with ≥50 % positive opioid urine screens over one year of follow-up as having poor treatment response. Additional data obtained via linkage with ICES administrative databases evaluated the relationship between HCV status, healthcare service utilization, and death over 3 years of follow-up. Multiple logistic regression models established the adjusted impact of HCV on various outcomes. RESULTS: Among recruited participants (n = 3430), 44.10 % were female with a mean age of 38.64 years (Standard deviation: 10.96). HCV was prevalent in 10.6 % of the cohort (n = 365). Methadone was used most often (83.9 %, n = 2876), followed by sublingual buprenorphine (16.2 %, n = 554). Over the three-year follow-up, 5.3 % of patients died (n = 181). Unadjusted results reveal rates of hospitalization (all-cause, mental-health related, critical care) and emergency department visits (mental health-related), were significantly higher among HCV patients. Associations diminished in adjusted models. Active injection drug use exhibited the highest predictive risk for all outcomes. CONCLUSION: A high degree of acute physical and mental illness and its resulting health service utilization burden is concentrated among patients with OUD and comorbid HCV. Future research should explore the role for targeted interventions and how best to implement integrated healthcare models to better address the complex health needs of HCV populations who inject drugs.

Serratia Sacroiliitis Secondary to Intravenous Drug Use: A Case Report.

Serratia spp. are ubiquitous, opportunistic, and infectious organisms that have historically been known to infect the upper respiratory, urinary, and circulatory systems. This manuscript presents the case of a 35-year-old White female with a past medical history of polysubstance abuse, intravenous drug use (IVDU), and poor dentition who was admitted to a community hospital with complaints of lower back pain for 10 days following the recent completion of treatment for a suspected epidural abscess. Per her report, her last IVDU with fentanyl was 11 days prior, and she admitted to using various sources of water to inject her drugs. Magnetic resonance imaging with contrast was significant for possible infectious sacroiliitis, and blood cultures grew Serratia marcescens. Due to this patient's extensive IVDU history, in-patient ceftriaxone was chosen over discharging the patient with a peripherally inserted central catheter line. Serratia spp.bacteremia with concomitant septic sacroiliitis in the setting of IVDU is an extremely rare presentation. Due to the nonspecific presentation of sacroiliitis, multidrug resistance profile of Serratia spp., and high mortality rate associated with S. marcescens sepsis, early detection and diagnosis is paramount in similar patients with extensive risk factors.

Hazardous Alcohol Use and Its Effect on Direct-Acting Antiviral Therapy Initiation among People with Active Injection Drug Use and Current Hepatitis C Infection.

BACKGROUND: Hepatitis C virus (HCV) infection and hazardous alcohol use are both preventable causes of morbidity and mortality among people who inject drugs (PWID). In the general population, hazardous alcohol is associated with a reduced likelihood of HCV treatment initiation. Less is known about the prevalence and impact of hazardous alcohol use on direct-acting antiviral (DAA) therapy initiation among PWID with active injection drug use. METHODS: PWID were recruited via street outreach in Baltimore, Maryland, between 2018 and 2019 and were enrolled in a study cohort. Participants completed a study survey and underwent HCV testing. Self-reported DAA therapy initiation was evaluated at follow-up visits every six months. Hazardous alcohol use was determined based on an AUDIT-C score of ≥4 for men or ≥3 for women. Data were analyzed using multivariable logistic regression with generalized estimating equations. RESULTS: Of the 720 PWID recruited, 291 had detectable HCV RNA, and only 134 were aware of their HCV infection. The mean (±standard deviation) age of those that were aware of their infection was 48.7 (±10.3) years, with a slight majority (53.0%) being male and predominantly African American (64.9%). The majority (80/134, 59.7%) met criteria for hazardous alcohol use. Only 16 (11.9%) PWID reported DAA therapy initiation within six months, and 20 (14.9%) reported it within 12 months of follow-up. Hazardous alcohol use (aOR = 1.23, 95% CI = 0.43-3.53) was not associated with DAA treatment initiation. CONCLUSIONS: There was a high prevalence of hazardous alcohol use, low rates of oral DAA therapy initiation, and no association between self-reported hazardous alcohol use and initiation of oral DAA therapy in our sample of PWID that were aware of their chronic HCV infection. Strategies to increase HCV treatment uptake in PWID with active drug use are urgently needed and should integrate alcohol and drug use evaluation and care.

A Case of Relapse Pseudomonas aeruginosa Tricuspid Valve Endocarditis After AngioVac Vegectomy and Antibiotic Treatment in a Patient Using Intravenous Drugs.

