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Wolie ZT, Roberts JA, Gilchrist M, McCarthy K, Sime FB. Current practices and challenges of outpatient parenteral antimicrobial therapy: a narrative review. J Antimicrob Chemother 2024; 79:2083-2102. [PMID: 38842523 PMCID: PMC11368434 DOI: 10.1093/jac/dkae177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Extended hospitalization for infection management increases inpatient care costs and the risk of healthcare-associated adverse events, including infections. The growing global demand for healthcare, the diminishing availability of hospital beds and an increasing patient preference for care within their own home have been the primary drivers of the expansion of hospital-in-the-home programmes. Such programmes include the use of IV antimicrobials in outpatient settings, known as outpatient parenteral antimicrobial therapy (OPAT). However, OPAT practices vary globally. This review article aims to describe the current OPAT practices and challenges worldwide. OPAT practice begins with patient evaluation and selection using eligibility criteria, which requires collaboration between the interdisciplinary OPAT team, patients and caregivers. Depending on care requirements, eligible patients may be enrolled to various models of care, receiving medication by healthcare professionals at outpatient infusion centres, hospital clinics, home visits or through self-administration. OPAT can be used for the management of many infections where an effective oral treatment option is lacking. Various classes of parenteral antimicrobials, including β-lactams, aminoglycosides, glycopeptides, fluoroquinolones and antifungals such as echinocandins, are used globally in OPAT practice. Despite its benefits, OPAT has numerous challenges, including complications from medication administration devices, antimicrobial side effects, monitoring requirements, antimicrobial instability, patient non-adherence, patient OPAT rejection, and challenges related to OPAT team structure and administration, all of which impact its outcome. A negative outcome could include unplanned hospital readmission. Future research should focus on mitigating these challenges to enable optimization of the OPAT service and thereby maximize the documented benefits for the healthcare system, patients and healthcare providers.
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Affiliation(s)
- Zenaw T Wolie
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - Mark Gilchrist
- Department of Pharmacy/Infection, Imperial College Healthcare NHS Trust, London, UK
- Department of Infectious Diseases, Imperial College, London, UK
| | - Kate McCarthy
- Royal Brisbane Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Infectious Diseases, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Fekade B Sime
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
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Joseph M, Batra S, Kamran W, Barrett K, Ebert B, Nassar A, Misselbeck T, Hawwa N. Home inotrope therapy in chronic stimulant-induced cardiomyopathy: a case series. Eur Heart J Case Rep 2024; 8:ytae406. [PMID: 39171134 PMCID: PMC11336994 DOI: 10.1093/ehjcr/ytae406] [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: 04/04/2024] [Revised: 05/30/2024] [Accepted: 08/05/2024] [Indexed: 08/23/2024]
Abstract
Background Patients with chronic stimulant-induced cardiomyopathy presenting with cardiogenic shock can be stabilized with conventional measures. However, their management post-stabilization has not been well described and poses unique challenges: (i) less chance of myocardial recovery compared to acute stimulant-induced cardiomyopathy, (ii) psychosocial barriers to left ventricular assist device (LVAD) and heart transplantation, and (iii) concern for use of peripherally inserted central catheter for home inotrope in those with a history of substance abuse. Case summary Three patients with chronic stimulant-induced cardiomyopathy were admitted with cardiogenic shock progressing to Society for Cardiovascular Angiography & Interventions stage D or E. They were stabilized with inotrope and/or biventricular mechanical circulatory support. Long-term home inotrope was used as either a bridge to LVAD, reverse remodelling, or stabilization. Discussion Home inotrope should be viewed as an option in chronic stimulant-induced cardiomyopathy on a case-by-case basis. It can buy time to allow for myocardial stabilization or recovery through goal-directed medical therapy and stimulant cessation. It can also serve as a 'psychosocial stress test' for future consideration of advanced heart failure therapies.
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Affiliation(s)
- Max Joseph
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, 1250 S Cedar Crest Blvd #300, Allentown, PA 18103, USA
| | - Sejal Batra
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, 1250 S Cedar Crest Blvd #300, Allentown, PA 18103, USA
| | - Wali Kamran
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, 1250 S Cedar Crest Blvd #300, Allentown, PA 18103, USA
| | - Kelsey Barrett
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, 1250 S Cedar Crest Blvd #300, Allentown, PA 18103, USA
| | - Barbara Ebert
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, 1250 S Cedar Crest Blvd #300, Allentown, PA 18103, USA
| | - Ahmed Nassar
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, 1250 S Cedar Crest Blvd #300, Allentown, PA 18103, USA
| | - Timothy Misselbeck
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, 1250 S Cedar Crest Blvd #300, Allentown, PA 18103, USA
| | - Nael Hawwa
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, 1250 S Cedar Crest Blvd #300, Allentown, PA 18103, USA
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Mohammed SA, Roberts JA, Cotta MO, Rogers B, Pollard J, Assefa GM, Erku D, Sime FB. Safety and efficacy of outpatient parenteral antimicrobial therapy: A systematic review and meta-analysis of randomized clinical trials. Int J Antimicrob Agents 2024; 64:107263. [PMID: 38960209 DOI: 10.1016/j.ijantimicag.2024.107263] [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: 04/16/2024] [Revised: 06/05/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Outpatient parenteral antimicrobial therapy (OPAT) offers an alternative to inpatient (hospital bed-based) treatment of infections that require intravenous administration of antimicrobials. This meta-analysis aimed to summarise the evidence available from randomised controlled trials (RCTs) regarding the efficacy and safety of OPAT compared to inpatient parenteral antimicrobial therapy. METHODS We searched the Cochrane Library, MEDLINE, Embase, PubMed, and Web of Sciences databases for RCTs comparing outpatient versus inpatient parenteral antimicrobial therapy. We included studies without restrictions on language or publication year. Eligibility was reviewed independently by two assessors, and data extraction was cross validated. We evaluated bias risk via the Cochrane tool and determined the evidence certainty using GRADE. Meta-analysis was conducted using a random effects model. The protocol of this review was registered on PROSPERO (CRD42023460389). RESULT Thirteen RCTs, involving 1,310 participants were included. We found no difference in mortality (Risk Ratio [RR] 0.54, 95% Confidence Interval [CI] 0.23 to 1.26; P = 0.93), treatment failure (RR 1.0, CI 0.59 to 1.72; P = 0.99), adverse reaction related to antimicrobials (RR 0.89, CI 0.69 to 1.15; P = 0.38), and administration device (RR 0.58, CI 0.17 to 1.98; P = 0.87) between outpatient and inpatient parenteral antimicrobial therapy. The overall body of evidence had a low level of certainty. CONCLUSION Existing evidence suggests OPAT is a safe and effective alternative to inpatient treatment. Further RCTs are warranted for a thorough comparison of inpatient and outpatient parenteral antimicrobial therapy with a high level of certainty.
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Affiliation(s)
- Solomon Ahmed Mohammed
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia; Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Queensland, Australia; Herston Infectious Disease Institute (HeIDI), Metro North Health, Queensland, Australia; Division of Anaesthesiology Critical Care Emerging and Pain Medicine, Nimes University Hospital, University of Montpellier, Nimes, France
| | - Menino Osbert Cotta
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia; Herston Infectious Disease Institute (HeIDI), Metro North Health, Queensland, Australia
| | - Benjamin Rogers
- Centre for Inflammatory Disease, Monash University, Melbourne, Australia
| | - James Pollard
- Cabrini @ Home, Cabrini Health, Melbourne, Australia
| | - Getnet Mengistu Assefa
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - Daniel Erku
- Centre for Applied Health Economics, Griffith University, Queensland, Australia
| | - Fekade B Sime
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia.
