Drug Use-Induced Endophthalmitis Rises Exponentially in US

By Marilynn Larkin

November 10, 2020

NEW YORK (Reuters Health) - Drug use-induced endophthalmitis increased four-fold in the U.S. between 2013-2016, and clinicians should maintain a "high index of suspicion" for the condition, researchers say.

"The increasing number of cases was probably exacerbated by several factors," Dr. David Hinkle of West Virginia University Eye Institute in Morgantown, told Reuters Health by email. Those factors include, he said: the shift from abuse of oral opiates, which became more expensive, to less expensive intravenous opiates such as heroin; the formulation shift in 2010 that made oxycodone pills more difficult to crush and then injected or absorbed sublingually; and the declining number of needle exchange programs following the 2008 recession.

He added that "similar increases have been seen for heart valve infections by other investigators."

As reported in JAMA Ophthalmology, Dr. Hinkle and colleagues analyzed close to 57,000 US patients from the Nationwide Inpatient Sample admitted with a diagnosis of endogenous endophthalmitis from 2003-2016; 55.6% were White, 13.6% were Black, and 10.6% were Hispanic.

Approximately 17.7% had a comorbid infectious condition - namely, bacteremia (3.3%) fungemia (3.1%), or sepsis (11.3%).

The most common systemic risk factor associated with endogenous endophthalmitis was diabetes (27.6%), followed by malignancy (19.2%), chronic kidney disease (14.2%), chronic obstructive pulmonary disease/asthma (10.1%), immunodeficiency diseases (2.0%), liver cirrhosis (1.9%), organ or tissue transplant (1.4%) and neutropenia (1.2%).

Notably, 13.7% of patients had a history of drug dependence or use. The drug-using population was significantly younger (49.6 vs. 57.5 years) and more likely to be male (61.8% vs. 49%).

The incidence of drug use-related endogenous endophthalmitis increased from 0.08 per 100,000 in 2003 to 0.32 per 100,000 population in 2016. The mortality rate was 1.8% compared with 3.6% in the non-drug-using population. The authors say the lower rate among drug users "can be explained by the fact that the non-drug-using population was significantly older with greater comorbidities, which likely (contributes) to the higher mortality rate."

Dr. Hinkle added, "The number of (eye) infections continues to rise every year. We must always keep this in mind because these infections can be mistaken for autoimmune or non-infectious forms of eye inflammation, leading to misdiagnosis and delay in treatment."

"Early and accurate diagnosis is the key to preserving vision," he said. "It is important to collaborate with primary care physicians and infectious disease specialists in order to identify other infectious/sexually transmitted diseases or conditions such as endocarditis, which may also be present."

Dr. Shriji Patel of the Vanderbilt Eye Institute in Nashville commented in an email to Reuters Health, "Intravenous drug abuse is certainly a risk factor for bacteremia and potential endogenous endophthalmitis. Importantly, this is only an association and we cannot be certain the drug abuse or dependence was causative for the eye infection."

Nonetheless, he said, "clinicians need to have a high index of suspicion if there is a history of past or present drug abuse, specifically high-risk intravenous use. Though there are no direct implications for treatment and management, this gives providers a new avenue to investigate in patients with endophthalmitis without a clear origin."

"The COVID-19 pandemic presents unique challenges for people with substance use disorders and in recovery," he added. "Based on the findings, this may be a problem we see more of moving forward. We should maintain vigilance for this potentially blinding issue."

SOURCE: https://bit.ly/3eIYpL9 JAMA Ophthalmology, online November 5, 2020.