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Wurcel AG, Suzuki J, Schranz AJ, Eaton EF, Cortes-Penfield N, Baddour LM. Strategies to Improve Patient-Centered Care for Drug Use-Associated Infective Endocarditis: JACC Focus Seminar 2/4. J Am Coll Cardiol 2024; 83:1338-1347. [PMID: 38569764 DOI: 10.1016/j.jacc.2024.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 04/05/2024]
Abstract
Drug use-associated infective endocarditis (DUA-IE) is a major cause of illness and death for people with substance use disorder (SUD). Investigations to date have largely focused on advancing the care of patients with DUA-IE and included drug use disorder treatment, decisions about surgery, and choice of antibiotics during the period of hospitalization. Transitions from hospital to outpatient care are relatively unstudied and frequently a key factor of uncontrolled infection, continued substance use, and death. In this paper, we review the evidence supporting cross-disciplinary care for people with DUA-IE and highlight domains that need further clinician, institutional, and research investment in clinicians and institutions. We highlight best practices for treating people with DUA-IE, with a focus on addressing health disparities, meeting health-related social needs, and policy changes that can support care for people with DUA-IE in the hospital and when transitioning to the community.
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Affiliation(s)
- Alysse G Wurcel
- Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA.
| | - Joji Suzuki
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Asher J Schranz
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ellen F Eaton
- Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | | | - Larry M Baddour
- Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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2
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El-Dalati S, Castillo MRC, Strnad L, Reda H, London T, Sekela M, Stoner BJ. Shared Decision-Making for Partial Oral Antibiotic Treatment of Infective Endocarditis: A Case Series. Open Forum Infect Dis 2024; 11:ofae166. [PMID: 38585184 PMCID: PMC10996124 DOI: 10.1093/ofid/ofae166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/18/2024] [Indexed: 04/09/2024] Open
Abstract
Although literature has demonstrated the noninferiority of oral antibiotics in the treatment of infectious endocarditis, widespread adoption of this practice has yet to occur in the United States. We report on 32 patients with infectious endocarditis treated by a multidisciplinary endocarditis team and a standardized approach to partial oral antibiotic therapy with a high rate of clinical success.
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Affiliation(s)
- Sami El-Dalati
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | | | - Luke Strnad
- Division of Infectious Diseases, Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Hassan Reda
- Department of Cardiac Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Tessa London
- Department of Cardiac Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Michael Sekela
- Department of Cardiac Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Bobbi Jo Stoner
- University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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3
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Bragg K, Albus M, Simon LV, Bragg B, Beste R. Development of a Medical Device in Response to a Fatal Self-Injection of Non-prescribed Opioids: A Case Report. Cureus 2024; 16:e56869. [PMID: 38529000 PMCID: PMC10961922 DOI: 10.7759/cureus.56869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 03/27/2024] Open
Abstract
Patients who inject drugs (PWID) pose unique challenges in their medical care due to risks of increased infection and overdose. There are no known commercially available devices to prevent patients from self-injecting non-prescribed substances into vascular access devices (VADs). A patient in the emergency department (ED) of a midsized suburban hospital self-injected an opioid in the ED restroom after the placement of a vascular catheter by the nursing staff as part of her ED care. Despite precautions taken for a patient with a known opioid use disorder (OUD) and a history of self-injecting non-prescribed substances into VADs, the patient suffered a self-induced fatal overdose. PWID are at significant risk of self-injection when requiring intravenous medications as part of their medical care. This case highlighted the need for formal reporting for patients who self-inject non-prescribed substances into VADs. It revealed a lack of medical devices to help providers ensure that PWID cannot access their medical devices when intravenous therapy is indicated.
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Affiliation(s)
- Kara Bragg
- Emergency Medicine, Mayo Clinic, Jacksonville, USA
| | | | - Leslie V Simon
- Emergency Medicine/Medical Simulation, Mayo Clinic, Jacksonville, USA
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4
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Streifel AC, Strnad LC, Sikka MK, Varley CD, Makadia J, Sukerman E, Douglass AH, Mayer H, Young K, Lewis JS. Dalba Got Back? Use of Dalbavancin for the Treatment of Vertebral Osteomyelitis. Open Forum Infect Dis 2024; 11:ofae070. [PMID: 38449918 PMCID: PMC10917187 DOI: 10.1093/ofid/ofae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Indexed: 03/08/2024] Open
Abstract
Data evaluating dalbavancin use for vertebral osteomyelitis remain limited. In our retrospective cohort, 29 of 34 (85.3%) patients completed their dalbavancin course. Adverse reactions occurred for 6 (17.6%) and infection recurrence in 3 (8.8%) within 90 days. Dalbavancin appears to be safe and well-tolerated for vertebral osteomyelitis.
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Affiliation(s)
- Amber C Streifel
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Luke C Strnad
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
- School of Public Health, Epidemiology Programs, Oregon Health & Science University and Portland State University, Portland, Oregon, USA
| | - Monica K Sikka
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Cara D Varley
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
- School of Public Health, Epidemiology Programs, Oregon Health & Science University and Portland State University, Portland, Oregon, USA
| | - Jina Makadia
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Ellie Sukerman
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Alyse H Douglass
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Heather Mayer
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Kathleen Young
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - James S Lewis
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
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5
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Stewardson AJ, Davis JS, Dunlop AJ, Tong SYC, Matthews GV. How I manage severe bacterial infections in people who inject drugs. Clin Microbiol Infect 2024:S1198-743X(24)00046-6. [PMID: 38316359 DOI: 10.1016/j.cmi.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/21/2024] [Accepted: 01/30/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Injecting drug use is a risk factor for severe bacterial infection, but there is limited high-quality evidence to guide clinicians providing care to people who inject drugs. Management can be complicated by mistrust, stigma, and competing patient priorities. OBJECTIVES To review the management of severe infections in people who inject drugs, using an illustrative clinical scenario of complicated Staphylococcus aureus bloodstream infection. SOURCES The discussion is based on recent literature searches of relevant topics. Very few randomized clinical trials have focussed specifically on the management of severe bacterial infections among people who inject drugs. Most recommendations are, therefore, based on observational studies, extrapolation from other patient groups, and the experience and opinions of the authors. CONTENT We discuss evidence and options regarding the following management issues for severe bacterial infections among people who inject drugs: initial management of sepsis; indications for surgical management; assessment and management of substance dependence; approaches to antibiotic administration following clinical stability; opportunistic health promotion; and secondary prevention of bacterial infections. Throughout, we highlight the importance of harm reduction and strategies to optimize patient engagement in care through a patient-centred approach. IMPLICATIONS We advocate for a multi-disciplinary trauma-informed approach to the management of severe bacterial infection among people who inject drugs. We emphasize the need for pragmatic trials to inform management guidelines, including those that are co-designed with the community. In particular, research is needed to establish the comparative effectiveness, safety, and cost-effectiveness of inpatient intravenous antibiotics vs. early oral antibiotic switch, outpatient parenteral therapy, and long-acting lipoglycopeptide antibiotics in this scenario.
