**5. Social implications**

The pandemic of intravenous drug abuse has resulted in a substantial increase in the incidence of endocarditis. There is at least a twofold increase in the number of heroin users from 2006 to 2013 [21]. The medical, social, and economic implications are obviously substantial. The role of infected needles, infected drugs, skin contamination, or some combination all contribute to the risk for endocarditis. Acute infections are further challenged by other substantial comorbidities, such as untreated Hepatitis B/C and the Human Immunodeficiency Virus (HIV) [22]. As a consequence of long-standing narcotic use/abuse, infected patients will often chronic pain syndromes and drug tolerance that can make symptom management difficult. In addition, mental health and personality disorders also challenge how these patients are treated – the mental and emotional fatigue placed upon the healthcare team can be substantial and might be used to influence the decisionmaking process for an individual patient. It is critical to consider all of these co-variates in the context of decision-making, need for compliance, and potential long-term therapy implications. For example, while replacement with biologic valves may predispose to early structural degeneration and need for additional surgery, their use might be a better longer-term strategy than subjecting a potentially non-compliant patient with untreated Hepatitis to life-long anticoagulation. In other words, even if the acute infectious problem is "cured", many of the decisions regarding the management of endocarditis – including the re-infection prevention opportunities – reflect that endocarditis can often be viewed as a life-long problem [23]. The ethical considerations of both acute and chronic disease management, as discussed in this chapter on the ethics of recurrent drug use/abuse, clearly demonstrates that long-term success often is as much a function of the overall team approach to the problems (rarely is endocarditis a singular problem) including the contributing factors, such as substance abuse. The tragic reality, however, is that while the ethics of the social approach to endocarditis often plays a substantial role in the management of individual patients, the foundation for such biases might be inherently flawed. Furthermore, there must be an understanding that despite everything being "done right" many patients, as a function of incurable comorbidities, much like complications of advanced cancers, patients might still die with and from endocarditis.

#### **6. Conclusions**

Improvements in diagnostic tools and an increasing understanding of the scope of associated problems have led to an increase in the recognition and management complexity of infectious endocarditis. Challenging social problems, advanced co-morbidities, and complex infections emphasize the role for early and aggressive management by a well-integrated and comprehensive multi-disciplinary team.

**5**

**Author details**

United States

Michael S. Firstenberg

Ascension NE Wisconsin–St. Elizabeth Campus, Appleton, Wisconsin,

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: msfirst@gmail.com

provided the original work is properly cited.

*Introductory Chapter: Endocarditis*

comes for all.

*DOI: http://dx.doi.org/10.5772/intechopen.98747*

Hopefully, while each chapter in this text will stand on its own, taken together, the goal of this project is to help emphasize the importance of collaborative Team work and consideration for all of the contributing co-morbidities, and a comprehensive

It cannot be emphasized enough that the goal of this volume is to lend valuable perspectives into some of the rapidly evolving topics and challenges surrounding the treatment of endocarditis – including management of complications, role and time of surgery, and the holistic approach to what often evolves into a life-long problem. Hopefully, with a greater understanding and emphasis on Teamwork, improvements in prevention, diagnosis, and treatment will result in better out-

plan are critical to the short and long-term treatment successes [24, 25].

#### *Introductory Chapter: Endocarditis DOI: http://dx.doi.org/10.5772/intechopen.98747*

*Advanced Concepts in Endocarditis - 2021*

material and replacement.

**5. Social implications**

long run.

and all providers must recognize that sometimes earlier intervention, even if in less-than-ideal surgical conditions, might be ultimately better for the patient in the

Similar considerations are used to guide the management of prosthetic valve endocarditis [20]. Despite the challenges of re-operative surgery in a "septic" patient, it must be appreciated that medical therapies alone are rarely successful, the best opportunity for a cure often requires complete removal of all prosthetic

The pandemic of intravenous drug abuse has resulted in a substantial increase in the incidence of endocarditis. There is at least a twofold increase in the number of heroin users from 2006 to 2013 [21]. The medical, social, and economic implications are obviously substantial. The role of infected needles, infected drugs, skin contamination, or some combination all contribute to the risk for endocarditis. Acute infections are further challenged by other substantial comorbidities, such as untreated Hepatitis B/C and the Human Immunodeficiency Virus (HIV) [22]. As a consequence of long-standing narcotic use/abuse, infected patients will often chronic pain syndromes and drug tolerance that can make symptom management difficult. In addition, mental health and personality disorders also challenge how these patients are treated – the mental and emotional fatigue placed upon the healthcare team can be substantial and might be used to influence the decisionmaking process for an individual patient. It is critical to consider all of these co-variates in the context of decision-making, need for compliance, and potential long-term therapy implications. For example, while replacement with biologic valves may predispose to early structural degeneration and need for additional surgery, their use might be a better longer-term strategy than subjecting a potentially non-compliant patient with untreated Hepatitis to life-long anticoagulation. In other words, even if the acute infectious problem is "cured", many of the decisions regarding the management of endocarditis – including the re-infection prevention opportunities – reflect that endocarditis can often be viewed as a life-long problem [23]. The ethical considerations of both acute and chronic disease management, as discussed in this chapter on the ethics of recurrent drug use/abuse, clearly demonstrates that long-term success often is as much a function of the overall team approach to the problems (rarely is endocarditis a singular problem) including the contributing factors, such as substance abuse. The tragic reality, however, is that while the ethics of the social approach to endocarditis often plays a substantial role in the management of individual patients, the foundation for such biases might be inherently flawed. Furthermore, there must be an understanding that despite everything being "done right" many patients, as a function of incurable comorbidities, much like complications of advanced cancers, patients might still die with and

Improvements in diagnostic tools and an increasing understanding of the scope of associated problems have led to an increase in the recognition and management complexity of infectious endocarditis. Challenging social problems, advanced co-morbidities, and complex infections emphasize the role for early and aggressive management by a well-integrated and comprehensive multi-disciplinary team.

**4**

from endocarditis.

**6. Conclusions**

Hopefully, while each chapter in this text will stand on its own, taken together, the goal of this project is to help emphasize the importance of collaborative Team work and consideration for all of the contributing co-morbidities, and a comprehensive plan are critical to the short and long-term treatment successes [24, 25].

It cannot be emphasized enough that the goal of this volume is to lend valuable perspectives into some of the rapidly evolving topics and challenges surrounding the treatment of endocarditis – including management of complications, role and time of surgery, and the holistic approach to what often evolves into a life-long problem. Hopefully, with a greater understanding and emphasis on Teamwork, improvements in prevention, diagnosis, and treatment will result in better outcomes for all.
