Managing Recurrent Endocarditis in Substance Use Disorder: The Role of Civil Commitment and Comprehensive Care

Introduction

The incidence of drug-induced infectious endocarditis (IE) is rapidly rising in the United States. The nation is witnessing a 38% increase in hospitalizations in the general population and an overwhelming 238% rise among persons who inject drugs (PWID) [1]. This intravenous drug-use-related epidemic presents significant public health concerns, as it simultaneously contributes to the spread of infectious diseases such as hepatitis C and HIV and imposes substantial financial burdens on the US healthcare system. Hospitalizations for IE cost an estimated $129 000 each in 2009, totaling over $1.7 billion annually [2]. Drug-related endocarditis is challenging to treat due to the multiple comorbidities of PWID. Moreover, the disease has a recurrence rate of up to 32% in this population [3].

Currently, mainstream treatment for drug-induced IE consists of a combination of antibiotics and, when appropriate, surgical intervention. Valve repair alone is suitable for patients with severe valve damage that cannot be sufficiently managed solely with antibiotics. This includes extensive destruction of valve tissues, resulting in significant valve dysfunction or structural compromise. According to the American Heart Association (AHA), surgical repair or replacement of the damaged valve is necessary in these situations to restore cardiac function and prevent complications that can arise, such as heart failure or recurrent infections [4].

Drug-induced IE is a challenge in healthcare due to its relapseprone nature, non-compliance with treatment regimens, and the associated social stigma. Patients with substance use disorder (SUD) often have difficulties adhering to prolonged antibiotic courses, which increases the risk of treatment failure and recurrent infections. Moreover, societal stigma may deter individuals from seeking timely medical care, which can cause patients to present later in the course of the disease when the endocarditis is more severe. These factors collectively complicate the management of drug-induced IE, requiring comprehensive strategies that address both medical and socio-behavioral aspects of these patients’ care. At present, there are no treatment guidelines for PWID with IE. The most recent AHA scientific statement recommended a multidisciplinary approach and consultation by addiction-trained clinicians to address the underlying SUD [5].

Civil commitment, a legal process allowing for the involuntary treatment of individuals with mental illness or SUD, has been a subject of ongoing debate and scrutiny. Proponents of this process reason that involuntary commitment is necessary to ensure individuals receive treatment when they are unable or unwilling to seek help voluntarily [6]. However, concerns have been raised about potential violations of civil rights and the effectiveness of mandated treatment in addressing underlying mental health disorders [7]. Despite these debates, civil commitment laws continue to play a significant role in treatment policies for mental health and addiction.

This report is of a young woman with a history of tricuspid valve surgery due to drug-induced IE. She presented again for recurrent IE and was initially deemed “not to be a surgical candidate” due to non-compliance and high risk of relapse. However, after involuntary commitment and inpatient addiction care, she became highly engaged in treatment and started feeling hopeful. The multiple modalities of treatment and comprehensive approach successfully led to the patient receiving a heart valve replacement surgery. The learning objective is to help readers recognize the importance of a multi-disciplinary approach in the management of infectious endocarditis in patients who use intravenous drugs, and to provide education on the usage of civil commitment for treatment in complicated substance use disorder patients.

Case Report

A 33-year-old woman began engaging in illicit substance use at the age of 16. Her substance use increased in severity at around the age of 18 when she began routine heroin use. Her drug use led to social-occupational impairment and ultimately culminated in incarceration. After her discharge from prison, she quickly went back to using heroin intravenously. She confirmed involvement in different forms of outpatient treatment throughout the time of her active addiction but admitted to having little success.

Her first hospitalization to address an IV drug-related infection occurred when she was 32 years of age. She initially presented to a local community hospital for 2-week history of chest pain, productive cough, diaphoresis, and fever. Upon admission she was tachycardic, hypotensive, and had lactic acidosis with significant leukocytosis. Multiple blood cultures were positive for methicillin-susceptible Staphylococcus aureus (MSSA). A transthoracic echocardiogram (TTE) found a large, mobile tricuspid valve vegetation. She was started on broad-spectrum antibiotics and fluid-resuscitated, then transferred to an academic general hospital. Again, repeated blood cultures collected per endocarditis protocol were positive for MSSA. She was given IV fluids and nafcillin 2 mg every 4 hours. A transesophageal echocardiogram (TEE) confirmed a large tricuspid valve vegetation with moderate to severe regurgitation. However, while in the medical intensive care unit, she developed respiratory distress requiring intubation. Given the severe tricuspid regurgitation and ongoing sepsis, after extubating, she quickly received a cardiothoracic surgery with a bioprosthetic valve implanted. Unfortunately, almost immediately following the procedure, she became agitated, noncompliant, and combative. She eventually left the hospital against medical advice (AMA).