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Affiliation(s)
- Andrew J Stewardson
- Department of Infectious Diseases, The Alfred and Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Joshua S Davis
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; Infection Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia; Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Adrian J Dunlop
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, NSW, Australia; Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Gail V Matthews
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; St Vincent's Hospital, Sydney, NSW, Australia
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6
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 123] [Impact Index Per Article: 123.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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7
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Durojaiye OC, Cole J, Kritsotakis EI. Risk of venous thromboembolism in outpatient parenteral antimicrobial therapy (OPAT): A systematic review and meta-analysis. Int J Antimicrob Agents 2023; 62:106911. [PMID: 37422098 DOI: 10.1016/j.ijantimicag.2023.106911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/30/2023] [Indexed: 07/10/2023]
Abstract
The risk of venous thromboembolism (VTE) in outpatient parenteral antimicrobial therapy (OPAT) is not fully understood and the optimal strategy for thromboprophylaxis remains unclear. This systematic review investigated the incidence of VTE in OPAT settings (PROSPERO CRD42022381523). MEDLINE, CINAHL, Emcare, Embase, Cochrane Library and grey literature were searched from earliest records to 18 January 2023. Primary studies reporting non-catheter-related VTE or catheter-related thromboembolism (CRT) events in adults who received parenteral antibiotics in home or outpatient settings were eligible. In total, 43 studies involving 23 432 patient episodes were reviewed, of which 4 studies reported non-catheter-related VTE and 39 included CRT. Based on generalised linear mixed-effects models, pooled risk estimates of non-catheter-related VTE and CRT were 0.2% [95% confidence interval (CI) 0.0-0.7%] and 1.1% [95% CI 0.8-1.5%; prediction interval (PI) 0.2-5.4%]. Heterogeneity was largely attributed to risk of bias by meta-regression (R2 = 21%). Excluding high-risk-of-bias studies, CRT risk was 0.8% (95% CI 0.5-1.2%; PI 0.1-4.5%). From 25 studies, the pooled CRT rate per 1000 catheter-days was 0.37 (95% CI 0.25-0.55; PI 0.08-1.64). These findings do not support universal thromboprophylaxis or routine use of an inpatient VTE risk assessment model in the OPAT setting. However, a high index of suspicion should be maintained, especially for patients with known risk factors for VTE. An optimised protocol of OPAT-specific VTE risk assessment should be sought.
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Affiliation(s)
- Oyewole Christopher Durojaiye
- Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; Department of Microbiology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK.
| | - Joby Cole
- Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, S10 2RX, UK
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, School of Medicine, University of Crete, Heraklion, 71003, Greece; School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S1 4DA, UK
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8
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Gupta A, Ashour D, Shebl FM, Platt L, Chiosi JJ, Nelson SB, Ard KL, Kim AY, Bassett IV. Evaluation of Hepatitis C Treatment Outcomes Among Patients Enrolled in Outpatient Parenteral Antibiotic Therapy-Boston, Massachusetts, 2016-2021. Open Forum Infect Dis 2023; 10:ofad342. [PMID: 37496604 PMCID: PMC10368317 DOI: 10.1093/ofid/ofad342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023] Open
Abstract
In our Boston-based outpatient parenteral antibiotic therapy (OPAT) program between 2016 and 2021, we found that a low proportion of patients with active hepatitis C virus (HCV) were prescribed HCV treatment by their OPAT provider and few achieved sustained virologic response. Clinicians should consider concurrent HCV treatment during OPAT.
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Affiliation(s)
- Akash Gupta
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dina Ashour
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Laura Platt
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - John J Chiosi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin L Ard
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arthur Y Kim
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid V Bassett
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
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9
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Solomon DA, Beieler AM, Levy S, Eaton EF, Sikka MK, Thornton A, Dhanireddy S. Perspectives on the Use of Outpatient Parenteral Antibiotic Therapy for People who Inject Drugs: Results From an Online Survey of Infectious Diseases Clinicians. Open Forum Infect Dis 2023; 10:ofad372. [PMID: 37520410 PMCID: PMC10372854 DOI: 10.1093/ofid/ofad372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Indexed: 08/01/2023] Open
Abstract
Injection-related infections require prolonged antibiotic therapy. Outpatient parenteral antimicrobial therapy (OPAT) has been shown to be feasible for people who inject drugs (PWID) in some settings. We report a national survey on practice patterns and attitudes of infectious diseases clinicians in the United States regarding use of OPAT for PWID.
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Affiliation(s)
- Daniel A Solomon
- Correspondence: Daniel A. Solomon, MD, 75 Francis St, Boston, MA 02115 ()
| | | | - Sera Levy
- University of Alabama, Birmingham, Alabama, USA
| | | | - Monica K Sikka
- Oregon Health & Sciences University, Portland, Oregon, USA
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10
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Schranz AJ, Tak C, Wu LT, Chu VH, Wohl DA, Rosen DL. The Impact of Discharge Against Medical Advice on Readmission After Opioid Use Disorder-Associated Infective Endocarditis: a National Cohort Study. J Gen Intern Med 2023; 38:1615-1622. [PMID: 36344644 PMCID: PMC10212894 DOI: 10.1007/s11606-022-07879-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hospitalizations for infective endocarditis (IE) associated with opioid use disorder (O-IE) have increased in the USA and have been linked to high rates of discharge against medical advice (DAMA). DAMA represents a truncation of care for a severe infection, yet patient outcomes after DAMA are unknown. OBJECTIVE This study aimed to assess readmissions following O-IE and quantify the impact of DAMA on outcomes. DESIGN A retrospective study of a nationally representative dataset of persons' inpatient discharges in the USA in 2016 PARTICIPANTS: A total of 6018 weighted persons were discharged for O-IE, stratified by DAMA vs. other discharge statuses. Of these, 1331 (22%) were DAMA. MAIN MEASURES The primary outcome of interest was 30-day readmission rates, stratified by discharge type. We also examined the total number of hospitalizations during the year and estimated the effect of DAMA on readmission. KEY RESULTS Compared with non-DAMA, those experiencing DAMA were more commonly female, resided in metropolitan areas, lower income, and uninsured. Crude 30-day readmission following DAMA was 50%, compared with 21% for other discharge types. DAMA was strongly associated with readmission in an adjusted logistic regression model (OR 3.72, CI 3.02-4.60). Persons experiencing DAMA more commonly had ≥2 more hospitalizations during the period (31% vs. 18%, p<0.01), and were less frequently readmitted at the same hospital (49% vs 64%, p<0.01). CONCLUSIONS DAMA occurs in nearly a quarter of patients hospitalized for O-IE and is strongly associated with short-term readmission. Interventions to address the root causes of premature discharges will enhance O-IE care, reduce hospitalizations and improve outcomes.
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Affiliation(s)
- Asher J Schranz
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Casey Tak
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Vivian H Chu
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - David A Wohl
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - David L Rosen
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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11
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Taylor JL, Wakeman SE, Walley AY, Kehoe LG. Substance use disorder bridge clinics: models, evidence, and future directions. Addict Sci Clin Pract 2023; 18:23. [PMID: 37055851 PMCID: PMC10101823 DOI: 10.1186/s13722-023-00365-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 02/02/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND The opioid overdose and polysubstance use crises have led to the development of low-barrier, transitional substance use disorder (SUD) treatment models, including bridge clinics. Bridge clinics offer immediate access to medications for opioid use disorder (MOUD) and other SUD treatment and are increasingly numerous. However, given relatively recent implementation, the clinical impact of bridge clinics is not well described. METHODS In this narrative review, we describe existing bridge clinic models, services provided, and unique characteristics, highlighting how bridge clinics fill critical gaps in the SUD care continuum. We discuss available evidence for bridge clinic effectiveness in care delivery, including retention in SUD care. We also highlight gaps in available data. RESULTS The first era of bridge clinic implementation has yielded diverse models united in the mission to lower barriers to SUD treatment entry, and preliminary data indicate success in patient-centered program design, MOUD initiation, MOUD retention, and SUD care innovation. However, data on effectiveness in linking to long-term care are limited. CONCLUSIONS Bridge clinics represent a critical innovation, offering on-demand access to MOUD and other services. Evaluating the effectiveness of bridge clinics in linking patients to long-term care settings remains an important research priority; however, available data show promising rates of treatment initiation and retention, potentially the most important metric amidst an increasingly dangerous drug supply.