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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; 30:877-882. [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] [MESH Headings] [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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Gorski LA. Update: The 2024 Infusion Therapy Standards of Practice. Home Healthc Now 2024; 42:198-205. [PMID: 38975817 DOI: 10.1097/nhh.0000000000001270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
The Infusion Therapy Standards of Practice provide evidence-based recommendations for infusion and access device related care in any healthcare setting. Developed and published by the Infusion Nurses Society, the Standards have increased the frequency of the revision process from an every 5-year cycle to a 3-year cycle due to the growing base of literature and to deliver the most updated and current practice recommendations. This article provides an overview of the development process and a brief description of selected standards. Notably, a new standard entitled Home Infusion Therapy was added in this latest edition. The Standards are an essential reference that should be available to every home care agency that provides home infusion therapy.
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Affiliation(s)
- Lisa A Gorski
- Lisa A. Gorski, MS, RN, HHCNS-BC, CRNI, FAAN, is a Clinical Education Specialist, Ascension at Home, and Editor, Home Healthcare Now
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Fabricant SA, Abramson EL, Hutchings K, Vien A, Scherer M, Kapadia SN. PICC Your Poison: Resident Beliefs and Attitudes Regarding Discharge Parenteral Antibiotics for Patients Who Inject Drugs. Open Forum Infect Dis 2024; 11:ofae364. [PMID: 38994443 PMCID: PMC11237634 DOI: 10.1093/ofid/ofae364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/26/2024] [Indexed: 07/13/2024] Open
Abstract
Background Serious injection-related infections (SIRIs) in people who inject drugs often lead to prolonged hospitalizations or premature discharges. This may be in part due to provider reluctance to place peripherally inserted central catheters (PICCs) for outpatient parenteral antibiotic therapy in this population. Because internal medicine (IM) residents are often frontline providers in academic centers, understanding their perspectives on SIRI care is important to improve outcomes. Methods We surveyed IM residents in a large urban multicenter hospital system about SIRI care with a novel case-based survey that elicited preferences, comfort, experience, and stigma. The survey was developed using expert review, cognitive interviewing, and pilot testing. Results are reported with descriptive statistics and linear regression. Results Of 116 respondents (response rate 34%), most (73%) were uncomfortable discharging a patient with active substance use home with a PICC, but comfortable (87%) with discharge to postacute facilities. Many (∼40%) endorsed high levels of concern for PICC misuse or secondary line infections, but larger numbers cited concerns about home environment (50%) or loss to follow-up (68%). While overall rates were low, higher stigma was associated with more concerns around PICC use (r = -0.3, P = .002). A majority (58%) believed hospital policies against PICC use in SIRI may act as a barrier to discharge, and 74% felt initiation of medications for opioid use disorder (MOUD) would increase their comfort discharging with a PICC. Conclusions Most IM residents endorsed high levels of concern about PICC use for SIRI, related to patient outcomes and perceived institutional barriers, but identified MOUD as a mitigating factor.
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Affiliation(s)
- Scott A Fabricant
- Department of Medicine, New York–Presbyterian, New York, New York, USA
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Kayla Hutchings
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Alexis Vien
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Matthew Scherer
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York, USA
| | - Shashi N Kapadia
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
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Donnelly D, Pillinger KE, Debnath A, DePasquale W, Munsiff S, Louie T, Jones CMC, Shulder S. Cost evaluation of continuation of therapy with dalbavancin compared to standard-of-care antibiotics alone in hospitalized persons who inject drugs with severe gram-positive infections. Am J Health Syst Pharm 2024; 81:S40-S48. [PMID: 38465838 DOI: 10.1093/ajhp/zxae025] [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: 01/27/2024] [Indexed: 03/12/2024] Open
Abstract
PURPOSE Persons who inject drugs (PWID) are at risk for severe gram-positive infections and may require prolonged hospitalization and intravenous (IV) antibiotic therapy. Dalbavancin (DBV) is a long-acting lipoglycopeptide that may reduce costs and provide effective treatment in this population. METHODS This was a retrospective review of PWID with severe gram-positive infections. Patients admitted from January 1, 2017, to November 1, 2019 (standard-of-care [SOC] group) and from November 15, 2019, to March 31, 2022 (DBV group) were included. The primary outcome was the total cost to the healthcare system. Secondary outcomes included hospital days saved and treatment failure. RESULTS A total of 87 patients were included (37 in the DBV group and 50 in the SOC group). Patients were a median of 34 years old and were predominantly Caucasian (82%). Staphylococcus aureus (82%) was the most common organism, and bacteremia (71%) was the most common type of infection. Compared to the SOC group, the DBV group would have had a median of 14 additional days of hospitalization if they had stayed to complete their therapy (P = 0.014). The median total cost to the healthcare system was significantly lower in the DBV group than in the SOC group ($31,698.00 vs $45,093.50; P = 0.035). The rate of treatment failure was similar between the groups (32.4% in the DBV group vs 36% in the SOC group; P = 0.729). CONCLUSION DBV is a cost-saving alternative to SOC IV antibiotics for severe gram-positive infections in PWID, with similar treatment outcomes. Larger prospective studies, including other patient populations, may demonstrate additional benefit.
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Affiliation(s)
- Devin Donnelly
- Department of Pharmacy, University of Rochester Medical Center: Strong Memorial Hospital, Rochester, NY, USA
| | | | | | - William DePasquale
- Department of Pharmacy, University of Rochester Medical Center: Highland Hospital, Rochester, NY, USA
| | - Sonal Munsiff
- Division of Infectious Diseases, University of Rochester Medical Center: Strong Memorial Hospital, Rochester, NY, USA
| | - Ted Louie
- Division of Infectious Diseases, University of Rochester Medical Center: Strong Memorial Hospital, Rochester, NY, USA
| | - Courtney Marie Cora Jones
- Department of Emergency Medicine, University of Rochester Medical Center: Strong Memorial Hospital, Rochester, NY, USA
| | - Stephanie Shulder
- Department of Pharmacy, University of Rochester Medical Center: Strong Memorial Hospital, Rochester, NY, USA
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8
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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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Morgan B, Lancaster R, Boyagoda B, Ananda R, Attwood LO, Jacka D, Woolley I. The burden of skin and soft tissue, bone and joint infections in an Australian cohort of people who inject drugs. BMC Infect Dis 2024; 24:299. [PMID: 38454356 PMCID: PMC10918955 DOI: 10.1186/s12879-024-09143-0] [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: 07/03/2023] [Accepted: 02/15/2024] [Indexed: 03/09/2024] Open
Abstract
INTRODUCTION There are currently limited data regarding the clinical and economic significance of skin and soft tissue infections (SSTI) and bone and joint infections in Australian people who inject drugs (PWID). METHODS Retrospective cohort study in adult PWID admitted to Monash Health, a large heath care network with six hospitals in Victoria, Australia. Inpatients were identified using administrative datasets and International Classification of Disease (ICD-10) coding for specific infection-related conditions. Cost analysis was based on mean ward, intensive care and hospital-in-the-home (HITH) lengths of stay. Spinal infections and endocarditis were excluded as part of previous studies. RESULTS A total of 185 PWID (61 female, 124 male, median age 37) meeting the study criteria were admitted to Monash Health between January 2010 and January 2021. Admitting diagnoses included 78 skin abscesses, 80 cellulitis, 17 septic arthritis, 4 osteomyelitis, 3 thrombophlebitis and 1 each of necrotising fasciitis, vasculitis and myositis. Pain (87.5%) and swelling (75.1%) were the most common presenting complaints. Opioids (67.4%) and methamphetamine (37.5%) were the most common primary drugs injected. Almost half (46.5%) of patients had concurrent active hepatitis C (HCV) infection on admission. Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV) were uncommon. The most significant causative organism was methicillin-susceptible Staphylococcus aureus (24.9%). In 40.0% (74/185) no organism was identified. Patients required a median acute hospital stay of 5 days (2-51 days). There were 15 patients admitted to the intensive care unit (ICU) with median duration 2 days. PICC line insertion for antibiotics was required in 16.8% of patients, while 51.4% required surgical intervention. Median duration of both oral and IV antibiotic therapy was 11 days. Almost half (48.6%) of patients were enrolled in an opioid maintenance program on discharge. Average estimated expenditure was AUD $16, 528 per admission. CONCLUSION Skin and soft tissue and joint infections are a major cause of morbidity for PWID. Admission to hospital provides opportunistic involvement of addiction specialty services.
