Medication Summary

For discussion of specific antibiotic therapies, please see Infective Endocarditis.

Dalbavancin is a novel therapeutic that has valuable attributes for treating IE owing to its potential to reduce length of hospitalization and reduce the risk for relapse due to once weekly IV infusions that do not require ongoing intravenous access. As of early 2022, dalbavancin is approved in the United States for treatment of acute bacterial skin and skin structure infections. Preliminary evidence for use in other infections (eg, osteomyelitis, prosthetic joint infections, and IE) is emerging.^{[37, 38, 45]}

Vancomycin is no longer considered a preferred therapeutic as it is difficult to titrate and has limited efficacy as resistance patterns shift. Additionally, use of vancomycin may render other antibiotics (eg, daptomycin) less effective.

No individual with a history of or current OUD should be discharged with intravascular access present because of the danger of it being used to inject a variety of “street drugs”.^[13]

To summarize, the incidence of IE has risen as a result of the opioid epidemic due to the increase in intravenous drug use. Diagnostic uncertainties owing to limited knowledge about COVID-19 have led to delayed diagnosis and treatment among patients with concomitant COVID-19 infection and IE, potentially leading to poor clinical outcomes.

With time, what has become clearer is that alternate diagnoses should be considered if a patient continues to decline despite standard of care for COVID-19 infection. IE should always be considered on the differential in a patient who has a history of IV drug use. Imaging techniques including surface and transesophageal echocardiograms should not be withheld from practice as these can provide lifesaving information throughout the clinical progression of disease.

Finally, with respect to treatment selection, intravenous antibiotics are currently the leading therapeutic for IE in the setting of COVID-19 infection as vegetations can develop later in the clinical course. While oral antibiotics are the preferred route of treatment among OUDs (POET study),^[37] they may not provide adequate coverage due to limitations in bioavailability. Indeed, this may be subject to change as more data emerge. Ongoing investigations are needed to build upon our knowledge of the natural history, epidemiology, and pathophysiology, which will help us select targeted therapies to better treat patients and improve clinical outcomes.

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Table 1: Clinical Complication Patterns of COVID-19 Infection

Major Pathological Mechanisms	Definitions	Targeted Pathogenic Pathway	Onset of Symptoms (Days)
Coinfection	Bacterial, fungal, viral co-infection	Interaction of viral specific proteins with host receptors leading to endothelial activation and dysfunction^[7]	6-12
Inflammatory		Endothelitis due to platelet activation^[7]
Type A	↑ CRP ↓ ferritin	IL-6	8-13
Type B	↑ CRP ↑ ferritin	IL-1, IL-6	10-13
Type C	↓ CRP ↑ ferritin	IL- 1	11-16
Thrombotic	DVT, PE	Hypercoagulable state induced by COVID-19 infection^[7]	10-18