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Affiliation(s)
- Jessica L Taylor
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, Second Floor, Boston, MA, 02118, USA.
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA.
| | - Sarah E Wakeman
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alexander Y Walley
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, Second Floor, Boston, MA, 02118, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - Laura G Kehoe
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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12
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Wildenthal JA, Atkinson A, Lewis S, Sayood S, Nolan NS, Cabrera NL, Marschall J, Durkin MJ, Marks LR. Outcomes of Partial Oral Antibiotic Treatment for Complicated Staphylococcus aureus Bacteremia in People Who Inject Drugs. Clin Infect Dis 2023; 76:487-496. [PMID: 36052413 PMCID: PMC10169408 DOI: 10.1093/cid/ciac714] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/18/2022] [Accepted: 08/29/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Staphylococcus aureus represents the leading cause of complicated bloodstream infections among persons who inject drugs (PWID). Standard of care (SOC) intravenous (IV) antibiotics result in high rates of treatment success but are not feasible for some PWID. Transition to oral antibiotics may represent an alternative treatment option. METHODS We evaluated all adult patients with a history of injection drug use hospitalized from January 2016 through December 2021 with complicated S. aureus bloodstream infections, including infective endocarditis, epidural abscess, vertebral osteomyelitis, and septic arthritis. Patients were compared by antibiotic treatment (standard of care intravenous [SOC IV] antibiotics, incomplete IV therapy, or transition from initial IV to partial oral) using the primary composite endpoint of death or readmission from microbiologic failure within 90 days of discharge. RESULTS Patients who received oral antibiotics after an incomplete IV antibiotic course were significantly less likely to experience microbiologic failure or death than patients discharged without oral antibiotics (P < .001). There was no significant difference in microbiologic failure rates when comparing patients who were discharged on partial oral antibiotics after receiving at least 10 days of IV antibiotics with SOC regimens (P > .9). CONCLUSIONS Discharge of PWID with partially treated complicated S. aureus bacteremias without oral antibiotics results in high rates of morbidity and should be avoided. For PWID hospitalized with complicated S. aureus bacteremias who have received at least 10 days of effective IV antibiotic therapy after clearance of bacteremia, transition to oral antibiotics with outpatient support represents a potential alternative if the patient does not desire SOC IV antibiotic therapy.
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Affiliation(s)
- John A Wildenthal
- Medical Scientist Training Program, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
- Department of Computational and Systems Biology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Sophia Lewis
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Sena Sayood
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Nathanial S Nolan
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Nicolo L Cabrera
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Jonas Marschall
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Rich KM, Solomon DA. Medical Complications of Injection Drug Use - Part I. NEJM EVIDENCE 2023; 2:EVIDra2200292. [PMID: 38320040 DOI: 10.1056/evidra2200292] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Medical Complications of Injection Drug Use - Part IDuring the past 2 decades, the risk of death and the prevalence of hospitalizations in the United States have increased substantially among people who inject drugs, in large part because of the opioid epidemic. This article reviews the complications observed in people who inject drugs as well as strategies to reduce harm.
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Affiliation(s)
| | - Daniel A Solomon
- Harvard Medical School, Boston
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston
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14
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Douglass AH, Mayer H, Young K, Sikka MK, Strnad L, Makadia J, Sukerman E, Lewis JS, Streifel AC. The hidden cost of dalbavancin: OPAT RN time required in coordination for persons who use drugs. Ther Adv Infect Dis 2023; 10:20499361231189405. [PMID: 37581105 PMCID: PMC10423448 DOI: 10.1177/20499361231189405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/05/2023] [Indexed: 08/16/2023] Open
Abstract
Background Serious infections in persons who use drugs (PWUD) are rising. Dalbavancin, due to its extended half-life, offers an alternative treatment for patients in whom standard of care antibiotics are not feasible or practical, allowing for reduced hospital days and the avoidance of central line placement or the use of complex oral regimens. Objectives We aim to describe the time and effort required for coordination of dalbavancin courses by outpatient registered nurses (RNs) and other outpatient parenteral antimicrobial therapy (OPAT) staff. Design and methods We conducted a retrospective review of adult patients with documented substance use who received at least one dose of dalbavancin and quantified the number of interventions required by our OPAT RNs and other OPAT staff for coordination of dalbavancin courses. Additionally, detailed data on time spent per intervention were prospectively collected for a 1-month period. Results A total of 52 patients with 53 dalbavancin courses were included. Most substance use was intravenous. Infectious diagnoses included bone and joint infections (61%) and endocarditis (7%), in addition to skin and soft tissue infections (19%). Infections were most commonly caused by Staphylococcus aureus (62%). RN intervention was required in the coordination of 60% of all courses and in 77% of courses in which at least one outpatient dose was needed. Adverse reactions occurred in one patient (2%) and 90-day readmissions due to infectious complications occurred in two patients (4%). Detailed time analysis was performed for seven consecutive patients, with a total of 179 min spent by OPAT RNs on coordination. Conclusions The ease of dalbavancin administration does not eliminate the need for extensive RN coordination for successful administration of doses in the outpatient setting for PWUD. This need should be accounted for in program staffing to help increase successful dalbavancin course completion.
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Affiliation(s)
- Alyse H. Douglass
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Heather Mayer
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Kathleen Young
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Luke Strnad
- School of Public Health, Epidemiology Programs, School of Public Health, Epidemiology Programs, Oregon Health & Science University and Portland State University, Portland, OR, USA
| | - Jina Makadia
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ellie Sukerman
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - James S. Lewis
- Department of Pharmacy, Oregon Health & Science University, Portland, OR, USA
| | - Amber C. Streifel
- Department of Pharmacy, Oregon Health & Science University, Portland, OR, USA
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15
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Larnard J, Swords K, Taupin D, Padival S. From sea to shining IV: the current state of OPAT in the United States. Ther Adv Infect Dis 2023; 10:20499361231181486. [PMID: 37363442 PMCID: PMC10285263 DOI: 10.1177/20499361231181486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
First described in the United States, outpatient parenteral antibiotic therapy (OPAT) has become an indispensable part of treating serious infections. The proportion of infectious disease (ID) physicians utilizing a formal OPAT program has increased in recent years, but remains a minority. In addition, many ID physicians have indicated that OPAT programs have inadequate financial and administrative support. Given the medical complexity of patients receiving OPAT, as well as the challenges of communicating with OPAT providers across health care facilities and systems, OPAT programs ideally should involve a multidisciplinary team. The majority of patients in the United States receive OPAT either at home with assistance from home infusion companies and visiting nurses or at a skilled nursing facility (SNF), though the latter has been associated with lower rates of patient satisfaction. Current and future opportunities and challenges for OPAT programs include providing OPAT services for people who inject drugs (PWID) and incorporating the increasing use of oral antibiotics for infections historically treated with parenteral therapy. In this review, we will discuss the current practice patterns and patient experiences with OPAT in the United States, as well as identify future challenges and opportunities for OPAT programs.