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Affiliation(s)
- B Morgan
- Department of Medicine, Monash Health, Clayton, Australia.
| | - R Lancaster
- Addiction Medicine Unit, Monash Health, Clayton, Australia
| | - B Boyagoda
- Central Clinical School, Monash University, Clayton, Australia
| | - R Ananda
- Department of Medicine, Monash Health, Clayton, Australia
| | - L O Attwood
- Central Clinical School, Monash University, Clayton, Australia
- Department of Infectious Diseases, Alfred Health, Clayton, Australia
- Monash Infectious Diseases, Monash Health, Clayton, Australia
| | - D Jacka
- Addiction Medicine Unit, Monash Health, Clayton, Australia
| | - I Woolley
- Central Clinical School, Monash University, Clayton, Australia.
- Department of Infectious Diseases, Alfred Health, Clayton, Australia.
- Monash Infectious Diseases, Monash Health, Clayton, Australia.
- School of Clinical Sciences, Monash University, Clayton, Australia.
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10
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Marcovitz D, Dear ML, Donald R, Edwards DA, Kast KA, Le TDV, Shah MV, Ferrell J, Gatto C, Hennessy C, Buie R, Rice TW, Sullivan W, White KD, Van Winkle G, Wolf R, Lindsell CJ. Effect of a Co-Located Bridging Recovery Initiative on Hospital Length of Stay Among Patients With Opioid Use Disorder: The BRIDGE Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2356430. [PMID: 38411964 PMCID: PMC10900965 DOI: 10.1001/jamanetworkopen.2023.56430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/20/2023] [Indexed: 02/28/2024] Open
Abstract
Importance Co-located bridge clinics aim to facilitate a timely transition to outpatient care for inpatients with opioid use disorder (OUD); however, their effect on hospital length of stay (LOS) and postdischarge outcomes remains unclear. Objective To evaluate the effect of a co-located bridge clinic on hospital LOS among inpatients with OUD. Design, Setting, and Participants This parallel-group randomized clinical trial recruited 335 adult inpatients with OUD seen by an addiction consultation service and without an existing outpatient clinician to provide medication for OUD (MOUD) between November 25, 2019, and September 28, 2021, at a tertiary care hospital affiliated with a large academic medical center and its bridge clinic. Intervention The bridge clinic included enhanced case management before and after hospital discharge, MOUD prescription, and referral to a co-located bridge clinic. Usual care included MOUD prescription and referrals to community health care professionals who provided MOUD. Main Outcomes and Measures The primary outcome was the index admission LOS. Secondary outcomes, assessed at 16 weeks, were linkage to health care professionals who provided MOUD, MOUD refills, same-center emergency department (ED) and hospital use, recurrent opioid use, quality of life (measured by the Schwartz Outcome Scale-10), overdose, mortality, and cost. Analysis was performed on an intent-to-treat basis. Results Of 335 participants recruited (167 randomized to the bridge clinic and 168 to usual care), the median age was 38.0 years (IQR, 31.9-45.7 years), and 194 (57.9%) were male. The median LOS did not differ between arms (adjusted odds ratio [AOR], 0.94 [95% CI, 0.65-1.37]; P = .74). At the 16-week follow-up, participants referred to the bridge clinic had fewer hospital-free days (AOR, 0.54 [95% CI, 0.32-0.92]), more readmissions (AOR, 2.17 [95% CI, 1.25-3.76]), and higher care costs (AOR, 2.25 [95% CI, 1.51-3.35]), with no differences in ED visits (AOR, 1.15 [95% CI, 0.68-1.94]) or deaths (AOR, 0.48 [95% CI, 0.08-2.72]) compared with those receiving usual care. Follow-up calls were completed for 88 participants (26.3%). Participants referred to the bridge clinic were more likely to receive linkage to health care professionals who provided MOUD (AOR, 2.37 [95% CI, 1.32-4.26]) and have more MOUD refills (AOR, 6.17 [95% CI, 3.69-10.30]) and less likely to experience an overdose (AOR, 0.11 [95% CI, 0.03-0.41]). Conclusions and Relevance This randomized clinical trial found that among inpatients with OUD, bridge clinic referrals did not improve hospital LOS. Referrals may improve outpatient metrics but with higher resource use and expenditure. Bending the cost curve may require broader community and regional partnerships. Trial Registration ClinicalTrials.gov Identifier: NCT04084392.
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Affiliation(s)
- David Marcovitz
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mary Lynn Dear
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Donald
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Pain Medicine, Department of Anesthesia, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A. Edwards
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Pain Medicine, Department of Anesthesia, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristopher A. Kast
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thao D. V. Le
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mauli V. Shah
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jason Ferrell
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cheryl Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Reagan Buie
- Office of Episodes of Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Sullivan
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katie D. White
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Grace Van Winkle
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel Wolf
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
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11
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Russo TA, Ritchie HR, Schimmel JJ, Lorenzo MP. Dalbavancin Use in Persons Who Use Drugs May Increase Adherence Without Increasing Cost. J Pharm Technol 2024; 40:3-9. [PMID: 38318254 PMCID: PMC10838542 DOI: 10.1177/87551225231205738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
Background: Dalbavancin (DAL) may obviate concerns regarding misuse of IV access in persons who use drugs (PWUD) completing treatment for infections in an outpatient setting. However, hesitancy to adopt its use exists due to the cost-prohibitive nature of DAL and perceived issues with insurance reimbursement. Our study looks to determine the financial impact of DAL use in actual, measured cost, and health care utilization, data as well as the effect on treatment completion rates. Methods: This is a retrospective cohort comparing cost information and treatment completion rates of patients who received DAL to a random sample of patients with Staphylococcus aureus bacteremia prior to the institutional availability of DAL. Results: From June 2020 to January 2022, 29 PWUD received DAL. Dalbavancin use resulted in the completion of intended duration in 19 patients (66%) compared with 11 (55%) without DAL. The contribution margin with DAL use was $7180 compared with $6655 without; this was not statistically significant (P = 0.47). Conclusion: Dalbavancin use in PWUD may increase treatment completion, with no statistically significant difference in contribution margins.
