COVID-19's Effect on Infective Endocarditis in People Who Inject Drugs Workup

Updated: Mar 02, 2022
  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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Approach Considerations

The hallmark of any type of IE is that of a continuous bacteremia. 


Laboratory Studies

A continuous bacteremia is the hallmark of endovascular infections such as OUD-IE. This is defined as a minimum of three sets of blood cultures positive for the same organism that are drawn from different sites at least 15 minutes apart. [16, 17]

Various molecular techniques, such as MALDI-TOF and 16SrDNA PCR PhenoTest BC Kit hold great promise in significantly reducing the turnaround time for the final identification of pathogens and antibiotic sensitivities from blood samples. [18, 19]

Because CRP levels increase during acute and chronic inflammation, including deep-seated infections, sepsis, autoimmune conditions, COVID-19 infection, and IE, serial CRP measurements are a convenient method of documenting therapeutic responsiveness of both diseases.

D-dimer is another marker used to determine the probability of a DVT or PE in a person with COVID-19 and IE given their pro-thrombotic state. Due to its high negative predictive value (NPV), a negative test provides reassurance that the probability of a DVT or a PE is low.

See Infective Endocarditis.


Imaging Studies

Some studies emphasize the importance of a full cardiac evaluation for COVID-19 positive OUD-IE. The purpose would be to rule out associated viral myocarditis as well as to detect valvular microthrombi that could increase the risk of a patient with OUD developing IE due to a variety of intravascular devices. [16, 17, 20, 21]   Guidelines from  the American College of Cardiology/American Heart Association and the Infectious Diseases Society of America recommend that all patients with S aureus bacteremia undergo evaluation with a transthoracic echocardiogram (TTE). We recommend a transesophageal echocardiogram (TEE) to follow a TTE in all patients with OUD who have positive blood cultures. This was not feasible during the COVID-19 pandemic owing to concern for transmission to healthcare workers as well as limited access because of the surge of inpatients. During the pandemic, the number of TEEs declined by 50%. This increased the risk of failing to diagnose or document infection of small endocardial thrombi associated among patients with OUD-IE and COVID-19 infection. [16, 17, 22]  The amount of echocardiograms performed likely has been limited because of the high hospital census. Such has led to significant delays in diagnosis leading to increased morbidity and mortality. [23, 24]

Alternative considerations such as cardiac magnetic resonance imaging and positron emission tomography scanning may be considered as they do not require close contact with personnel for extended periods of time while still documenting valve function and evidence of vegetations. [25] These alternative imaging modalities may reduce the number of cases of occult thrombi that were identified after poor outcomes from acute onset PEs or DVTs.