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Affiliation(s)
| | - Kyleen Swords
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dan Taupin
- Division of Infectious Diseases, Jefferson Health, Philadelphia, PA, USA
| | - Simi Padival
- Division of Infectious Diseases, University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
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16
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Mehta M, Benning M, Johnson JE, Ryan KL. Facilitating OPAT in rural areas. Ther Adv Infect Dis 2023; 10:20499361231210353. [PMID: 37954405 PMCID: PMC10634261 DOI: 10.1177/20499361231210353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
A sizable portion of the United States' population lives in a rural setting. Coupled with a limited number of infectious diseases providers, this has created a need for innovative practice models to deliver outpatient antimicrobial therapy and clinical monitoring in rural settings. This article reviews existing literature regarding outpatient parenteral antimicrobial therapy in rural settings and explores existing barriers and potential solutions that may be of assistance to providers looking to provide these services.
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Affiliation(s)
- Meera Mehta
- West Virginia University Hospitals, Morgantown, WV, USA
| | - Molly Benning
- Inpatient Pharmacy Department, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Jessica E. Johnson
- Department of Medicine, Section of Infectious Diseases, West Virginia University, Morgantown, WV, USA
| | - Keenan L. Ryan
- Inpatient Pharmacy Department, University of New Mexico Hospital, 2211 Lomas Blvd, Albuquerque, NM 87106, USA
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17
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Kershaw C, Lurie JD, Brackett C, Loukas E, Smith K, Mullins S, Gooley C, Borrows M, Bardach S, Perry A, Carpenter-Song E, Landsman HS, Pierotti D, Bergeron E, McMahon E, Finn C. Improving care for individuals with serious infections who inject drugs. Ther Adv Infect Dis 2022; 9:20499361221142476. [PMID: 36600726 PMCID: PMC9806364 DOI: 10.1177/20499361221142476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 11/14/2022] [Indexed: 12/28/2022] Open
Abstract
Background Hospitalizations for serious infections requiring long-term intravenous (IV) antimicrobials related to injection drug use have risen sharply over the last decade. At our rural tertiary care center, opportunities for treatment of underlying substance use disorders were often missed during these hospital admissions. Once medically stable, home IV antimicrobial therapy has not traditionally been offered to this patient population due to theoretical concerns about misuse of long-term IV catheters, leading to discharges with suboptimal treatment regimens, lengthy hospital stays, or care that is incongruent with patient goals and preferences. Methods A multidisciplinary group of clinicians and patients set out to redesign and improve care for this patient population through a health care innovation process, with a focus on increasing the proportion of patients who may be discharged on home IV therapy. Baseline assessment of current experience was established through retrospective chart review and extensive stakeholder analysis. The innovation process was based in design thinking and facilitated by a health care delivery improvement incubator. Results The components of the resulting intervention included early identification of hospitalized people who inject drugs with serious infections, a proactive psychiatry consultation service for addiction management for all patients, a multidisciplinary care conference to support decision making around treatment options for infection and substance use, and care coordination/navigation in the outpatient setting with a substance use peer recovery coach and infectious disease nurse for patients discharged on home IV antimicrobials. Patients discharged on home IV therapy followed routine outpatient parenteral antimicrobial therapy (OPAT) protocols and treatment protocols for addiction with their chosen provider. Conclusion An intervention developed through a design-thinking-based health care redesign process improved patient-centered care for people with serious infections who inject drugs.
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Affiliation(s)
| | - Jon D Lurie
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA; Dartmouth College Geisel School of Medicine, Hanover, NH, USA,The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | - Charles Brackett
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Elias Loukas
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Katie Smith
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA
| | - Sarah Mullins
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA
| | | | | | - Shoshana Bardach
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | - Amanda Perry
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | | | - H. Samuel Landsman
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Danielle Pierotti
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Ericka Bergeron
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Erin McMahon
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Christine Finn
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
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18
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Tassey TE, Ott GE, Alvanzo AAH, Peirce JM, Antoine D, Buresh ME. OUD MEETS: A novel program to increase initiation of medications for opioid use disorder and improve outcomes for hospitalized patients being discharged to skilled nursing facilities. J Subst Abuse Treat 2022; 143:108895. [PMID: 36215913 DOI: 10.1016/j.jsat.2022.108895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/09/2022] [Accepted: 09/20/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Rates of hospitalizations from medical complications of opioid use disorder (OUD) are rising and many of these patients require post-acute care at skilled nursing facilities (SNFs). However, access to medication for OUD (MOUD) at SNFs remains low and patients with OUD have high rates of patient-directed discharge (PDD) and hospital readmissions. METHODS Opioid Use Disorder Medical Patient Engagement, Enrollment in treatment and Transitional Supports (OUD MEETS) program was a clinical pilot designed to increase initiation of buprenorphine and methadone for hospitalized patients with OUD requiring post-acute care. The program comprises a hospital partnership with two SNFs and two opioid treatment programs (OTPs) to improve recovery supports and access to MOUD for patients discharged to SNF. RESULTS Between August 2019 and August 2020, study staff approached 49 hospitalized patients with OUD for participation in OUD MEETS. Twenty-eight of 30 eligible patients enrolled in the program and initiated buprenorphine or methadone. Twenty-seven (96 %) enrolled patients successfully completed hospital treatment. Twenty-three (85 %) patients successfully completed medical treatment at SNF. Thirteen (46 %) enrolled patients had confirmed linkage to OUD treatment post-SNF. One patient left the hospital (4 %) and four patients left SNF (15 %) via PDD. CONCLUSION OUD MEETS demonstrates feasibility of hospital, SNF, and OTP partnership to integrate MOUD treatment into SNFs, with high rates of completion of medical treatment and low rates of PDD. Future research should find sustainable ways to improve access to MOUD at post-acute care facilities, including through regulatory and policy changes.
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Affiliation(s)
- Theresa E Tassey
- Behavioral Health Systems Baltimore, Baltimore, MD, United States of America
| | - Geoffrey E Ott
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Anika A H Alvanzo
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Jessica M Peirce
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Denis Antoine
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Megan E Buresh
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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19
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Morales Y, Smyth E, Zubiago J, Bearnot B, Wurcel AG. "They Just Assume That We're All Going to Do the Wrong Thing With It. It's Just Not True": Stakeholder Perspectives About Peripherally Inserted Central Catheters in People Who Inject Drugs. Open Forum Infect Dis 2022; 9:ofac364. [PMID: 36267246 PMCID: PMC9579457 DOI: 10.1093/ofid/ofac364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background In the absence of adequate harm reduction opportunities, people who inject drugs (PWID) are at increased risk for serious infections. Infectious diseases guidelines recommend extended periods of intravenous antibiotic treatment through peripherally inserted central catheters (PICCs), but PWID are often deemed unsuitable for this treatment. We conducted semi-structured interviews and focus groups to understand the perspectives and opinions of patients and clinicians on the use of PICCs for PWID. Methods We approached patients and clinicians (doctors, nurses, PICC nurses, social workers, and case workers) involved in patient care at Tufts Medical Center (Boston, Massachusetts) between August 2019 and April 2020 for semi-structured interviews and focus groups. Results Eleven of 14 (79%) patients agreed to participate in an in-depth interview, and 5 role-specific clinician focus groups (1 group consisting of infectious diseases, internal medicine, and addiction psychiatry doctors, 2 separate groups of floor nurses, 1 group of PICC nurses, and 1 group of social workers) were completed. Emergent themes included the overall agreement that PICCs improve healthcare, patients' feelings that their stage of recovery from addiction was not taken into consideration, and clinicians' anecdotal negative experiences driving decisions on PICCs. Conclusions When analyzed together, the experiences of PWID and clinicians shed light on ways the healthcare system can improve the quality of care for PWID hospitalized for infections. Further research is needed to develop a system of person-centered care for PWID that meets the specific needs of patients and improves the relationship between them and the healthcare system.
