Streptococcus pyogenes Infective Endocarditis-Association With Injection Drug Use: Case Series and Review of the Literature

Melanie T Rebechi; Emily L Heil; Paul M Luethy; Sarah A Schmalzle

doi:10.1093/ofid/ofab240

Streptococcus pyogenes Infective Endocarditis-Association With Injection Drug Use: Case Series and Review of the Literature

Open Forum Infect Dis. 2021 May 11;8(6):ofab240. doi: 10.1093/ofid/ofab240. eCollection 2021 Jun.

Authors

Melanie T Rebechi¹, Emily L Heil², Paul M Luethy³, Sarah A Schmalzle^{1

4}

Affiliations

¹ University of Maryland School of Medicine, Baltimore, Maryland, USA.
² Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA.
³ Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
⁴ Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA.

Abstract

Background: Streptococcus pyogenes, or Group A Streptococcus (GAS), is not considered a typical cause of infective endocarditis (IE), but has anecdotally been observed in unexpectedly high rates in people who inject drugs (PWID) at our institution.

Methods: All cases of possible or definite GAS IE per Modified Duke Criteria in adults at an academic hospital between 11/15/2015 and 11/15/2020 were identified. Medical records were reviewed for demographics, comorbidities, treatment, and outcomes related to GAS IE. The literature on cases of GAS IE was reviewed.

Results: Eighteen cases of probable (11) or definite (7) GAS IE were identified; the mean age was 38 years, and the population was predominantly female (56%) and Caucasian (67%), which is inconsistent with local population demographics. Sixteen cases were in people who inject drugs (PWID; 89%); 14 were also homeless, 6 also had HIV (33%), and 2 were also pregnant. Antibiotic regimens were variable due to polymicrobial bacteremia (39%). One patient underwent surgical valve replacement. Four patients (22%) died due to complications of infection. The literature review revealed 42 adult cases of GAS IE, only 17 of which were in PWID (24%).

Conclusions: The 16 cases of possible and definite GAS IE in PWID over a 5-year period in a single institution reported nearly doubles the number of cases in PWID from all previous reports. This suggests a potential increase in GAS IE particularly in PWID and PWH, which warrants further epidemiologic investigation.

Keywords: Group A Streptococcus; Streptococcus pyogenes; infective endocarditis; injection drug use; people who inject drugs.