**Author details**

other acquired comorbidities associated with their substance abuse that challenge their management and long-term prognosis. Hepatitis B and C as well as human immunodeficiency virus are often encountered in this patient population [25]. Chronic pain syndromes as well as their underlying drug addiction and associated personality and psychological disorders not only makes this population difficult to manage in the hospital setting but also raises the concern of long-term compliance with medical therapies. While there might be a general reluctance, for example, to use mechanical valves in younger patients, concerns about compliance with anticoagulation often leaves little choice. This is particularly true when patients present with a history of hepatitis and their long-term liver function (critical for clotting factors and Coumadin management) is unpredictable. Without doubt, this population is at risk for recurrent problems secondary to their substance abuse history. A recent study by Kim and colleagues illustrate the scope of this problem. Between 2002 and 2014, there was a twofold increase in the number of patients requiring surgery for infected endocarditis at their institution space (14.8% in 2002–26% in 2012). Of the 436 patients studied, over a mean follow-up of 29 months adverse events occurred in 20% including 10% developing re-infections—often as a function of continued substance abuse. While their findings demonstrated a lower operative mortality in patients with drug abuse predominately as a function of their age, propensity score analysis indicated that IV drug abuse was associated with an almost fourfold increase in valve-related complications and a 6.2-fold increase in reinfection. Because of the concerns of noncompliance, relapse of drug abuse, and poor socioeconomic status of many of these patients, surgical intervention in the setting of long-standing drug abuse is often viewed as intervening on an end-stage, often inherently fatal, disease. Some clinicians viewed attempts at curing these patients of their infections and substance abuse as being futile. In fact, while often discussed but rarely written, most programs will refuse surgical re-intervention except for extenuating circumstances in those patients who continue to demonstrate ongoing drug abuse who subsequently developed recurrent prosthetic valve infections. Prior to refusing potentially lifesaving, but high-risk, surgery in such patients or referral to palliative care, an

open and honest discussion with an Institutional Ethics Team might be indicated.

or even reduce the risk of infections at all [26, 27]

**7. Conclusion**

8 Contemporary Challenges in Endocarditis

Because of the cost of therapy that often includes prolonged hospitalizations, extensive diagnostic evaluations, complex surgery, or multiple surgical interventions, and often a prolonged recovery that can also be challenged by baseline comorbidities, disease complications, and access to potentially limited resources, the growing epidemic of endocarditis is clearly a problem. This is all in the background of whether the social programs that reduce the risk of infections, such as prophylactic antibiotics prior to dental procedures, are cost effective

As technology has improved over the years, so has the ability to detect and guide the management of patients with infections. This has also paralleled the significant increase in the incidence of such infections as patients get older, develop more comorbidities (especially from lifestyle choices), have more implanted devices that can potentially get infected, and have more Michael S. Firstenberg

Address all correspondence to: msfirst@gmail.com

Department of Surgery (Cardiothoracic), Northeast Ohio Medical University, Akron City Hospital—Summa Health System, Akron, Ohio, USA