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Affiliation(s)
- Yoelkys Morales
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Emma Smyth
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Julia Zubiago
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Benjamin Bearnot
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Alysse G Wurcel
- Correspondence: Alysse G. Wurcel, MD, MS, Tufts Medical Center, Department of Geographic Medicine and Infectious Diseases, 800 Washington St, Boston MA 02111, USA ()
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20
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Moore N, Kohut M, Stoddard H, Burris D, Chessa F, Sikka MK, Solomon D, Kershaw CM, Eaton E, Hutchinson R, Fairfield KM, Stopka TJ, Friedmann P, Thakarar K. Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections. Ther Adv Infect Dis 2022; 9:20499361221126868. [PMID: 36225855 PMCID: PMC9549088 DOI: 10.1177/20499361221126868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/30/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Patients with injection drug use (IDU)-associated infections traditionally
experience prolonged hospitalizations, which often result in negative
experiences and bad outcomes. Harm reduction approaches that value patient
autonomy and shared decision-making regarding outpatient treatment options
may improve outcomes. We sought to identify health care professionals (HCPs)
perspectives on the barriers to offering four different options to
hospitalized people who use drugs (PWUD): long-term hospitalization, oral
antibiotics, long-acting antibiotics at an infusion center, and outpatient
parenteral antibiotics. Methods: We recruited HCPs (n = 19) from a single tertiary care
center in Portland, Maine. We interviewed HCPs involved with discharge
decision-making and other HCPs involved in the specialized care of PWUD.
Semi-structured interviews elicited lead HCP values, preferences, and
concerns about presenting outpatient antimicrobial treatment options to
PWUD, while support HCPs provided contextual information. We used the
iterative categorization approach to code and thematically analyze
transcripts. Results: HCPs were willing to present outpatient treatment options for patients with
IDU-associated infections, yet several factors contributed to reluctance.
First, insufficient resources, such as transportation, may make these
options impractical. However, HCPs may be unaware of existing community
resources or viable treatment options. They also may believe the hospital
protects patients, and that discharging patients into the community exposes
them to structural harms. Some HCPs are concerned that patients with
substance use disorder will not make ‘good’ decisions regarding outpatient
antimicrobial options. Finally, there is uncertainty about how
responsibility for offering outpatient treatment is shared across changing
care teams. Conclusion: HCPs perceive many barriers to offering outpatient care for people with
IDU-associated infections, but with appropriate interventions to address
their concerns, may be open to considering more options. This study provides
important insights and contextual information that can help inform specific
harm reduction interventions aimed at improving care of people with
IDU-associated infections.
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Affiliation(s)
- Nichole Moore
- Tufts University School of Medicine, Boston,
MA, USA
| | - Michael Kohut
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Henry Stoddard
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Debra Burris
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Frank Chessa
- Tufts University School of Medicine, Boston,
MA, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of
Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Daniel Solomon
- Division of Infectious Disease, Brigham and
Women’s Hospital, Boston, MA, USA
| | - Colleen M. Kershaw
- Section of Infectious Disease and International
Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth,
Hanover, NH, USA
| | - Ellen Eaton
- Division of Infectious Disease, The University
of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Hutchinson
- Tufts University School of Medicine, Boston,
MA, USA,Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA,Maine Medical Center, Portland, ME, USA
| | - Kathleen M. Fairfield
- Tufts University School of Medicine, Boston,
MA, USA,Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA,Maine Medical Center, Portland, ME, USA
| | - Thomas J. Stopka
- Department of Public Health & Community
Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Peter Friedmann
- Office of Research, UMass Chan Medical
School-Baystate, Springfield, MA, USA,Frank Chessa is also affiliated to MaineHealth
Institute for Research, Portland, ME, USA; Maine Medical Center, Portland,
ME, USA
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21
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Baddour LM, Weimer MB, Wurcel AG, McElhinney DB, Marks LR, Fanucchi LC, Esquer Garrigos Z, Pettersson GB, DeSimone DC. Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e187-e201. [PMID: 36043414 DOI: 10.1161/cir.0000000000001090] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The American Heart Association has sponsored both guidelines and scientific statements that address the diagnosis, management, and prevention of infective endocarditis. As a result of the unprecedented and increasing incidence of infective endocarditis cases among people who inject drugs, the American Heart Association sponsored this original scientific statement. It provides a more in-depth focus on the management of infective endocarditis among this unique population than what has been provided in prior American Heart Association infective endocarditis-related documents. METHODS A writing group was named and consisted of recognized experts in the fields of infectious diseases, cardiology, addiction medicine, and cardiovascular surgery in October 2021. A literature search was conducted in Embase on November 19, 2021, and multiple terms were used, with 1345 English-language articles identified after removal of duplicates. CONCLUSIONS Management of infective endocarditis in people who inject drugs is complex and requires a unique approach in all aspects of care. Clinicians must appreciate that it requires involvement of a variety of specialists and that consultation by addiction-trained clinicians is as important as that of more traditional members of the endocarditis team to improve infective endocarditis outcomes. Preventive measures are critical in people who inject drugs and are cured of an initial bout of infective endocarditis because they remain at extremely high risk for subsequent bouts of infective endocarditis, regardless of whether injection drug use is continued.
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22
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Vervoort D, An KR, Elbatarny M, Tam DY, Quastel A, Verma S, Connelly KA, Yanagawa B, Fremes SE. Dealing with the epidemic of endocarditis in people who inject drugs. Can J Cardiol 2022; 38:1406-1417. [PMID: 35691567 DOI: 10.1016/j.cjca.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/18/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022] Open
Abstract
North America is facing an opioid epidemic and growing illicit drug supply, contributing to growing numbers of injection drug use-related infective endocarditis (IDU-IE). Patients with IDU-IE have high early and late mortality. Patients with IDU-IE more commonly present with right-sided IE compared to those with non-IDU-IE and a majority are a result of S. aureus. While most patients can be successfully managed with intravenous antibiotic treatment, surgery is often required in part related to high relapse rates, potential treatment biases, and more aggressive pathophysiology in some. Multidisciplinary management as endocarditis teams, including not only cardiologists and cardiac surgeons but also infectious disease specialists, drug addiction experts, social workers, neurologists and/or neurosurgeons, is essential to best manage substance use disorder and facilitate safe discharge to home and society. Structural and population-level interventions, such as harm reduction programs, are necessary to reduce IDU-IE relapse rates in the community and other IDU-related health concerns such as overdoses. In this review, we describe the pathophysiological, clinical, surgical, social, and ethical characteristics of IDU-IE and the management thereof. We present the most recent clinical guidelines for this condition and discuss existing gaps in knowledge to guide future research, practice changes, and policy interventions.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Adam Quastel
- Department of Psychiatry, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kim A Connelly
- Division of Cardiology, Department of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Research, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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23
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Jawa R, Rozansky H, Clemens D, Fagan M, Walley AY. Rethinking Home-based Outpatient Parenteral Antibiotic Therapy for Persons Who Inject Drugs: An Opportunity for Change in the Time of COVID-19. J Addict Med 2022; 16:e70-e72. [PMID: 33870955 PMCID: PMC8501142 DOI: 10.1097/adm.0000000000000856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/18/2021] [Indexed: 11/25/2022]
Abstract
Outpatient parenteral antibiotic therapy (OPAT) refers to the monitored provision of intravenous antibiotics for complicated infections outside of a hospital setting, typically in a rehabilitation facility, an infusion center, or the home. Home-based OPAT allows for safe completion of prolonged courses of therapy while decreasing costs to the healthcare system, minimizing the risk of hospital-related infectious exposures for patients, and permitting patients to recover in a familiar environment. Amidst the COVID-19 pandemic, during which nursing facilities have been at the center of many outbreaks of the SARS-CoV-2 virus, completion of antimicrobial therapy in the home is an even more appealing option. Persons who inject drugs (PWID) frequently present with infectious complications of their injection drug use which require long courses of parenteral therapy. However, these individuals are frequently excluded from home-based OPAT on the basis of their addiction history. This commentary describes perceived challenges to establishing home-based OPAT for PWID, discusses ways in which this is discriminatory and unsupported by available data, highlights ways in which the COVID-19 pandemic has accentuated inequities in care, and proposes a multidisciplinary approach championed by Addiction specialists to increasing implementation of OPAT for appropriate patients with substance use disorders.
