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Injection drug use and right sided endocarditis
  1. Rob Moss,
  2. Brad Munt
  1. St Paul’s Hospital, Vancouver, British Columbia, Canada
  1. Correspondence to:
    Dr Brad Munt, St Paul’s Hospital, 2350-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada;
    bmunt{at}providencehealth.bc.ca

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If William Osler were alive today he would no doubt remark on the fundamental change in the nature of the disease that he originally described. Staphylococcal endocarditis in injection drug users is now the dominant form of the disease in many urban communities where there is a high incidence of injection drug use and homelessness. At our institution (a tertiary care, university affiliated hospital in inner Vancouver), 63% of 116 hospitalisations between 1994 and 2000 for infective endocarditis (IE) were in injection drug users. Right sided endocarditis accounts for 10% of all IE in population based surveys1 and a higher proportion of IE in injection drug users. Modern echocardiographic techniques have considerably augmented our ability to diagnose IE and to understand its natural history. Despite this, there are many areas in which our understanding of right sided IE remains incomplete.

Right sided IE has a significant morbidity and mortality that adds a notable economic burden to stretched inner city health care facilities. The challenges of caring for this population of patients should not be underestimated and demands a logical and coordinated approach among care providers and physicians from a variety of specialties. This article reviews aspects of the epidemiology, clinical features, diagnosis, and treatment of right sided IE in injection drug users.

EPIDEMIOLOGY AND PREDISPOSING FACTORS

Although right sided IE may occur in association with congenital heart disease and instrumentation of the right heart, it is overwhelmingly a disease of injection drug users, at least in western populations. Among injection drug users presenting with fever, 13% will have echocardiographic evidence of IE.2 If injection drug users with bacteraemia from an inner city demographic are considered, up to 41% will have evidence of IE.3

The pathogenic mechanisms that explain the increased prevalence of right sided IE in injection drug users are not …

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