Project MORE Morbidity & Mortality Reduction in Infective Endocarditis PI: Madhura Myla, MD Mentor: Charles A Pizanis, MD Research Club 05/15/2018

Background Estimates of the incidence of IE and outcomes have been hampered by the lack of reliable data; approximately 2 to 4 cases per 1000 years of IDU have been described. In inner city communities most cases of infective endocarditis (IE) occur in injection drug users; many of these will have right sided IE caused by staphylococci. Streptococci account for 50%–80% of IE cases in general. S. aureus is the most common pathogen in isolated tricuspid valve endocarditis, accounting for 50%–60% of cases among injection drug users.

Infective endocarditis is associated with poor prognosis of almost 10% mortality rate despite improvements in medical and surgical therapies. The conjunction of bacteremia, fever, and multiple pulmonary infiltrates on chest radiography should always prompt a search for right sided IE. Any patient suspected of having infective endocarditis by clinical criteria should be screened by TTE. TEE should also be performed if the results of the TTE are equivocal owing to underlying structural abnormalities or poor acoustic windows.

If the TEE is negative and the suspicion of endocarditis is high, TEE should be repeated after 3 to 5 days to allow potential vegetations to become more apparent. A repeated negative study should virtually rule out the diagnosis unless TEE images are of poor quality. An early diagnosis is a critical determinant of final outcome. The key to long-term success in IE is early and radical surgical debridement of the infected tissue followed by an aggressive postoperative antibiotic therapy. The surgical indications are the valve dysfunction causing heart failure, development of abscess / fistula / heart block, difficult-to- treat pathogen, persistent bacteremia, recurrent embolization with persistent vegetation despite appropriate antibiotic therapy.

Many factors affect the outcome, including virulence of the microorganism, characteristics of the patients, presence of underlying disease, delays in diagnosis and treatment, surgical indications, and timing of surgery. Successful outcome of right sided IE in injection drug users requires a multidisciplinary approach with internists, infectious disease specialists, cardiologists, cardio thoracic surgeons, social workers on board.

Study Goals Management of infective endocarditis in an active Injection drug user is challenging given the lack of literature to support clinical decision making which is leading to bad outcomes. Our goal is to improve the outcomes in endocarditis patients with injection drug use and develop a comprehensive UNM guideline for practice by performing a sub group analysis in endocarditis patients getting admitted to UNM, comparing the results with national averages and performing interventions. AIM statement: “To identify the causes of morbidity and mortality in injection drug users with endocarditis who underwent treatment in the time period 2015 –2016, compare the results with the national averages and develop interventions to reduce the morbidity and mortality by 10% in the next 1 year.”

UNM QI and Patient Safety Goal Strategy 5.1 Quality and Safety Strategy 5.4 System Integration and Efficiency We will achieve this by proposing interventions to improve the outcomes. The types of intervention depend on the results obtained in the cycle 1

Baseline Data MRN: of patients with primary or secondary diagnosis of Endocarditis. (as per ICD 9 & 10 coding) Age Sex Injection drug Use: Current and/or past use. Co morbidities: h/o valve surgery, immune compromised states (HIV/HCV). TTE: whether performed or not and also time gap from admission date to date TTE done. TEE: same as above Bacteria found in the blood cultures Valve involved RX: Treatment administered – type of antibiotic, route and duration? ID consult placed or no?

Surgery: performed or not Surgery: performed or not. When were the cardiology and CT surgery consults placed (time gap from admission date to the date consult placed) Complications: congestive heart failure, intracardiac abcess, embolism, persistent positive cultures LOS: Total length of hospital stay. Drug abuse counselling: suboxone/methadone prescribed at discharge OR referral placed to substance abuse counselling programs (ASAP clinic) OR psychiatry consult placed or no? Repeat admissions: 30-day and 90-day Mortality: 6 month Case-Mix index Service Line Financial Data: Hospital charges and professional Fees.

Planning/Study Phase Q2 form was submitted and approved In the process of submission for IRB approval. Currently performing data analysis.

Quality Council (Q2) helped us with data gathering. INTERVENTIONS OR METHODS: - We will perform a chart review to look for whether the standard of care is being met. - We will perform a retrospective analysis and compare the results with the national averages using VIZIENT. - We will submit the baseline findings and the type of intervention we would be proposing to make the change depends on the results we obtain in our 1st cycle and based on existing data from other sources.

Results Currently performing data analysis We will identify the areas for improvement for e.g. delays in diagnosis and treatment, timing of surgery and drug abuse counselling and will propose future directions. We need to finish the 1st cycle of data collection and analysis to know the current state of the problem at UNM and to propose the focused intervention.

Barriers/Challenges Timing of surgery in Active Drug users Effective drug abuse counselling

Team and Roles Madhura Myla: Primary Investigator Charles A Pizanis: Project Mentor Sahitya Podila: Medical Student/Learner Venus Barlas: Medical Student/Learner

Upcoming Deadlines AAMC-Integrating Quality – usually in Spring National Healthcare Coalition Preparedness Conference-June Mountain West SGIM is usually in July UNM Health Science Center Annual Education Day - August NM ACP HVC, QI, research, clinical vignettes - September NM SHM research and innovations abstracts - September National SGIM – September Western Regional Meeting of the American Federation of Medical Research​- Sept SACME- October APDIM- Academic Internal Medicine week- November National ACP - November American Geriatrics Society -December National SHM – December Please leave this in at the end

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