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Affiliation(s)
- Raagini Jawa
- Section of Infectious Disease, Department of Medicine, Boston Medical Center, Boston, MA (RJ, DC, MF), Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA (RJ, HR, AYW)
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24
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Appa A, Barocas JA. Can I Safely Discharge a Patient with a Substance Use Disorder Home with a Peripherally Inserted Central Catheter? NEJM EVIDENCE 2022; 1:EVIDccon2100012. [PMID: 38319183 DOI: 10.1056/evidccon2100012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Discharging Patients Who Use Drugs Home with PICCAmid the U.S. overdose crisis, serious injection-related infections are rising. Determining where a patient goes after hospitalization can be a challenge due to the need for prolonged parenteral antibiotics, prompting a common clinical question: Can I safely discharge a patient with a substance use disorder home with a peripherally inserted central catheter?
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Affiliation(s)
- Ayesha Appa
- Division of HIV, Infectious Diseases, and Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Joshua A Barocas
- Divisions of General Internal Medicine and Infectious Diseases, University of Colorado School of Medicine, Aurora
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Appa A, Adamo M, Le S, Davis J, Winston L, Doernberg SB, Chambers H, Martin M, Hills NK, Coffin PO, Jain V. Comparative 1-Year Outcomes of Invasive Staphylococcus aureus Infections Among Persons With and Without Drug Use: An Observational Cohort Study. Clin Infect Dis 2022; 74:263-270. [PMID: 33904900 PMCID: PMC8800187 DOI: 10.1093/cid/ciab367] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Persons who use drugs (PWUD) face substantial risk of Staphylococcus aureus infections. Limited data exist describing clinical and substance use characteristics of PWUD with invasive S. aureus infections or comparing treatment and mortality outcomes in PWUD vs non-PWUD. These are needed to inform optimal care for this marginalized population. METHODS We identified adults hospitalized from 2013 to 2018 at 2 medical centers in San Francisco with S. aureus bacteremia or International Classification of Diseases-coded diagnoses of endocarditis, epidural abscess, or vertebral osteomyelitis with compatible culture. In addition to demographic and clinical characteristic comparison, we constructed multivariate Cox proportional hazards models for 1-year infection-related readmission and mortality, adjusted for age, race/ethnicity, housing, comorbidities, and methicillin-resistant S. aureus (MRSA). RESULTS Of 963 hospitalizations for S. aureus infections in 946 patients, 372 of 963 (39%) occurred in PWUD. Among PWUD, heroin (198/372 [53%]) and methamphetamine use (185/372 [50%]) were common. Among 214 individuals using opioids, 98 of 214 (46%) did not receive methadone or buprenorphine. PWUD had lower antibiotic completion than non-PWUD (70% vs 87%; P < .001). While drug use was not associated with increased mortality, 1-year readmission for ongoing or recurrent infection was double in PWUD vs non-PWUD (28% vs 14%; adjusted hazard ratio [aHR], 2.0 [95% confidence interval {CI}: 1.3-2.9]). MRSA was independently associated with 1-year readmission for infection (aHR, 1.5 [95% CI: 1.1-2.2]). CONCLUSIONS Compared to non-PWUD, PWUD with invasive S. aureus infections had lower rates of antibiotic completion and twice the risk of infection persistence/recurrence at 1 year. Among PWUD, both opioid and stimulant use were common. Models for combined treatment of substance use disorders and infections, particularly MRSA, are needed.
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Affiliation(s)
- Ayesha Appa
- University of California, San Francisco, San Francisco, California, USA
| | - Meredith Adamo
- University of California, San Francisco, San Francisco, California, USA
| | - Stephenie Le
- University of California, San Francisco, San Francisco, California, USA
| | - Jennifer Davis
- University of California, San Francisco, San Francisco, California, USA
| | - Lisa Winston
- University of California, San Francisco, San Francisco, California, USA
| | - Sarah B Doernberg
- University of California, San Francisco, San Francisco, California, USA
| | - Henry Chambers
- University of California, San Francisco, San Francisco, California, USA
| | - Marlene Martin
- University of California, San Francisco, San Francisco, California, USA
| | - Nancy K Hills
- University of California, San Francisco, San Francisco, California, USA
| | - Phillip O Coffin
- University of California, San Francisco, San Francisco, California, USA
- San Francisco Department of Public Health, San Francisco, California, USA
| | - Vivek Jain
- University of California, San Francisco, San Francisco, California, USA
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Moran GJ, Chitra S, McGovern PC. Efficacy and Safety of Omadacycline Versus Linezolid in Acute Bacterial Skin and Skin Structure Infections in Persons Who Inject Drugs. Infect Dis Ther 2022; 11:517-531. [PMID: 35015255 PMCID: PMC8847501 DOI: 10.1007/s40121-021-00587-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/23/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction Acute bacterial skin and skin structure infections (ABSSSI) represent one of the most common reasons for emergency department visits, and are frequent complications of intravenous drug use in persons who inject drugs (PWID). This study examined the efficacy and safety of omadacycline, versus linezolid, in PWID and persons who do not inject drugs, in the Phase 3 Omadacycline in Acute Skin and Skin Structure Infection (OASIS-1, OASIS-2) studies. Methods Eligible participants were aged ≥ 18 years with qualifying skin infections: wound infection, cellulitis, erysipelas, or major abscess. The primary efficacy endpoint was early clinical response (ECR) in the modified intent-to-treat (mITT) population, defined as survival with ≥ 20% reduction in lesion size at 48–72 h after the first dose of omadacycline or linezolid. Key secondary endpoints included investigator-assessed clinical response at the post-treatment evaluation (PTE) in the mITT and clinical per-protocol populations, and clinical response at PTE in the micro-mITT population. Safety was assessed based on adverse events (AEs) and standard clinical laboratory tests. Efficacy endpoints of clinical response at ECR and PTE were analyzed for the mITT and clinically evaluable (CE) PTE populations. Results In total, 1380 patients (822 PWID, 558 non-PWID) were included in this secondary analysis. Wound infections were reported more frequently in the PWID subgroup (72.8%) at baseline; cellulitis or erysipelas (43.9%) and major abscess (37.4%) were the most frequently reported baseline infections in the non-PWID subgroup. Clinical success rates at ECR and PTE in the mITT population, and at PTE in the CE population, were high for patients receiving omadacycline or linezolid. Severe or serious treatment-emergent AEs (TEAEs), and TEAEs leading to discontinuation, were infrequent. Conclusion This subgroup analysis showed that omadacycline was effective and well tolerated, regardless of PWID status.
