Tricuspid valve endocarditis in people who inject drugs: strategies to reduce mortality and recurrent infection.

Abstract

Tricuspid valve infective endocarditis (TV-IE) in people who inject drugs (PWID) has become an increasingly important clinical and public health concern, driven largely by the expanding opioid epidemic. Although PWID with TV-IE are typically young and often lack major comorbidities, they experience disproportionately high rates of mortality, reinfection, and recurrent hospitalizations. Repeated intravenous injection introduces contaminated particulate matter and pathogens into the venous circulation, promoting microbial adherence to the tricuspid valve, with Staphylococcus aureus including methicillin-resistant strains remaining the predominant pathogen. Clinical presentation commonly includes fever, chills, and pulmonary symptoms caused by septic emboli, while diagnostic evaluation relies on multiple blood cultures and echocardiographic assessment, complemented by computed tomography when pulmonary complications are suspected. Approximately 90% of right-sided TV-IE cases can be managed medically, highlighting the importance of optimized antimicrobial therapy tailored to the organism, disease severity, and patient-specific factors. Outpatient parenteral antibiotic therapy (OPAT) remains controversial in PWID, warranting individualized strategies to ensure treatment continuity, particularly in patients at risk of leaving the hospital before completing therapy. Surgical intervention follows standard right-sided IE criteria, with tricuspid valve repair preferred when feasible. Tricuspid valvectomy or emerging percutaneous debulking approaches may serve as adjunctive or temporizing strategies. Addiction treatment is central to improving outcomes, as ongoing injection drug use remains the strongest driver of reinfection and preventable mortality. Early involvement of addiction medicine and initiation of medication-assisted treatment can significantly improve long-term engagement. Optimal management requires a multidisciplinary approach that integrates cardiology, cardiac surgery, infectious disease, and early initiated as well as continued addiction treatment follow-up, behavioral health support, and social services to reduce reinfection risk and support recovery. This review summarizes current evidence regarding epidemiology, microbiology, clinical presentation, and management, with a focus on reducing mortality and preventing recurrent infection in PWID with TV-IE.