注射吸毒者感染性心内膜炎的临床转归。
Clinical Outcomes of Infective Endocarditis in Injection Drug Users.
机构信息
Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California. Electronic address: https://twitter.com/Sarah_Rudasill.
Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California.
出版信息
J Am Coll Cardiol. 2019 Feb 12;73(5):559-570. doi: 10.1016/j.jacc.2018.10.082.
BACKGROUND
Rising rates of hospitalization for infective endocarditis (IE) have been increasingly tied to rising injection drug use (IDU) associated with the opioid epidemic.
OBJECTIVES
This study analyzed recent trends in IDU-IE hospitalization and characterized outcomes and readmissions for IDU-IE patients.
METHODS
The authors evaluated the National Readmissions Database (NRD) for IE cases between January 2010 and September 2015. Patients were stratified by IDU status and surgical versus medical management. Primary outcome was 30-day readmission and cause, with secondary outcomes including mortality, length of stay (LOS), adjusted costs, and 180-day readmission. The Kruskal-Wallis and chi-square tests were used to analyze baseline differences by IDU status. Multivariable regressions were used to analyze mortality, readmissions, LOS, and adjusted costs.
RESULTS
The survey-weighted sample contained 96,344 (77.8%) non-IDU-IE and 27,432 (22.2%) IDU-IE cases. IDU-IE increased from 15.3% to 29.1% of IE cases between 2010 and 2015 (p < 0.001). At index hospitalization, IDU-IE was associated with reduced mortality (6.8% vs. 9.6%; p < 0.001) but not 30-day readmission (23.8% vs. 22.9%; p = 0.077) relative to non-IDU-IE. Medically managed IDU-IE patients had higher LOS (β = 1.36 days; 95% confidence interval [CI]: 0.71 to 2.01), reduced costs (β = -$4,427; 95% CI: -$7,093 to -$1,761), and increased readmission for endocarditis (18.1% vs. 5.6%; p < 0.001), septicemia (14.0% vs. 7.3%; p < 0.001), and drug abuse (4.3% vs. 0.7%; p < 0.001) compared with medically managed non-IDU-IE. Surgically managed IDU-IE patients had increased LOS (β = 4.26 days; 95% CI: 2.73 to 5.80) and readmission for septicemia (15.6% vs. 5.2%; p < 0.001) and drug abuse (7.3% vs. 0.9%; p < 0.001) compared with non-IDU-IE.
CONCLUSIONS
The incidence of IDU-IE continues to rise nationally. Given the increased readmission for endocarditis, septicemia, and drug abuse, IDU-IE presents a serious challenge to current management of IE.
背景
感染性心内膜炎（IE）的住院率不断上升，与阿片类药物流行相关的注射吸毒（IDU）的增加密切相关。
目的
本研究分析了近期 IDU-IE 住院治疗的趋势，并对 IDU-IE 患者的结局和再入院情况进行了特征描述。
方法
作者对 2010 年 1 月至 2015 年 9 月期间的国家再入院数据库（NRD）中的 IE 病例进行了评估。患者根据 IDU 状态和手术与药物治疗进行分层。主要结局为 30 天再入院率和原因，次要结局包括死亡率、住院时间（LOS）、调整后的费用和 180 天再入院率。采用 Kruskal-Wallis 和卡方检验分析 IDU 状态的基线差异。采用多变量回归分析死亡率、再入院率、LOS 和调整后的费用。
结果
经调查加权后的样本包含 96344 例（77.8%）非 IDU-IE 和 27432 例（22.2%）IDU-IE 病例。2010 年至 2015 年间，IDU-IE 从 IE 病例的 15.3%增加到 29.1%（p<0.001）。在入院时，与非 IDU-IE 相比，IDU-IE 与较低的死亡率（6.8% vs. 9.6%；p<0.001）相关，但与 30 天再入院率（23.8% vs. 22.9%；p=0.077）无关。接受药物治疗的 IDU-IE 患者 LOS 较长（β=1.36 天；95%置信区间：0.71 至 2.01），成本降低（β=-4427 美元；95%置信区间：-7093 美元至-1761 美元），且因心内膜炎（18.1% vs. 5.6%；p<0.001）、败血症（14.0% vs. 7.3%；p<0.001）和药物滥用（4.3% vs. 0.7%；p<0.001）的再入院率较高。与接受药物治疗的非 IDU-IE 相比，接受手术治疗的 IDU-IE 患者 LOS 较长（β=4.26 天；95%置信区间：2.73 天至 5.80 天），败血症（15.6% vs. 5.2%；p<0.001）和药物滥用（7.3% vs. 0.9%；p<0.001）的再入院率较高。
结论
IDU-IE 的发病率在全国范围内继续上升。鉴于心内膜炎、败血症和药物滥用的再入院率增加，IDU-IE 对当前 IE 的治疗管理提出了严峻挑战。
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