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Affiliation(s)
| | - Hannah R. Ritchie
- Department of Pharmacy, Baystate Medical Center, Springfield, MA, USA
| | - Jennifer J. Schimmel
- Department of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA
- University of Massachusetts Chan Medical School, Worcester, MA, USA
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12
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Minter DJ, Appa A, Chambers HF, Doernberg SB. Contemporary Management of Staphylococcus aureus Bacteremia-Controversies in Clinical Practice. Clin Infect Dis 2023; 77:e57-e68. [PMID: 37950887 DOI: 10.1093/cid/ciad500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Indexed: 11/13/2023] Open
Abstract
Staphylococcus aureus bacteremia (SAB) carries a high risk for excess morbidity and mortality. Despite its prevalence, significant practice variation continues to permeate clinical management of this syndrome. Since the publication of the 2011 Infectious Diseases Society of America (IDSA) guidelines on management of methicillin-resistant Staphylococcus aureus infections, the field of SAB has evolved with the emergence of newer diagnostic strategies and therapeutic options. In this review, we seek to provide a comprehensive overview of the evaluation and management of SAB, with special focus on areas where the highest level of evidence is lacking to inform best practices.
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Affiliation(s)
- Daniel J Minter
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ayesha Appa
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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13
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Curtis SJ, Colledge-Frisby S, Stewardson AJ, Doyle JS, Higgs P, Maher L, Hickman M, Stoové MA, Dietze PM. Prevalence and incidence of emergency department presentations and hospital separations with injecting-related infections in a longitudinal cohort of people who inject drugs. Epidemiol Infect 2023; 151:e192. [PMID: 37953739 PMCID: PMC10728979 DOI: 10.1017/s0950268823001784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/05/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023] Open
Abstract
People who inject drugs are at risk of acute bacterial and fungal injecting-related infections. There is evidence that incidence of hospitalizations for injecting-related infections are increasing in several countries, but little is known at an individual level. We aimed to examine injecting-related infections in a linked longitudinal cohort of people who inject drugs in Melbourne, Australia. A retrospective descriptive analysis was conducted to estimate the prevalence and incidence of injecting-related infections using administrative emergency department and hospital separation datasets linked to the SuperMIX cohort, from 2008 to 2018. Over the study period, 33% (95%CI: 31-36%) of participants presented to emergency department with any injecting-related infections and 27% (95%CI: 25-30%) were admitted to hospital. Of 1,044 emergency department presentations and 740 hospital separations, skin and soft tissue infections were most common, 88% and 76%, respectively. From 2008 to 2018, there was a substantial increase in emergency department presentations and hospital separations with any injecting-related infections, 48 to 135 per 1,000 person-years, and 18 to 102 per 1,000 person-years, respectively. The results emphasize that injecting-related infections are increasing, and that new models of care are needed to help prevent and facilitate early detection of superficial infection to avoid potentially life-threatening severe infections.
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Affiliation(s)
- Stephanie J. Curtis
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Samantha Colledge-Frisby
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- National Drug Research Institute, Curtin University, Melbourne, VIC, Australia
| | - Andrew J. Stewardson
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Joseph S. Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Lisa Maher
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- The Kirby Institute, Faculty of Medicine, UNSW, Wallace Wurth Building, Kensington, NSW, Australia
| | - Matthew Hickman
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mark A. Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- The Kirby Institute, Faculty of Medicine, UNSW, Wallace Wurth Building, Kensington, NSW, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul M. Dietze
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- National Drug Research Institute, Curtin University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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14
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Freling S, Wald-Dickler N, Banerjee J, Canamar CP, Tangpraphaphorn S, Bruce D, Davar K, Dominguez F, Norwitz D, Krishnamurthi G, Fung L, Guanzon A, Minejima E, Spellberg M, Spellberg C, Baden R, Holtom P, Spellberg B. Real-World Application of Oral Therapy for Infective Endocarditis: A Multicenter, Retrospective, Cohort Study. Clin Infect Dis 2023; 77:672-679. [PMID: 36881940 DOI: 10.1093/cid/ciad119] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND We sought to compare the outcomes of patients treated with intravenous (IV)-only vs oral transitional antimicrobial therapy for infective endocarditis (IE) after implementing a new expected practice within the Los Angeles County Department of Health Services (LAC DHS). METHODS We conducted a multicentered, retrospective cohort study of adults with definite or possible IE treated with IV-only vs oral therapy at the 3 acute care public hospitals in the LAC DHS system between December 2018 and June 2022. The primary outcome was clinical success at 90 days, defined as being alive and without recurrence of bacteremia or treatment-emergent infectious complications. RESULTS We identified 257 patients with IE treated with IV-only (n = 211) or oral transitional (n = 46) therapy who met study inclusion criteria. Study arms were similar for many demographics; however, the IV cohort was older, had more aortic valve involvement, were hemodialysis patients, and had central venous catheters present. In contrast, the oral cohort had a higher percentage of IE caused by methicillin-resistant Staphylococcus aureus. There was no significant difference between the groups in clinical success at 90 days or last follow-up. There was no difference in recurrence of bacteremia or readmission rates. However, patients treated with oral therapy had significantly fewer adverse events. Multivariable regression adjustments did not find significant associations between any selected variables and clinical success across treatment groups. CONCLUSIONS These results demonstrate similar outcomes of real-world use of oral vs IV-only therapy for IE, in accord with prior randomized, controlled trials and meta-analyses.