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Affiliation(s)
- Gregory J Moran
- Olive View-UCLA Medical Center, 14445 Olive View Dr, Sylmar, CA, 91342, USA.
| | - Surya Chitra
- Paratek Pharmaceuticals, Inc., King of Prussia, PA, USA
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Conte M, Schneider B, Varley CD, Streifel AC, Sikka MK. Description and outcomes of patients with substance use disorder with serious bacterial infections who had a multidisciplinary care conference. Ther Adv Infect Dis 2022; 9:20499361221117974. [PMID: 35992495 PMCID: PMC9389031 DOI: 10.1177/20499361221117974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background Patients with substance use disorders (SUDs) and severe bacterial infections requiring prolonged antibiotic therapy represent a significant challenge to providers due to complexity of care coordination required to ensure safe and effective treatment. Our institution developed a patient-centered multidisciplinary discharge planning conference, OPTIONS-DC, to address this challenge. Methods We conducted a retrospective review to evaluates parameters between patients who received an OPTIONS-DC and those who did not. Results We identified 73 patients receiving an OPTIONS-DC and 100 who did not. More patients with an OPTIONS-DC were < 40 years of age (76.7% versus 61.0%, OR = 2.3, 95% CI = 1.1-4.7, p = 0.02), had positive HCV antibody testing (58.9% versus 41.0%, OR = 2.1, 95% CI = 1.1-3.8, p = 0.02), injection drug use (93.2% versus 79.0%, OR = 3.6 95% CI = 1.3-10.1, p = 0.01), used methamphetamines (84.9% versus 72.0%, OR = 2.2, 95% CI = 1.0-4.8, p = 0.04), and started inpatient SUD treatment (80.8% versus 63%, OR = 2.5, 95% CI = 1.2-5.0, p = 0.04) compared with those without a conference. The OPTIONS-DC group was more likely to be diagnosed with bacteremia (74.0% versus 57.0%, OR = 2.1, 95% CI = 1.1-4.1, p = 0.02), endocarditis (39.7% versus21.0%, OR = 2.5, 95% CI = 1.3-4.9, p = 0.03), vertebral osteomyelitis (45.2% versus 15.0%, OR = 4.7, 95% CI = 2.3-9.6, p < 0.01), and epidural abscess (35.6% versus 10.0%, OR = 5.0, 95% CI = 2.2-11.2, p < 0.01) and require 4 weeks or more of antibiotic treatment (97.3% versus 51.1%, OR = 34.1, 95% CI = 7.9-146.7, p = 0.01). Patients with an OPTIONS-DC were also more likely to be admitted between 2019 and 2020 than between 2018 and 2019 (OR = 4.1, 95% CI = 2.1-7.9, p < 0.01). Conclusion Patients with an OPTIONS-DC tended to have more complicated infections and longer courses of antibiotic treatment. While further research on outcomes is needed, patients receiving an OPTIONS-DC were able to successfully complete antibiotic courses across a variety of settings.
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Affiliation(s)
- Michael Conte
- Division of Infectious Diseases, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brent Schneider
- Division of Infectious Diseases, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Cara D Varley
- Division of Infectious Diseases, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Amber C Streifel
- Department of Pharmacy, Oregon Health & Science University, Portland, OR, USA
| | - Monica K Sikka
- Division of Infectious Diseases, School of Medicine, Oregon Health & Science University, Portland, OR 97239-3098, USA
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Traver EC, Ching PR, Narayanan S. Medication for opioid use disorder at hospital discharge is not associated with intravenous antibiotic completion in post-acute care facilities. Ther Adv Infect Dis 2022; 9:20499361221103877. [PMID: 35755123 PMCID: PMC9218897 DOI: 10.1177/20499361221103877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background: People with opioid use disorder and severe infections may complete their prolonged courses of outpatient parenteral antimicrobial therapy at a post-acute care facility due to adherence and safety concerns. We hypothesized that treatment with medications for opioid use disorder, such as methadone and buprenorphine, would increase antibiotic completion in these facilities. Methods: We performed a retrospective cohort study of people with opioid use disorder and severe infections who were discharged from the University of Maryland Medical Center to a post-acute care facility to complete intravenous antibiotic therapy. The primary outcome was completion of outpatient parenteral antimicrobial therapy. We compared the rate of antibiotic completion between patients prescribed and not prescribed medication for opioid use disorder at discharge from the acute care hospital. Results: A total of 161 patient encounters were included; the mean age was 43.4 years and 56% of patients were male. In 48% of the encounters, the patient was homeless and in 68% they recently injected drugs. The most common infectious syndrome was osteoarticular (44.1%). Medication for opioid use disorder was prescribed at discharge in 103 of 161 encounters and was newly started in 27 encounters. Similar rates of outpatient parenteral antimicrobial therapy completion were found in those who received (65/103) and did not receive (33/58) medication for opioid use disorder at discharge (odds ratio: 1.29; 95% confidence interval: 0.68–2.54; p = 0.44). Conclusion: Medication for opioid use disorder prescription at discharge was not associated with completion of outpatient parenteral antimicrobial therapy in a post-acute care facility. Our study is limited by possible selection bias and infrequent initiation of medication for opioid use disorder, which may have minimized the effect on antibiotic completion.
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Affiliation(s)
- Edward C Traver
- University of Maryland Medical Center, 22 S. Greene St, Baltimore, MD 21201, USA
| | - Patrick R Ching
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Shivakumar Narayanan
- Division of Clinical Care and Research, Institute of Human Virology, School of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Sikka MK, Gore S, Vega T, Strnad L, Gregg J, Englander H. "OPTIONS-DC", a feasible discharge planning conference to expand infection treatment options for people with substance use disorder. BMC Infect Dis 2021; 21:772. [PMID: 34372776 PMCID: PMC8351414 DOI: 10.1186/s12879-021-06514-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background Serious bacterial infections associated with substance use often result in long hospitalizations, premature discharges, and high costs. Out-of-hospital treatment options in people with substance use disorder (SUD) are often limited. Methods We describe a novel multidisciplinary and interprofessional care conference, “OPTIONS-DC,” to identify treatment options agreeable to both patients and providers using the frameworks of harm reduction and patient-centered care. We retrospectively reviewed charts of patients who had an OPTIONS-DC between February 2018 and July 2019 and used content analysis to understand the conferences’ effects on antibiotic treatment options. Results Fifty patients had an OPTIONS-DC during the study window. Forty-two (84%) had some intravenous (IV) substance use and 44 (88%) had an active substance use disorder. Participants’ primary substances included opioids (65%) or methamphetamines (28%). On average, conferences lasted 28 min. OPTIONS-DC providers recommended out-of-hospital antibiotic treatment options for 34 (68%) of patients. OPTIONS-DC recommended first line therapy of IV antibiotics for 35 (70%) patients, long-acting injectable antibiotics for 14 (28%), and oral therapy for 1 (2%). 35 (70%) patients that had an OPTIONS-DC completed an antibiotic course and 6 (12%) left the hospital prematurely. OPTIONS-DC expanded treatment options by exposing and contextualizing SUD, psychosocial risk and protective factors; incorporating patient preferences; and allowing providers to tailor antibiotic and SUD recommendations. Conclusions OPTIONS-DC is a feasible intervention that allows providers to integrate principles of harm reduction and offer patient-centered choices among patients needing prolonged antibiotic treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06514-9.