Approximately 3 months after her first tricuspid valve replacement (TVR), she was re-admitted to the medical intensive care unit because of reusing IV drugs, which led to septic shock. She was tachycardic and severely hypotensive. A new TTE showed normal right ventricular size and normal right ventricular systolic function. However, there was a prosthetic tricuspid stenosis and evidence of a vegetation on the prosthetic tricuspid valve. A blood culture was positive for methicillin-resistant Staphylococcus aureus (MRSA). It was at this time that she was determined to not be a surgical candidate due to “continued intravenous drug use and poor rehab potential.” One documented contributing factor was having left the hospital AMA 16 days after the TVR procedure. Referrals to other academic surgical institutions were sent but all were denied.

Psychiatry was consulted 13 days into the current admission and was asked to assess the patient as she was medically more stable than predicted but had little to no motivation to engage in treatment. She was evaluated and minimally participated in bedside therapy and discussions regarding psychopharmacological management such as buprenorphine medication for opioid use disorder (MOUD). At the time, the main treatment team prescribed IV Vancocin (vancomycin) at 20 mg/kg and Rifadin (rifampin) at 300 mg 3 times a day. It was noted that her engagement with the service decreased and she became more irritable and guarded, again requesting AMA discharge. A petition for involuntary commitment was filed because of her non-compliance with treatment and potential life-threatening harm to self without further treatment. Just before the hearing, she explained, “I have no purpose in life, and I like to get high.”

She was civilly committed to acute psychiatric inpatient treatment at a dual-diagnosis unit (DDU). She attended motivational therapy, individual and group sessions, and all other forms of treatments offered at the DDU. She gradually became more and more engaged in therapy sessions. She later explained that it was at this point that things started to “click.” Her motivation had increased, and she started talking about initiating changes in her life to become a “better person.”

She stayed on DDU for about 4 weeks, during which time the inpatient psychiatric treatment team continuously communicated with psychiatry consultation/liaison and cardiothoracic surgery, advocating for a reconsideration of a second TVR. By this time, she had completed her six-week course of vancomycin and rifampin. She was continued on rifampin and Monodox (doxycycline) 100 mg twice a day for roughly 2 weeks until she was restarted on the same dose of vancomycin. Ongoing coordination of care and a positive response to addiction treatment after the probable cause finding led to a recalculation of her risk-benefit profile. The team unanimously felt she had successfully navigated addiction treatment and had become highly motivated for abstinence and continuous addiction care, so the team re-presented her case to cardiothoracic surgery, who finally agreed to perform a second TVR surgery. Intraoperatively, the cardiothoracic surgeon noticed a large vegetation of the cusps of the bioprosthetic tricuspid valve without evidence of annular involvement, and thus redid a tricuspid valve replacement with a 31-mm St. Jude Epic bioprosthetic valve. After the surgery, she required 6 additional weeks of IV vancomycin with a pharmacy dosing protocol of a goal trough of 15–18 mg/L. This goal equated to roughly 1000–1500 mg every 12 hours given intravascularly. During this time, she received addiction treatment in the general hospital on her medicine service and again at the DDU. With the support of the multidisciplinary teams, she successfully adhered to her course of antibiotics. Multiple repeated blood cultures showed no growth of bacteria. Unfortunately, after hospital discharge, she did not continue to participate in a rehabilitation program as recommended by the treatment team. She chose to follow up at a local buprenorphine MOUD clinic. While the clinic required weekly visits, psychotherapy, and peer-support community groups, she only attended 2 times and then subsequently relapsed. Three months later, she was re-admitted to the hospital due to recurrent chest pain and a lung infarction due to a pulmonary embolism (PE). A repeat TTE demonstrated severe tricuspid valve stenosis and a large mobile vegetation attached to TVR. At the time, she was not a candidate for a third valve replacement, so medical management of intravascular vancomycin with the same goal trough as 15 mg/L as antimicrobial suppression was offered, which the patient agreed with.

Discussion

MULTIDISCIPLINARY APPROACH FOR DRUG-INDUCED ENDOCARDITIS PATIENTS:

Drug-induced endocarditis treatment is complex. The high relapse rate of substance user and their recurrent medical complications require comprehensive strategies that include SUD management. Early Psychiatric Consultation/Liaison Service (PCLS) intervention is crucial for improved outcomes, as the service can facilitate timely med-surgical intervention, which has been linked to reduced mortality [8]. The literature emphasizes the importance of multidisciplinary approaches to the treatment of infective endocarditis, including long-term antibiotics, cardiovascular surgery, and patient education [5,10,11]. Integrating PCLS within acute hospital settings can facilitate more rapid and comprehensive intervention and care for patients presenting with drug-use-related complications. Our patient did not receive addiction-focused intervention until 2 weeks after admission, when the cardiovascular team determined she was not a surgical candidate. After she verbalized a desire to leave AMA, she was civilly committed and transferred to a DDU for group therapy and motivational therapy. While at the DDU, her mental condition improved, and she became hopeful and motivated to participate in further medical treatment.