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Affiliation(s)
- Sarah Freling
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Noah Wald-Dickler
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Josh Banerjee
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Catherine P Canamar
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Soodtida Tangpraphaphorn
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Dara Bruce
- Department of Integrative Anatomical Sciences, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Kusha Davar
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Fernando Dominguez
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Daniel Norwitz
- Department of Integrative Anatomical Sciences, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Ganesh Krishnamurthi
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Lilian Fung
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Ashley Guanzon
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Pharmacy, University of Southern California Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, California, USA
| | - Emi Minejima
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Pharmacy, University of Southern California Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, California, USA
| | - Michael Spellberg
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Catherine Spellberg
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Rachel Baden
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Paul Holtom
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Brad Spellberg
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
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15
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Barnes E, Washburn RG, Russ-Friedman C, Aranda E, Pierre K. Concerns for Discharge of Persons Who Inject Drugs Home With Central Venous Catheters: A Letter to the Editor. J Addict Med 2023; 17:624-625. [PMID: 37788624 DOI: 10.1097/adm.0000000000001166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
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16
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Alrawashdeh M, Rhee C, Klompas M, Larochelle MR, Poland RE, Guy JS, Kimmel SD. Association of Early Opioid Withdrawal Treatment Strategy and Patient-Directed Discharge Among Hospitalized Patients with Opioid Use Disorder. J Gen Intern Med 2023; 38:2289-2297. [PMID: 36788169 PMCID: PMC10406767 DOI: 10.1007/s11606-023-08059-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Medical hospitalizations for people with opioid use disorder (OUD) frequently result in patient-directed discharges (PDD), often due to untreated pain and withdrawal. OBJECTIVE To investigate the association between early opioid withdrawal management strategies and PDD. DESIGN Retrospective cohort study using three datasets representing 362 US hospitals. PARTICIPANTS Adult patients hospitalized between 2009 and 2015 with OUD (as identified using ICD-9-CM codes or inpatient buprenorphine administration) and no PDD on the day of admission. INTERVENTIONS Opioid withdrawal management strategies were classified based on day-of-admission receipt of any of the following treatments: (1) medications for OUD (MOUD) including methadone or buprenorphine, (2) other opioid analgesics, (3) adjunctive symptomatic medications without opioids (e.g., clonidine), and (4) no withdrawal treatment. MAIN MEASURES PDD was assessed as the main outcome and hospital length of stay as a secondary outcome. KEY RESULTS Of 6,715,286 hospitalizations, 127,158 (1.9%) patients had OUD and no PDD on the day of admission, of whom 7166 (5.6%) had a later PDD and 91,051 (71.6%) patients received some early opioid withdrawal treatment (22.3% MOUD; 43.4% opioid analgesics; 5.9% adjunctive medications). Compared to no withdrawal treatment, MOUD was associated with a lower risk of PDD (adjusted odds ratio [aOR] = 0.73, 95%CI 0.68-0.8, p < .001), adjunctive treatment alone was associated with higher risk (aOR = 1.13, 95%CI: 1.01-1.26, p = .031), and treatment with opioid analgesics alone was associated with similar risk (aOR 0.95, 95%CI: 0.89-1.02, p = .148). Among those with PDD, both MOUD (adjusted incidence rate ratio [aIRR] = 1.24, 95%CI: 1.17-1.3, p < .001) and opioid analgesic treatments (aIRR = 1.39, 95%CI: 1.34-1.45, p < .001) were associated with longer hospital stays. CONCLUSIONS MOUD was associated with decreased risk of PDD but was utilized in < 1 in 4 patients. Efforts are needed to ensure all patients with OUD have access to effective opioid withdrawal management to improve the likelihood they receive recommended hospital care.
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Affiliation(s)
- Mohammad Alrawashdeh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
- Jordan University of Science and Technology, Irbid, Jordan.
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marc R Larochelle
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- HCA Healthcare, Nashville, TN, USA
| | | | - Simeon D Kimmel
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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17
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Wurcel AG, DeSimone DC, Marks L, Baddour LM, Sendi P. Which trial do we need? Long-acting glycopeptides versus oral antibiotics for infective endocarditis in patients with substance use disorder. Clin Microbiol Infect 2023; 29:952-954. [PMID: 37044275 DOI: 10.1016/j.cmi.2023.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/14/2023] [Accepted: 04/02/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Daniel C DeSimone
- Division of Public Health, Infectious Diseases and Occupational Medicine, Departments of Medicine and Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | - Laura Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Larry M Baddour
- Division of Public Health, Infectious Diseases and Occupational Medicine, Departments of Medicine and Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
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18
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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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19
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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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20
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Attwood LO, Bryant M, Lee SJ, Vujovic O, Higgs P, Doyle JS, Stewardson AJ. Epidemiology and Management of invasive infections among people who Use drugs (EMU): protocol for a prospective, multicentre cohort study. BMJ Open 2023; 13:e070236. [PMID: 37012020 PMCID: PMC10083776 DOI: 10.1136/bmjopen-2022-070236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
INTRODUCTION People who inject drugs (PWID) are at risk of invasive infections such as bloodstream infections, endocarditis, osteomyelitis and septic arthritis. Such infections require prolonged antibiotic therapy, but there is limited evidence about the optimal care model to deliver to this population. The Epidemiology and Management of invasive infections among people who Use drugs (EMU) study aims to (1) describe the current burden, clinical spectrum, management and outcomes of invasive infections in PWID; (2) determine the impact of currently available models of care on completion of planned antimicrobials for PWID admitted to hospital with invasive infections and (3) determine postdischarge outcomes of PWID admitted with invasive infections at 30 and 90 days. METHODS AND ANALYSIS EMU is a prospective multicentre cohort study of Australian public hospitals who provide care to PWIDs with invasive infections. All patients who have injected drugs in the previous six months and are admitted to a participating site for management of an invasive infection are eligible. EMU has two components: (1) EMU-Audit will collect information from medical records, including demographics, clinical presentation, management and outcomes; (2) EMU-Cohort will augment this with interviews at baseline, 30 and 90 days post-discharge, and data linkage examining readmission rates and mortality. The primary exposure is antimicrobial treatment modality, categorised as inpatient intravenous antimicrobials, outpatient antimicrobial therapy, early oral antibiotics or lipoglycopeptide. The primary outcome is confirmed completion of planned antimicrobials. We aim to recruit 146 participants over a 2-year period. ETHICS AND DISSEMINATION EMU has been approved by the Alfred Hospital Human Research Ethics Committee (Project number 78815.) EMU-Audit will collect non-identifiable data with a waiver of consent. EMU-Cohort will collect identifiable data with informed consent. Findings will be presented at scientific conferences and disseminated by peer-review publications. TRIAL REGISTRATION NUMBER ACTRN12622001173785; Pre-results.
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Affiliation(s)
- Lucy O Attwood
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mellissa Bryant
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Sue J Lee
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Olga Vujovic
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Joseph S Doyle
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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21
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Oliver NT, Skalweit MJ. Outpatient Parenteral Antibiotic Therapy in Older Adults. Infect Dis Clin North Am 2023; 37:123-137. [PMID: 36805009 DOI: 10.1016/j.idc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) for older adults is a complex process that involves multiple stakeholders and care coordination, but it is a useful and patient-centered tool with opportunities for the treatment of complicated infections, improved patient satisfaction, and reduced health-care costs. Older age should not be an exclusion for OPAT but rather prompt the OPAT provider to thoroughly evaluate candidacy and safety. Amid the on-going COVID-19 pandemic, innovations in OPAT are needed to shepherd OPAT care into a more patient-centered, thoughtful practice, whereas minimizing harm to older patients from unnecessary health-care exposure and thus health-care associated infections.
