title: Clinical manifestations and outcome in Staphylococcus aureus endocarditis among injection drug users and nonaddicts: a prospective study of 74 patients.
abstract: BACKGROUND
  Endocarditis is a common complication in Staphylococcus aureus bacteremia (SAB). We compared risk factors, clinical manifestations, and outcome in a large, prospective cohort of patients with S. aureus endocarditis in injection drug users (IDUs) and in nonaddicts.
  
  
  METHODS
  Four hundred and thirty consecutive adult patients with SAB were prospectively followed up for 3 months. Definite or possible endocarditis by modified Duke criteria was found in 74 patients: 20 patients were IDUs and 54 nonaddicts.
  
  
  RESULTS
  Endocarditis was more common in SAB among drug abusers (46%) than in nonaddicts (14%) (odds ratio [OR], 5.12; 95% confidence interval [CI], 2.65-9.91; P < 0.001). IDUs were significantly younger (27 +/- 15 vs 65 +/- 15 years, P < 0.001), had less ultimately or rapidly fatal underlying diseases (0% vs 37%, P < 0.001) or predisposing heart diseases (20% vs 50%, P = 0.03), and their SAB was more often community-acquired (95% vs 39%, P < 0.001). Right-sided endocarditis was observed in 60% of IDUs whereas 93% of nonaddicts had left-sided involvement (P < 0.001). An extracardiac deep infection was found in 85% of IDUs and in 89% of nonaddicts (P = 0.70). Arterial thromboembolic events and severe sepsis were also equally common in both groups. There was no difference in mortality between the groups at 7 days, but at 3 months it was lower among IDUs (10%) compared with nonaddicts (39%) (OR, 5.73; 95% CI, 1.20-27.25; P = 0.02).
  
  
  CONCLUSIONS
  S. aureus endocarditis in IDUs was associated with as high complication rates including extracardiac deep infections, thromboembolic events, or severe sepsis as in nonaddicts. Injection drug abuse in accordance with younger age and lack of underlying diseases were associated with lower mortality, but after adjusting by age and underlying diseases injection drug abuse was not significantly associated with mortality.
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland. eeva.ruotsalainen@hus.fi
authors.forename: Eeva
authors.initials: E
authors.lastname: Ruotsalainen
authors.forename: Kari
authors.initials: K
authors.lastname: Sammalkorpi
authors.forename: Janne
authors.initials: J
authors.lastname: Laine
authors.forename: Kaisa
authors.initials: K
authors.lastname: Huotari
authors.forename: Seppo
authors.initials: S
authors.lastname: Sarna
authors.forename: Ville
authors.initials: V
authors.lastname: Valtonen
authors.forename: Asko
authors.initials: A
authors.lastname: Järvinen
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003023:Cloxacillin / Q000627:therapeutic use; D004009:Dicloxacillin / Q000627:therapeutic use; D004452:Echocardiography / Q000379:methods; D004697:Endocarditis, Bacterial / Q000188:drug therapy / Q000209:etiology* / Q000382:microbiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007964:Leukocytosis / Q000276:immunology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013203:Staphylococcal Infections / Q000188:drug therapy / Q000209:etiology* / Q000382:microbiology*; D013211:Staphylococcus aureus / Q000302:isolation & purification*; D015819:Substance Abuse, Intravenous / Q000382:microbiology*; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D004009:Dicloxacillin; D003023:Cloxacillin