The longitudinal process of this patient being accepted to receive a life-saving TVR took a total of 4 months and countless medical resources. If PCLS had been integrated into the patient’s care from the start of hospitalization, a more comprehensive treatment plan would have been initiated to minimize unnecessary costs and optimize outcomes. This scenario highlights the importance of early utilization of PCLS for cases of drug-induced endocarditis and suggests the benefits of applying this service to the larger population of patients with SUD.

CIVIL COMMITMENT TO ADDICTION TREATMENT:

Civil commitment to addiction treatment has a complex history rooted in efforts to address substance use disorders through legal mechanisms. Originating in the late 19^th century as part of broader public health initiatives, civil commitment laws were initially intended to provide treatment for individuals deemed unable to control their substance use due to addiction. However, debates surrounding civil commitment to addiction treatment have centered on issues of personal autonomy, individual rights, and the efficacy of involuntary treatment in addressing SUD. The legal framework for civil commitment to addiction treatment varies significantly among states in the US due to differences in mental hygiene laws. In West Virginia, it is governed by the West Virginia Code § 27–5. There are multiple facets to this law in West Virginia, which can allow persons to be committed under various circumstances. Examples include an adult who can apply for hospitalization (§27-5-2), a physician who can involuntarily hospitalize someone (§27-5-2a), or a circuit court who can involuntarily commit someone (§27-5-4) who is considered to be an imminent danger to self or others due to a serious addiction problem with or without concurrent non-SUD mental conditions.

Fortunately, our patient was able to receive the necessary psychiatric and medical treatment due to civil commitment. The involuntary hospitalization initially prevented her from leaving the hospital AMA, which allowed her time to regain her mental faculties and accept the necessity of medical treatment. During the involuntary stay, the psychiatry treatment team provided individual and group therapies that instilled hope and motivated her for further treatment. Her attitude quickly changed from feeling hopeless and purposeless to wanting to overcome her SUD, which allowed for her to receive a second valve surgery. If she was not civilly committed, she would not have received the addiction treatment that allowed her to take an active role in her care and begin to recover from her SUD. This example illustrates that civil commitment can be a beneficial process to allow certain patients struggling with SUD or other mental illnesses to receive treatment and achieve better health outcomes. In this case, the civil commitment and subsequent probable cause finding for involuntary hospitalization allowed for treatment in a specialized dual-diagnosis setting. Despite ethical dilemmas associated with autonomy, our patient improved shortly after commitment and began participating in a manner more consistent with voluntarily treated patients. Unintended consequences of basing civil commitment on dangerousness rather than a need for treatment have led to marginalization and criminalization into unsafe and inappropriate settings. Treatment reluctance is common in substance use disorders despite the high mortality risks. Despite evidence surrounding compulsory treatment for substance use, civil commitment remains utilized less often, even in states with statutes. Like other conditions, SUD is treated on a continuum, and outpatient civil commitment and voluntary treatment agreements could also be considered [12]. Evidence from drug treatment courts has been positive and also presents an opportunity for better integration across legal and clinical domains [13].

THE IMPORTANCE OF ADDICTION TREATMENT CONTINUUM OF CARE:

Like many other chronic medical conditions, SUD is a chronic illness that needs long-term and continuous care. Abundant evidence shows that continual care can help patients achieve abstinence and better health, wellness, and quality of life. At different stages of recovery, patients need different levels of care. Matching treatment settings and services to a patient’s individual needs is critical to the ultimate success in recovery. For patients who require a long-term antibiotics, close monitoring, and engagement in a higher level of care enhance the chance of achieving a sustainable recovery. Due to high relapse potential, significant biomedical conditions, and complications in this population, residential treatment or inpatient rehabilitation may be the necessary level of care required after a patient on long-term antibiotics (LTA) leaves the acute hospital setting. After further stabilization, the patient may transition to outpatient care and begin school or employment while still living in a structured environment, such as a recovery residence or sober house.

The present case underscores the importance of a continuum of care in addiction treatment. Addiction-related behaviors, emotions, and negative coping skills cannot be undone in a short hospital stay. For drug-induced endocarditis patients, even if the length of stay in a hospital or controlled environment is longer than usual because of LTA, it is imperative to have a long-term comprehensive addiction care plan and enforce the appropriate next level of treatment. If after discharge, our patient had completed an American Society of Addiction Medicine (ASAM) Level 3 care plan, in which a residential program is transitioned to a structured peer-support living environment, there was a likelihood that she would still be in the recovery process and her subsequent relapse and re-infection have been avoided.

Conclusions

This case report presents a patient with recurrent drug-induced endocarditis due to drug use relapse. Civil commitment was used for this patient, which allowed her to obtain dual treatment, become motivated and hopeful, and eventually receive a TVR. The case highlights the importance of a multidisciplinary approach in the management of IE in the PWID and demonstrates the benefits of using civil commitment and early psychiatric interventions in patients with SUD to improve overall patient outcomes.