Infective endocarditis (IE) is a bloodstream infection affecting the valves of the heart. IE is highly associated with morbidity and mortality if not properly managed. Pseudomonas aeruginosa (P. aeruginosa) as a cause of IE is extremely rare. This is a case of IE involving a male patient with a history of intravenous drug use (IVDU), secondary to P. aeruginosa, with associated relapse of bacteremia and native tricuspid valve endocarditis, complicated by septic pulmonary emboli, despite undergoing recent vegetation debulking using the AngioVac system (AngioDynamics, Inc., New York, USA) along with six weeks of IV antibiotics and no IVDU since then being on treatment.

Harm reduction-focused behavioral activation for people who inject drugs: Mixed methods outcomes from a pilot open trial.

INTRODUCTION: People who inject drugs (PWID) experience high rates of mental health problems and drug-related harms. Harm reduction-focused interventions aim to reduce harms associated with drug use and are an important approach for engaging people who are not seeking traditional abstinence-focused treatment. Yet, few studies to date have examined the effectiveness of harm reduction psychosocial treatment for drug use. We evaluated the outcomes of a harm reduction-focused behavioral activation (BA) intervention from pretreatment to a 1-month follow-up. METHODS: A total of N = 23 PWID (65.2 % White; 52.2 % women; mean age 35.4 ± 7.8 years) were recruited from syringe services programs and n = 19 received the intervention via teletherapy. Assessment of study outcome measures occurred at pre- and posttreatment and a one-month follow-up. RESULTS: Results reflected post-intervention increases in behavioral activation and readiness to change drug use, as well as decreases in substance use, depression, and HIV risk behaviors. There were mixed outcomes on substance-related problems with increases at follow-up, possibly reflecting increased problem recognition. CONCLUSIONS: These results suggest initial promise for the harm reduction-focused treatment. Additional research with randomized designs and larger sample sizes is needed, and more intensive treatment may be required to support sustained treatment gains in this population.

A surgical odyssey: Conquering a titanic tricuspid vegetation reaching into the superior vena cava - A case report.

INTRODUCTION: Right-sided infective endocarditis, particularly of the tricuspid valve, is rare and challenging to diagnose, often presenting with nonspecific symptoms, and associated with high mortality rates. This case underscores the complexities in managing such conditions and the importance of early diagnosis and multidisciplinary intervention. CASE PRESENTATION: This case study details the medical history of a 34-year-old woman who had a background of intravenous drug abuse. She subsequently developed a fungal tricuspid valve endocarditis, leading to the formation of vegetation that extended into the superior vena cava. The mass measured 15 × 3 cm upon surgical removal. DISCUSSION: Right-sided infective endocarditis is rare, comprising only 5-10 % of cases, with tricuspid valve endocarditis being even rarer. Damage to the endothelium facilitates bacterial attachment, especially in IV drug users, with Staphylococcus aureus being common. Fungal endocarditis is rare but deadly, with high mortality. Diagnosis relies on the modified Duke criteria, including microbiological and imaging evidence. Major complications affect both valvular and systemic areas. Treatment p1rimarily involves IV antibiotics, but surgery is needed for persistent infections or severe complications. CONCLUSION: This case underscores the critical importance of early diagnosis and intervention in managing right-sided infective endocarditis, especially with a fungal pathology and in patients with complex medical histories.

Development of Palpable Purpura in a Patient With Infective Endocarditis: A Case Report.

Infective endocarditis (IE) can present with a variety of signs and symptoms, including skin lesions. The few papers describing a relationship between IE and vasculitis are split between IE being able to mimic vasculitis and between IE indeed being associated with a vasculitis involving the skin, kidney, gastrointestinal tract, or peripheral nerves. It is important for clinicians to distinguish between an isolated vasculitis, infective endocarditis, and IE-associated vasculitis because the treatments and outcomes are different. We report a case of a patient with a history of intravenous (IV) drug use who initially presented with chest pain, was started on vancomycin following diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) IE, left against medical advice (AMA), and then returned to the hospital due to development of a purpuric rash. We contend that while he did not have a skin biopsy due to time delay, his symmetrically distributed purpura was consistent with cutaneous vasculitis. His symptoms, including his rash and an acute kidney injury (AKI), improved with antibiotics to treat the endocarditis.

Infective Endocarditis Secondary to Needle Embolization to the Heart: A Case Report.

