Managing infective endocarditis among people who inject drugs: Challenges and emerging solutions

Persistent gaps in addiction treatment, harm reduction, multidisciplinary care, and longitudinal follow-up result in suboptimal outcomes of infective endocarditis among people who inject drugs. People who inject drugs who develop infective endocarditis are considerably younger than other patients with IE, more often have right-sided disease, and face a long-term mortality that appears to be driven by ongoing substance use and its complications, as well as cardiac infection itself. Here we summarize the changing epidemiology, the clinical and structural challenges it creates, contemporary outcomes, and evolving treatment strategies including outpatient parenteral therapy, shortened intravenous courses, early oral step-down, long-acting lipoglycopeptides, and percutaneous vegetation debulking. We argue that addiction care, harm reduction, and multidisciplinary endocarditis teams are not optional adjuncts to infection management, but core components of evidence-based care.