Comparing Echocardiographic Modalities in Native-Valve Infective Endocarditis Due to Methicillin-Resistant Staphylococcus Aureus in People Who Inject Drugs

Background: Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Current IE guidelines recommend transesophageal echocardiogram (TEE) over transthoracic echocardiogram (TTE) to diagnose infective endocarditis. Management of IE in people who inject drugs (PWID) in many medical centers is mainly conservative with prolonged intravenous antibiotics. Cardiac valve replacement in these patients remains controversial, given the high risk of reinfection. This study’s purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients. Methods: A retrospective cohort of patients who are 18 years of age or older and inject drugs with definite MRSA IE between 2013 and 2019 were studied. Their echocardiographic reports and overall management plans were reviewed. Results: One hundred and twenty-six patients met the inclusion criteria. TTE was performed in 121 patients and, of these patients, 69 (57%) had detectable valvular vegetations while 52 (43%) did not. Of the 52 patients with a negative TTE, 44 underwent TEE, 28 (53%) of which showed vegetation. A total of 18 (14%) patients underwent surgery. Of these, six (33%) patients had a positive TTE only, with no subsequent TEE. Ten (56%) patients had both a positive TTE and TEE, and two (11%) patients had a negative TTE but positive TEE. Conclusion: In this retrospective cohort, obtaining a sequential TEE after a TTE in PWID with proven MRSA native IE by modified Duke’s criteria changed the management plan in two patients. The decision to perform a TEE in these patients needs to be individualized. Larger studies are needed to better evaluate the role of TEE in this patient population.