This case report explores the rare occurrence of a needle embolism in the heart among individuals with intravenous drug use (IVDU). The intricate symptomatology, ranging from overt chest pain to asymptomatic cases, poses diagnostic challenges and may lead to underrecognition. Healthcare professionals must navigate varied presentations, emphasizing the need for a nuanced diagnostic approach. The interplay of needle embolisms with infective endocarditis and sepsis adds complexity, requiring a comprehensive understanding. Ongoing education and training are crucial for healthcare professionals to address the evolving challenges of needle embolism management within the broader context of infective endocarditis and sepsis. Our patient is a 31-year-old female with a history of IVDU who presented with heart palpitations and shortness of breath. A CT scan revealed lung lesions and a needle in the right ventricle. The patient was admitted for methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, where she underwent video-assisted thoracoscopic surgery (VATS) involving empyemectomy and wedge resection of the right-middle and lower lobes. However, it was deemed very risky to remove the needle from the right ventricle. Despite extensive discussion and patient education, she left the rehabilitation center without follow-up, highlighting the challenges of managing IV drug-related complications. In conclusion, heightened awareness and a proactive approach are crucial in managing rare complications such as needle embolisms in IVDU patients. This case underscores the significance of staying informed to improve patient care and outcomes amid evolving healthcare practices.

Extensive folliculitis and abscesses with a sporotrichoid distribution in a parenteral drug user.

We present the case of a 53-year-old Caucasian man with a history of intravenous drug use who presented with fever and multiple pustules predominantly affecting hairy areas of the body, with no clinical improvement despite previous antibiotic treatment. Culture of the pustules confirmed Candida albicans infection and histological examination of skin biopsies revealed suppurative granulomas compatible with candidomycetic folliculitis. The patient was successfully treated with systemic antifungals and discharged with resolution of symptoms. Candidomycetic folliculitis is a condition typically associated with brown heroin consumption due to the use of acidic solvent that promotes Candida growth. Clinical manifestations include fever followed by skin lesions, with possible systemic involvement if untreated. Extensive folliculitis with associated fever in an IVDU should raise suspicion of this pathology since early diagnosis and appropriate treatment are crucial to prevent complications.

Community pharmacists' attitudes toward and practice of pharmacy-based harm reduction services in Pittsburgh, PA: a descriptive survey.

BACKGROUND: In Pittsburgh, PA, legal changes in recent decades have set the stage for an expanded role for community pharmacists to provide harm reduction services, including distributing naloxone and non-prescription syringes (NPS). In the wake of the syndemics of the COVID-19 pandemic and worsening overdose deaths from synthetic opioids, we examine knowledge, attitudes, and practices of harm reduction services among community pharmacists in Pittsburgh and identify potential barriers of expanded pharmacy-based harm reduction services. METHODS: We provided flyers to 83 community pharmacies within a 5-mile radius of the University of Pittsburgh Medical Center to recruit practicing community pharmacists to participate in an anonymous electronic survey. We used a 53-question Qualtrics survey consisting of multiple-choice, 5 or 6 point-Likert scale, and open-ended questions adapted from 5 existing survey instruments. Survey measures included demographics, knowledge, attitudes, and practices of harm reduction services (specifically naloxone and NPS provision), and explored self-reported barriers to future implementation. Data was collected July-August 2022. We conducted descriptive analysis using frequencies and proportions reported for categorical variables as well as means and standard deviations (SD) for continuous variables. We analyzed open-ended responses using inductive content analysis. RESULTS: Eighty-eight community pharmacists responded to the survey. 90% of participants agreed pharmacists had a role in overdose prevention efforts, and 92% of participants had previously distributed naloxone. Although no pharmacists reported ever refusing to distribute naloxone, only 29% always provided overdose prevention counseling with each naloxone distributed. In contrast, while 87% of participants had positive attitudes toward the usefulness of NPS for reducing disease, only 73% of participants ever distributed NPS, and 54% had refused NPS to a customer. Participants endorsed a lack of time and concerns over clientele who used drugs as the most significant barriers to offering more comprehensive harm reduction services. CONCLUSIONS: Our findings highlight that while most community pharmacists have embraced naloxone provision, pharmacy policies and individual pharmacists continue to limit accessibility of NPS. Future expansion efforts for pharmacy-based harm reduction services should not only address the time and labor constraints identified by community pharmacists, but also fear-based policy and stigma toward people who inject drugs and harm reduction more broadly.

A Large Tricuspid Subvalvular Apparatus Infective Endocarditis Undetected by Transthoracic Echocardiography.

