**7. Prognosis**

Overall, IVDA with RSIE have a lower mortality than those with left-sided infective endocarditis [14, 24, 35–39]. In one study the mortality was noted to be 6% [40]. Factors associated with high mortality included a large vegetation size (>20 mm) and a fungal aetiology [41, 42].

 In general patients with HIV do not have a poor outcome, except those with CD4 count <200 cells/ml. The major reason for repeat hospitalisation and recurrent endocarditis in IVDA is related to persistent use of drugs [30, 43, 44].

Finally, management of RSIE related to IVDA poses some ethical dilemmas. From the limited available literature, surgery should be offered for patients with surgical indications, with a first episode of IE in IVDAs, who are willing to undergo rehabilitation. If the patient presents with a second episode of IE due to recurrent IVDA, the decision to re-operate the patient, if indicated, is complex. It should be individualised and discussed by the endocarditis team. It is reasonable to decline further surgical intervention in this group, especially in resource-limited settings [45].