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Affiliation(s)
- Nora T Oliver
- Section of Infectious Diseases, Atlanta VA Medical Center, 1670 Clairmont Road, RIM 111, Decatur, GA 30033, USA.
| | - Marion J Skalweit
- Department of Medicine and Biochemistry, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland OH 44106, USA
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22
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Eckland A, Kohut M, Stoddard H, Burris D, Chessa F, Sikka MK, Solomon DA, Kershaw CM, Eaton EF, Hutchinson R, Friedmann PD, Stopka TJ, Fairfield KM, Thakarar K. "I know my body better than anyone else": a qualitative study of perspectives of people with lived experience on antimicrobial treatment decisions for injection drug use-associated infections. Ther Adv Infect Dis 2023; 10:20499361231197065. [PMID: 37693858 PMCID: PMC10492466 DOI: 10.1177/20499361231197065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Background People who inject drugs (PWID) are at risk for severe bacterial and fungal infections including skin and soft tissue infections, endocarditis, and osteomyelitis. PWID have high rates of self-directed discharge and are often not offered outpatient antimicrobial therapies, despite studies showing their efficacy and safety in PWID. This study fills a gap in knowledge of patient and community partner perspectives on treatment and discharge decision making for injection drug use (IDU)-associated infections. Methods We conducted semi-structured interviews with patients (n = 10) hospitalized with IDU-associated infections and community partners (n = 6) in the Portland, Maine region. Community partners include peer support workers at syringe services programs (SSPs) and outreach specialists working with PWID. We transcribed and thematically analyzed interviews to explore perspectives on three domains: perspectives on long-term hospitalization, outpatient treatment options, and patient involvement in decision making. Results Participants noted that stigma and inadequate pain management created poor hospitalization experiences that contributed to self-directed discharge. On the other hand, patients reported hospitalization provided opportunities to connect to substance use disorder (SUD) treatment and protect them from outside substance use triggers. Many patients expressed interest in outpatient antimicrobial treatment options conditional upon perceived efficacy of the treatment, perceived ability to complete treatment, and available resources and social support. Finally, both patients and community partners emphasized the importance of autonomy and inclusion in medical decision making. Although some participants acknowledged their SUD, withdrawal symptoms, or undertreated pain might interfere with decision making, they felt these medical conditions were not justification for health care professionals withholding treatment options. They recommended open communication to build trust and reduce harms. Conclusion Patients with IDU-associated infections desire autonomy, respect, and patient-centered care from healthcare workers, and may self-discharge when needs or preferences are not met. Involving patients in treatment decisions and offering outpatient antimicrobial options may result in better outcomes. However, patient involvement in decision making may be complicated by many contextual factors unique to each patient, suggesting a need for shared decision making to meet the needs of hospitalized patients with IDU-associated infections.
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Affiliation(s)
- Amy Eckland
- Tufts University School of Medicine, Boston, MA, USA
| | - Michael Kohut
- Maine Health Institute for Research, Center for Interdisciplinary Population and Health Research, Portland, ME, USA
| | - Henry Stoddard
- Maine Health Institute for Research, Center for Interdisciplinary Population and Health Research, Portland, ME, USA
| | - Deb Burris
- Maine Health Institute for Research, Center for Interdisciplinary Population and Health Research, Portland, ME, USA
| | - Frank Chessa
- Tufts University School of Medicine, Boston, MA, USA
- Maine Medical Center, Portland, ME, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Daniel A. 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 F. Eaton
- Division of Infectious Disease, University of Alabama, Birmingham, AL, USA
| | - Rebecca Hutchinson
- Tufts University School of Medicine, Boston, MA, USA
- Maine Health Institute for Research, Center for Interdisciplinary Population and Health Research, Portland, ME, USA
- Maine Medical Center, Portland, ME, USA
| | - Peter D. Friedmann
- Office of Research, Baystate Health and UMass Chan Medical School—Baystate, Springfield, MA, USA
| | - Thomas J. Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Kathleen M. Fairfield
- Tufts University School of Medicine, Boston, MA, USA
- Maine Health Institute for Research, Center for Interdisciplinary Population and Health Research, Portland, ME, USA
- Maine Medical Center, South Portland, ME, USA
| | - Kinna Thakarar
- Maine Medical Center, 41 Donald B. Dean Drive, Suite B, South Portland, ME 04106, USA
- Tufts University School of Medicine, Boston MA, USA
- Maine Health Institute for Research, Center for Interdisciplinary Population and Health Research, Portland, ME, USA
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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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24
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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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25
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Narayanan S, Ching PR, Traver EC, George N, Amoroso A, Kottilil S. Predictors of Nonadherence Among Patients With Infectious Complications of Substance Use Who Are Discharged on Parenteral Antimicrobial Therapy. Open Forum Infect Dis 2022; 10:ofac633. [PMID: 36686627 PMCID: PMC9845962 DOI: 10.1093/ofid/ofac633] [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: 04/25/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
Background The management of invasive infections related to substance use disorder (SUD) needing parenteral antimicrobial therapy is challenging and may have poor treatment outcomes including nonadherence and lack of completion of parenteral antimicrobial therapy. Methods In this retrospective cohort of 201 patients with invasive infections related to SUD, we looked at frequency and determinants of unfavorable outcomes including nonadherence. Results Seventy-nine percent of patients with SUD-related infection completed parenteral antibiotic therapy in skilled nursing facilities. A total of 21.5% of patient episodes had documentation of nonadherence. Nonadherence was higher in patients with active injection drug use (IDU) (28.5% versus 15% in non IDU; adjusted odds ratio [OR] 2.36; 95% confidence interval [CI], 1.1-5.5; P = .024), patients with active SUD in the prior year (24.5% vs 11%, P = .047), patients with use of more than 1 illicit substance (30.3% vs 17%, P = .031), as well as in people experiencing homelessness (32.8% vs 15.7% in stably housed, P = .005). In a multivariate model, nonadherence was significantly associated with IDU (OR, 2.38; 95% CI, 1.03-5.5) and homelessness (OR, 2.25; 95% CI, 1.01-4.8) Medication for opioid use disorder was prescribed at discharge in 68% of overall cohort and was not associated with improved outcomes for any of the above groups. Conclusions Nonadherence to parenteral antimicrobial therapy is high in the most vulnerable patients with unstable high-risk SUD and adverse social determinants of health.
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Affiliation(s)
- Shivakumar Narayanan
- Correspondence: Shivakumar Narayanan, MD, Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, S211B, Baltimore, MD 21201 ()
| | - Patrick R Ching
- Division of Infectious Diseases, Department of Medicine, Washington UniversitySchool of Medicine, St. Louis, Missouri, USA
| | - Edward C Traver
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nivya George
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anthony Amoroso
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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26
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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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Chase J, Nicholson M, Dogherty E, Garrod E, Hill J, Brar R, Weaver V, Connors WJ. Self-injecting non-prescribed substances into vascular access devices: a case study of one health system's ongoing journey from clinical concern to practice and policy response. Harm Reduct J 2022; 19:130. [PMID: 36424629 PMCID: PMC9694828 DOI: 10.1186/s12954-022-00707-4] [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: 01/26/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Overdose-associated deaths and morbidity related to substance use is a global public health emergency with devastating social and economic costs. Complications of substance use are most pronounced among people who inject drugs (PWID), particularly infections, resulting in increased risk of hospitalization. PWID often require intravenous access for medical treatments such as antibiotics; however, vascular access may be limited due to the impacts of long-term self-venipuncture. While vascular access devices including peripherally inserted central catheters (PICCs) allow reliable and sustained routes of administration for indicated therapies, the use of PICCs among PWID presents unique challenges. The incidence and risks associated with self-injecting non-prescribed substances into vascular access devices (SIVAD) is one such concern for which there is limited evidence and absence of formal practice guidance. CASE PRESENTATION We report the experience of a multidisciplinary team at a health organization in Vancouver, Canada, working to characterize the incidence, patient and healthcare provider perspectives, and overall impact of SIVAD. The case study of SIVAD begins with a patient's perspective, including patient rationale for SIVAD, understanding of risks and the varying responses given by healthcare providers following disclosure of SIVAD. Using the limited literature available on the subject, we summarize the intersection of SIVAD and substance use and outline known and anticipated health risks. The case study is further contextualized by experience from a Vancouver in-hospital Overdose Prevention Site (OPS), where 37% of all individual visits involve SIVAD. The case study concludes by describing the systematic process by which local clinical guidance for SIVAD harm reduction was developed with stakeholder engagement, medical ethics consultation, expert consensus guideline development and implementation with staff education and planned research evaluation. CONCLUSION SIVAD is encountered with enough frequency in an urban healthcare setting in Vancouver, Canada, to warrant an organizational approach. This case study aims to enhance appreciation of SIVAD as a common and complex clinical issue with anticipated health risks. The authors conclude that using a harm reduction lens for SIVAD policy and research can provide benefit to clinicians and patients by offering a clear and a consistent healthcare response to this common issue.