A 39-year-old male with a history of intravenous drug use (IVDU) and no significant cardiovascular disease was admitted to the ICU for management of septic shock and acute hypoxic respiratory failure secondary to septic pulmonary emboli. Due to a high clinical suspicion for right-sided infective endocarditis (IE), he received a transthoracic echocardiogram (TTE), which did not reveal any vegetations. However, a transesophageal echocardiogram (TEE) was subsequently performed; this showed a large 2.4 cm vegetation in the septal aspect of the tricuspid valve (TV) subvalvular apparatus. He urgently underwent surgical removal of the vegetation and repair of the TV. Postoperatively, he clinically recovered with appropriate antibiotic therapy. TEE is the ideal imaging modality in evaluation for IE, but a minimally invasive TTE is often performed first. This case highlights a highly unusual anatomic location of IE, which harbored a large vegetation undetected by TTE. In patients without cardiac devices or non-native valves, an urgent TEE remains diagnostically essential if there is a high clinical suspicion for right-sided IE, even if a TTE shows no evidence of IE.

Developing a remotely delivered intensive outpatient program adapted for hospitalized patients with opioid use disorder: A qualitative study.

Introduction: Individuals with opioid use disorder (OUD) who inject drugs have an elevated risk of experiencing serious injection-related infections. While such infections can be treated, treatment for the underlying OUD is often limited. One potential strategy for more intensive addiction treatment is to offer a remotely delivered intensive outpatient program (IOP), adapted from an existing remote IOP ("Smart IOP"). We aimed to conduct a qualitative study to gather feedback on Smart IOP and identify adaptations needed for hospitalized patients. Methods: Individuals with OUD and a history of serious injection-related infections completed a semi-structured interview and were shown samples of the videos and program content. The interviews were transcribed verbatim and coded to conduct a thematic analysis. Results: Seventeen individuals participated. The mean age was 40.8 years and 70.6 % were men. Participants reported that IOP during the hospitalization would have been helpful to their recovery. The themes that emerged were the importance of medications for OUD, having a relapse prevention plan, engaging with a recovery coach, and ensuring treatment linkage post-discharge. Other themes included the recognition of the severity of one's illness and the emotional experiences related to the hospitalization. Conclusions: Participants expressed the value of an IOP during hospitalization and provided insights into the support needed while hospitalized. The tailored IOP is now being developed and will undergo a pilot feasibility trial.

Impact of the SARS-CoV-2 Pandemic on the Management and Prognosis of Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) is a serious condition which is difficult to diagnose and to treat, both medically and surgically. OBJECTIVES: The objective of this study was to evaluate the impact of the SARS-CoV-2 pandemic on the management of patients with IE. METHODS: We conducted a single-centre retrospective study including patients hospitalized for IE during the pandemic (Group 2) compared with the same period the year before (Group 1). We compared clinical, laboratory, imagery, therapeutic, and patient outcomes between the two groups. RESULTS: A total of 283 patients were managed for possible or definite IE (164 in Group 1 and 119 in Group 2). There were more intravenous drug-related IE patients in Group 2 (p = 0.009). There was no significant difference in surgery including intra-cardiac device extraction (p = 0.412) or time to surgery (p = 0.894). The one-year mortality was similar in both groups (16% versus 17.7%, p = 0.704). The recurrence rate was not significantly different between the two groups (5.9% in Group 2 versus 9.1% in Group 1, p = 0.311). CONCLUSIONS: The SARS-CoV-2 pandemic did not appear to have had a negative impact on the management of patients with IE. Maintenance of the activities of the endocarditis team within the referral centre probably contributed to this result. Nevertheless, the high proportion of intravenous drug-addicted patients in the pandemic cohort suggests that the SARS-CoV-2 pandemic had a major psychosocial impact.

Integration of Hepatitis C and Addiction Treatment in People Who Inject Drugs: The San Patrignano HCV-Free and Drug-Free Experience.

Injection drug use represents an important contributor to hepatitis C virus (HCV) transmission, hence therapeutic communities (TCs) are promising points of care for the identification and treatment of HCV-infected persons who inject drugs (PWIDs). We evaluated the effectiveness and efficacy of an HCV micro-elimination program targeting PWIDs in the context of a drug-free TC; we applied the cascade of care (CoC) evaluation by calculating frequencies of infection diagnosis, confirmation, treatment and achievement of a sustained virological response (SVR). We also evaluated the risk of reinfection of PWIDs achieving HCV eradication by collecting follow-up virologic information of previously recovered individuals and eventual relapse in drug use, assuming the latter as a potential source of reinfection. We considered 811 PWIDs (aged 18+ years) residing in San Patrignano TC at the beginning of the observation period (January 2018-March 2022) or admitted thereafter, assessing for HCV and HIV serology and viral load by standard laboratory procedures. Ongoing infections were treated with direct-acting antivirals (DAA), according to the current national guidelines. Out of the 792 individuals tested on admission, 503 (63.5%) were found to be seropositive for antibodies against HCV. A total of 481 of these 503 individuals (95.6%) underwent HCV RNA testing. Out of the 331 participants positive for HCV RNA, 225 were ultimately prescribed a DAA treatment with a sustained viral response (SVR), which was achieved by 222 PWIDs (98.7%). Of the 222 PWIDs, 186 (83.8%) with SVR remained HCV-free on follow-up (with a median follow-up of 2.73 years after SVR ascertainment). The CoC model in our TC proved efficient in implementing HCV micro-elimination, as well as in preventing reinfection and promoting retention in the care of individuals, which aligns with the therapeutic goals of addiction treatment.