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Affiliation(s)
- Monica K Sikka
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, L457, Portland, OR, 97239-3098, USA.
| | - Sara Gore
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, L457, Portland, OR, 97239-3098, USA
| | - Taylor Vega
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Luke Strnad
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, L457, Portland, OR, 97239-3098, USA.,Epidemiology Programs, School of Public Health, Oregon Health and Science University and Portland State University, Portland, OR, USA
| | - Jessica Gregg
- Section of Addiction Medicine, Division of General Internal Medicine, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, BTE 119, Portland, OR, 97239-3098, USA.,Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Honora Englander
- Section of Addiction Medicine, Division of General Internal Medicine, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, BTE 119, Portland, OR, 97239-3098, USA. .,Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
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Beieler AM, Klein JW, Bhatraju E, Iles-Shih M, Enzian L, Dhanireddy S. Evaluation of Bundled Interventions for Patients With Opioid Use Disorder Experiencing Homelessness Receiving Extended Antibiotics for Severe Infection. Open Forum Infect Dis 2021; 8:ofab285. [PMID: 34189180 PMCID: PMC8231362 DOI: 10.1093/ofid/ofab285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/26/2021] [Indexed: 11/14/2022] Open
Abstract
Hospitalizations for serious infections in patients with opioid use disorder (OUD) experiencing homelessness are common. Patients receiving 4 interventions (infectious disease consultation, addiction consultation, case management, and medications for OUD [MOUD]) had higher odds of clinical cure (unadjusted odds ratio [OR], 3.15; P = .03; adjusted OR, 3.03; P = .049) and successful retention in addiction care at 30 days (unadjusted OR, 5.46; P = .01; adjusted OR, 6.36; P = .003).
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Affiliation(s)
- Alison M Beieler
- Harborview Medical Center, Seattle, Washington, USA
- Correspondence: Alison M Beieler, PA-C, MPAS, Infectious Disease, Harborview Medical Center, 325 Ninth Ave, Box #359930, Seattle, WA 98104 ()
| | - Jared W Klein
- Harborview Medical Center, Seattle, Washington, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Elenore Bhatraju
- Harborview Medical Center, Seattle, Washington, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Matthew Iles-Shih
- Harborview Medical Center, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Leslie Enzian
- Harborview Medical Center, Seattle, Washington, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
- Edward Thomas House Medical Respite, Seattle, Washington, USA
| | - Shireesha Dhanireddy
- Harborview Medical Center, Seattle, Washington, USA
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle, Washington, USA
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Ceniceros AG, Shridhar N, Fazzari M, Felsen U, Fox AD. Low Use of Outpatient Parenteral Antimicrobial Therapy for Drug Use-Associated Infective Endocarditis in an Urban Hospital System. Open Forum Infect Dis 2021; 8:ofab083. [PMID: 33796596 PMCID: PMC7990064 DOI: 10.1093/ofid/ofab083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/12/2021] [Indexed: 01/30/2023] Open
Abstract
Background The opioid crisis in the United States has led to increasing hospitalizations for drug use-associated infective endocarditis (DUA-IE). Outpatient parenteral antimicrobial therapy (OPAT), the preferred modality for intravenous antibiotics for infective endocarditis, has demonstrated similar outcomes among patients with DUA-IE versus non-DUA-IE, but current studies suffer selection bias. The utilization of OPAT for DUA-IE more generally is not well studied. Methods This retrospective cohort study compared OPAT use for DUA-IE versus non-DUA-IE in adults hospitalized between January 1, 2015 and September 1, 2019 at 3 urban hospitals. We used multivariable regression analysis to assess the association between DUA-IE and discharge with OPAT, adjusting for clinically significant covariables. Results The cohort included 518 patients (126 DUA-IE, 392 non-DUA-IE). Compared to those with non-DUA-IE, DUA-IE patients were younger (53.0 vs 68.2 years, P < .001) and more commonly undomiciled (9.5% vs 0.3%, P < .01). Patients with DUA-IE had a significantly lower odds of discharge with OPAT than non-DUA-IE patients (adjusted odds ratio [aOR] = 0.20; 95% confidence interval [CI], 0.10–0.39). Odds of discharge with OPAT remained lower for patients with DUA-IE after excluding undomiciled patients (aOR = 0.22; 95% CI, 0.11–0.43) and those with patient-directed discharges (aOR = 0.27; 95% CI, 0.14–0.52). Conclusions Significantly fewer patients with DUA-IE were discharged with OPAT compared to those with non-DUA-IE, and undomiciled patients or patient-directed discharges did not fully account for this difference. Efforts to increase OPAT utilization among patients with DUA-IE could have important benefits for patients and the healthcare system.
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Affiliation(s)
- Ashley G Ceniceros
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nupur Shridhar
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Melissa Fazzari
- Department of Epidemiology & Population Health (Biostatistics), Albert Einstein College of Medicine, Bronx, New York, USA
| | - Uriel Felsen
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Aaron D Fox
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Capizzi J, Leahy J, Wheelock H, Garcia J, Strnad L, Sikka M, Englander H, Thomas A, Korthuis PT, Menza TW. Population-based trends in hospitalizations due to injection drug use-related serious bacterial infections, Oregon, 2008 to 2018. PLoS One 2020; 15:e0242165. [PMID: 33166363 PMCID: PMC7652306 DOI: 10.1371/journal.pone.0242165] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/27/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Injection drug use has far-reaching social, economic, and health consequences. Serious bacterial infections, including skin/soft tissue infections, osteomyelitis, bacteremia, and endocarditis, are particularly morbid and mortal consequences of injection drug use. METHODS We conducted a population-based retrospective cohort analysis of hospitalizations among patients with a diagnosis code for substance use and a serious bacterial infection during the same hospital admission using Oregon Hospital Discharge Data. We examined trends in hospitalizations and costs of hospitalizations attributable to injection drug use-related serious bacterial infections from January 1, 2008 through December 31, 2018. RESULTS From 2008 to 2018, Oregon hospital discharge data included 4,084,743 hospitalizations among 2,090,359 patients. During the study period, hospitalizations for injection drug use-related serious bacterial infection increased from 980 to 6,265 per year, or from 0.26% to 1.68% of all hospitalizations (P<0.001). The number of unique patients with an injection drug use-related serious bacterial infection increased from 839 to 5,055, or from 2.52% to 8.46% of all patients (P<0.001). While hospitalizations for all injection drug use-related serious bacterial infections increased over the study period, bacteremia/sepsis hospitalizations rose most rapidly with an 18-fold increase. Opioid use diagnoses accounted for the largest percentage of hospitalizations for injection drug use-related serious bacterial infections, but hospitalizations for amphetamine-type stimulant-related serious bacterial infections rose most rapidly with a 15-fold increase. People living with HIV and HCV experienced increases in hospitalizations for injection drug use-related serious bacterial infection during the study period. Overall, the total cost of hospitalizations for injection drug use-related serious bacterial infections increased from $16,305,129 in 2008 to $150,879,237 in 2018 (P<0.001). CONCLUSIONS In Oregon, hospitalizations for injection drug use-related serious bacterial infections increased dramatically and exacted a substantial cost on the health care system from 2008 to 2018. This increase in hospitalizations represents an opportunity to initiate substance use disorder treatment and harm reduction services to improve outcomes for people who inject drugs.
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Affiliation(s)
- Jeffrey Capizzi
- Public Health Division, Oregon Health Authority, Portland, Oregon, United States of America
| | - Judith Leahy
- Public Health Division, Oregon Health Authority, Portland, Oregon, United States of America
| | - Haven Wheelock
- OutsideIn, A Federally Qualified Health Center (FQHC), Portland, Oregon, United States of America
| | - Jonathan Garcia
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, United States of America
| | - Luke Strnad
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Monica Sikka
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Honora Englander
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Ann Thomas
- Public Health Division, Oregon Health Authority, Portland, Oregon, United States of America
| | - P. Todd Korthuis
- Public Health Division, Oregon Health Authority, Portland, Oregon, United States of America
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Timothy William Menza
- Public Health Division, Oregon Health Authority, Portland, Oregon, United States of America
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
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