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Affiliation(s)
- Jocelyn Chase
- grid.17091.3e0000 0001 2288 9830Department of Medicine, University of British Columbia, Vancouver, Canada ,grid.416553.00000 0000 8589 2327Division of Geriatric Medicine, St. Paul’s Hospital, Providence Health Care, Vancouver, BC Canada ,grid.415289.30000 0004 0633 9101Providence Health Care, Vancouver, BC Canada
| | - Melissa Nicholson
- grid.415289.30000 0004 0633 9101Providence Health Care, Vancouver, BC Canada
| | - Elizabeth Dogherty
- grid.415289.30000 0004 0633 9101Providence Health Care, Vancouver, BC Canada
| | - Emma Garrod
- grid.415289.30000 0004 0633 9101Providence Health Care, Vancouver, BC Canada ,grid.511486.f0000 0004 8021 645XBritish Columbia Centre On Substance Use, Vancouver, Canada
| | - Jocelyn Hill
- grid.415289.30000 0004 0633 9101Providence Health Care, Vancouver, BC Canada
| | - Rupinder Brar
- grid.17091.3e0000 0001 2288 9830Department of Medicine, University of British Columbia, Vancouver, Canada ,grid.415289.30000 0004 0633 9101Providence Health Care, Vancouver, BC Canada ,grid.498786.c0000 0001 0505 0734Vancouver Coastal Health, Vancouver, BC Canada ,grid.415289.30000 0004 0633 9101Inter-Department Division of Addiction Medicine, Providence Health Care, Vancouver, BC Canada
| | - Victoria Weaver
- grid.17091.3e0000 0001 2288 9830Department of Medicine, University of British Columbia, Vancouver, Canada ,grid.415289.30000 0004 0633 9101Providence Health Care, Vancouver, BC Canada ,grid.511486.f0000 0004 8021 645XBritish Columbia Centre On Substance Use, Vancouver, Canada ,grid.415289.30000 0004 0633 9101Inter-Department Division of Addiction Medicine, Providence Health Care, Vancouver, BC Canada ,grid.416553.00000 0000 8589 2327Division of Infectious Diseases, St. Paul’s Hospital, Providence Health Care, Vancouver, BC Canada
| | - William J. Connors
- grid.17091.3e0000 0001 2288 9830Department of Medicine, University of British Columbia, Vancouver, Canada ,grid.415289.30000 0004 0633 9101Providence Health Care, Vancouver, BC Canada ,grid.416553.00000 0000 8589 2327Division of Infectious Diseases, St. Paul’s Hospital, Providence Health Care, Vancouver, BC Canada
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Langham FJ, Curtis SJ, Tang MJ, Jomon B, Doyle JS, Vujovic O, Stewardson AJ. Acute injection-related infections requiring hospitalisation among people who inject drugs: Clinical features, microbiology and management. Drug Alcohol Rev 2022; 41:1543-1553. [PMID: 36053863 PMCID: PMC9804300 DOI: 10.1111/dar.13525] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION People who inject drugs are at risk of hospitalisation with injection-related infections (IRI). We audited the clinical features, microbiology and management of IRI at a tertiary service in Melbourne to describe the burden and identify quality improvement opportunities. METHODS We performed retrospective review of IRI admissions from January 2017 to April 2019. We extracted admissions where ICD-10 codes or triage text suggested injecting drug use, and the diagnosis suggested IRI. We reviewed these for eligibility and extracted data using a standardised form. We performed mixed-effects logistic regression to determine predictors of unplanned discharge. RESULTS From 574 extracted candidate admissions, 226 were eligible, representing 178 patients. Median age was 41 years (interquartile range 36-47), 66% (117/178) male and 49% (111/226) had unstable housing. Over 50% (96/178) had a psychiatric diagnosis and 35% (62/178) were on opioid agonist therapy (OAT) on admission. Skin and soft tissue infection was the most common IRI (119/205, 58%), followed by bacteraemia (36/205, 18%) and endocarditis (26/205, 13%). Management included addictions review (143/226, 63%), blood-borne virus screening (115/226, 51%), surgery (77/226, 34%) and OAT commencement (68/226, 30%). Aggression events (54/226, 15%) and unplanned discharge (69/226, 30%) complicated some admissions. Opioid use without OAT was associated with almost 3-fold increased odds of unplanned discharge compared to no opioid use (odds ratio 2.90, 95% confidence interval 1.23, 6.85, p = 0.015). DISCUSSION AND CONCLUSION Comorbidities associated with IRI may be amenable to opportunistic intervention during hospitalisation. Further research is needed to develop optimal models of care for this vulnerable patient group.
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Affiliation(s)
- Freya J. Langham
- Department of Infectious DiseasesThe Alfred Hospital and Monash UniversityMelbourneAustralia
| | - Stephanie J. Curtis
- Department of Infectious DiseasesThe Alfred Hospital and Monash UniversityMelbourneAustralia
| | - Mei Jie Tang
- Department of Infectious DiseasesThe Alfred Hospital and Monash UniversityMelbourneAustralia
| | - Bismi Jomon
- Data and AnalyticsThe Alfred HospitalMelbourneAustralia
| | - Joseph S. Doyle
- Department of Infectious DiseasesThe Alfred Hospital and Monash UniversityMelbourneAustralia
| | - Olga Vujovic
- Department of Infectious DiseasesThe Alfred Hospital and Monash UniversityMelbourneAustralia
| | - Andrew J. Stewardson
- Department of Infectious DiseasesThe Alfred Hospital and Monash UniversityMelbourneAustralia
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29
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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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30
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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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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: 41] [Impact Index Per Article: 20.5] [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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Nolan S, Kelian S, Kerr T, Young S, Malmgren I, Ghafari C, Harrison S, Wood E, Lysyshyn M, Holliday E. Harm reduction in the hospital: An overdose prevention site (OPS) at a Canadian hospital. Drug Alcohol Depend 2022; 239:109608. [PMID: 36063622 PMCID: PMC9970047 DOI: 10.1016/j.drugalcdep.2022.109608] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/19/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Substance use management in hospitals can be challenging. In response, a Canadian hospital opened an overdose prevention site (OPS) where community members and hospital inpatients can inject pre-obtained illicit drugs under supervision. This study aims to: (1) describe program utilization patterns; (2) characterize OPS visits; and (3) evaluate overdose events and related outcomes. METHODS A retrospective chart review was completed at one hospital in Vancouver, Canada. All community members and hospital inpatients who visited the OPS between May 2018 and July 2019 were included. Client measures included: hospital inpatient status, use of intravenous access line for drug injection, and substances used. Program measures included: number of visits (daily/monthly), overdose (fatal/non-fatal) events and overdose-related outcomes. RESULTS Overall, 11,673 OPS visits were recorded. Monthly visits increased from 306 to 1198 between May 2018 and July 2019 respectively. On average, 26 visits occurred daily. Among all visits, 20% reported being a hospital inpatient, and 5% reported using a hospital intravenous access line for drug injection. Opioids (56%) and stimulants (24%) were the most common substances used. Overall 39 overdose events occurred - 82% required naloxone reversal, 28% required transfer to the hospital's emergency department and none were fatal. Overdose events were more common among hospital inpatients compared to community clients (6.6 vs 2.2 per 1000 visits respectively; p value = 0.046). CONCLUSIONS This unique OPS is an example of a hospital-based harm reduction initiative. Use of the site increased over time among both groups with no fatal overdose events occurring.