Hepatitis C virus detection and management after implementation of universal screening in pregnancy.

BACKGROUND: Accurately identifying cases of hepatitis C virus has important medical and public health consequences. In the setting of rising hepatitis C virus prevalence and highly effective treatment with direct-acting antivirals, the Society for Maternal-Fetal Medicine guidelines recently changed to recommend universal screening for hepatitis C virus during pregnancy. However, there is little data on the influence of this policy change on case identification and management. OBJECTIVE: We aimed to examine the influence of universal hepatitis C virus screening on our patient population. Our primary objective was to determine if there was a difference in the detected hepatitis C virus prevalence after the policy change. Our secondary objectives were to determine which factors were associated with a positive test for hepatitis C virus and to examine postpartum management of pregnant patients living with hepatitis C virus, including the (1) gastroenterology referral rate, (2) treatment rate, (3) infantile hepatitis C virus screening rate, and (4) factors associated with being referred for treatment. STUDY DESIGN: We conducted a single-center, retrospective cohort study of deliveries that occurred before (July 2018-June 2020) and after (July 2020-December 2021) the implementation of universal hepatitis C virus screening. Information on hepatitis C virus and HIV status, if patients were screened for hepatitis C virus, history of intravenous drug use, and basic demographic information were abstracted from the electronic medical records. A subset of patients was administered a questionnaire regarding hepatitis C virus risk factors. For all patients who tested positive for hepatitis C virus, information on if they were referred for treatment in the postpartum period and if their infant was screened for hepatitis C virus were abstracted from the electronic medical records. RESULTS: A total of 8973 deliveries occurred during this study period. A total of 71 (0.79%) patients had a detectable viral load. With implementation of universal screening, hepatitis C virus screening rates increased from 5.78% to 77.25% of deliveries (P<.01). The hepatitis C virus prevalence rates before and after universal screening was implemented were 0.78% and 0.81%, respectively (P=.88). There were significant demographic shifts in our pregnant population over this time period, including a reduction in intravenous drug use. A subset of 958 patients completed a hepatitis C virus risk factor questionnaire, in addition to undergoing universal hepatitis C virus screening. Ten patients screened positive with universal screening; only 8 of these individuals would have been identified with risk-based screening. Among the patients with a detectable viral load, 67.61% were referred for treatment and 18.75% were treated. A multivariate logistic regression model indicated that intravenous drug use was associated with significantly decreased odds of being referred for treatment (odds ratio, 0.14; 95% confidence interval, 0.04-0.59; P=.01). At the time of our evaluation, 52 infants were at least 18 months old and thus eligible for hepatitis C virus screening. Among these infants, 8 (15.38%) were screened for hepatitis C virus, and all were negative. CONCLUSION: Following the practice shift, we saw a significant increase in hepatitis C virus screening during pregnancy. However, postpartum treatment and infant screening remained low. Intravenous drug use was associated with a decreased likelihood of being referred for treatment. Pregnancy represents a unique time for hepatitis C virus case identification, although better linkage to care is needed to increase postpartum treatment.

IgA-Dominant Staphylococcus-Associated Glomerulonephritis: An Uncommon Complication of Intravenous Drug Use.

A 24-year-old female with a history of intravenous heroin use presented with two weeks of chills, myalgias, and cough and was found to be in acute hypoxemic respiratory failure. Subsequent workup revealed the presence of bilateral septic pulmonary emboli and tricuspid valve endocarditis. Several weeks into her hospitalization, she developed periorbital edema and laboratory testing revealed she had developed acute renal failure and nephrotic range proteinuria. A renal biopsy confirmed the diagnosis of IgA-dominant Staphylococcus-associated glomerulonephritis (IgA-SAGN). Early recognition of this newly recognized variant of glomerulonephritis is paramount, as improper treatment may lead to catastrophic consequences.

Infective Endocarditis in Patients Addicted to Injected Opioid Drugs.

BACKGROUND: Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death. OBJECTIVES: The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors. METHODS: From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE). RESULTS: Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse. CONCLUSIONS: Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.