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Affiliation(s)
- Seonaid Nolan
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, V6Z 2A9 BC, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 553B-1081 Burrard Street, Vancouver, V6Z 1Y6 BC, Canada.
| | - Salpy Kelian
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, V6Z 2A9 BC, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, V6Z 2A9 BC, Canada
| | - Samantha Young
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 553B-1081 Burrard Street, Vancouver, V6Z 1Y6 BC, Canada; Providence Health Care, 1081 Burrard Street, Vancouver, V6Z 1Y6 BC, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, 155 College Street, 6th floor, Toronto, M5T 3M7 ON, Canada; General Internal Medicine, St. Michael's Hospital, Unity Health, 30 Bond Street, Toronto, M5B 1W8 ON, Canada
| | - Isaac Malmgren
- General Internal Medicine, St. Michael's Hospital, Unity Health, 30 Bond Street, Toronto, M5B 1W8 ON, Canada
| | - Cher Ghafari
- Raincity Housing and Support Society, 616 Powell Street, Vancouver, V6A 1H4 BC, Canada
| | - Scott Harrison
- Providence Health Care, 1081 Burrard Street, Vancouver, V6Z 1Y6 BC, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, V6Z 2A9 BC, Canada
| | - Mark Lysyshyn
- Vancouver Coastal Health, 800-601 West Broadway, V5Z 4C2 BC, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, V6T 1Z3 BC, Canada
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Calcaterra SL, Lockhart S, Callister C, Hoover K, Binswanger IA. Opioid Use Disorder Treatment Initiation and Continuation: a Qualitative Study of Patients Who Received Addiction Consultation and Hospital-Based Providers. J Gen Intern Med 2022; 37:2786-2794. [PMID: 34981359 PMCID: PMC8722657 DOI: 10.1007/s11606-021-07305-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/23/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hospitalizations related to opioid use disorder (OUD) are rising. Addiction consultation services (ACS) increasingly provide OUD treatment to hospitalized patients, but barriers to initiating and continuing medications for OUD remain. We examined facilitators and barriers to hospital-based OUD treatment initiation and continuation from the perspective of patients and healthcare workers in the context of an ACS. METHODS In this qualitative study, we sought input using key informant interviews and focus groups from patients who received care from an ACS during their hospitalization and from hospitalists, pharmacists, social workers, and nurses who work in the hospital setting. A multidisciplinary team coded and analyzed transcripts using a directed content analysis. FINDINGS We conducted 20 key informant interviews with patients, nine of whom were interviewed following hospital discharge and 12 of whom were interviewed during a rehospitalization. We completed six focus groups and eight key informant interviews with hospitalists and hospital-based medical staff (n = 62). Emergent themes related to hospital-based OUD treatment included the following: the benefit of an ACS to facilitate OUD treatment engagement; expanded use of methadone or buprenorphine to treat opioid withdrawal; the triad of hospitalization, self-efficacy, and easily accessible, patient-centered treatment motivates change in opioid use; adequate pain control and stabilization of mental health conditions among patients with OUD contributed to opioid agonist therapy (OAT) continuation; and stable housing and social support are prerequisites for OAT uptake and continuation. CONCLUSION Modifiable factors which facilitate hospital-based OUD treatment initiation and continuation include availability of in-hospital addiction expertise to offer easily accessible, patient-centered treatment and the use of methadone or buprenorphine to manage opioid withdrawal. Further research and public policy efforts are urgently needed to address reported barriers to hospital-based OUD treatment initiation and continuation which include unstable housing, poorly controlled chronic medical and mental illness, and lack of social support.
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Affiliation(s)
- Susan L Calcaterra
- Division of General Internal Medicine, University of Colorado, 8th Floor, Academic Office 1, Mailstop B180, 12631 E 17th Ave, Aurora, CO, 80045, USA.
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA.
| | - Steve Lockhart
- Adult and Child Consortium for Health Outcomes Research and Delivery Service, Univeristy of Colorado, School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Kaitlyn Hoover
- Clinical Science Graduate Program, University of Colorado, Aurora, CO, USA
| | - Ingrid A Binswanger
- Division of General Internal Medicine, University of Colorado, 8th Floor, Academic Office 1, Mailstop B180, 12631 E 17th Ave, Aurora, CO, 80045, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado Permanente Medical Group, Aurora, CO, USA
- Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Attwood LO, McKechnie M, Vujovic O, Higgs P, Lloyd‐Jones M, Doyle JS, Stewardson AJ. Review of management priorities for invasive infections in people who inject drugs: highlighting the need for patient-centred multidisciplinary care. Med J Aust 2022; 217:102-109. [PMID: 35754144 PMCID: PMC9539935 DOI: 10.5694/mja2.51623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/18/2022] [Accepted: 05/30/2022] [Indexed: 09/26/2023]
Abstract
There has been a global increase in the burden of invasive infections in people who inject drugs (PWID). It is essential that patient-centred multidisciplinary care is provided in the management of these infections to engage PWID in care and deliver evidence-based management and preventive strategies. The multidisciplinary team should include infectious diseases, addictions medicine (inclusive of alcohol and other drug services), surgery, psychiatry, pain specialists, pharmacy, nursing staff, social work and peer support workers (where available) to help address the comorbid conditions that may have contributed to the patient's presentation. PWID have a range of antimicrobial delivery options that can be tailored in a patient-centred manner and thus are not limited to prolonged hospital admissions to receive intravenous antimicrobials for invasive infections. These options include discharge with outpatient parenteral antimicrobial therapy, long-acting lipoglycopeptides (dalbavancin and oritavancin) and early oral antimicrobials. Open and respectful discussion with PWID including around harm reduction strategies may decrease the risk of repeat presentations with injecting-related harms.
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Affiliation(s)
| | | | - Olga Vujovic
- Alfred HealthMelbourneVIC
- Monash UniversityMelbourneVIC
| | - Peter Higgs
- Burnet InstituteMelbourneVIC
- La Trobe UniversityMelbourneVIC
| | | | - Joseph S Doyle
- Alfred HealthMelbourneVIC
- Monash UniversityMelbourneVIC
- Burnet InstituteMelbourneVIC
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35
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Carswell N, Angermaier G, Castaneda C, Delgado F. Management of opioid withdrawal and initiation of medications for opioid use disorder in the hospital setting. Hosp Pract (1995) 2022; 50:251-258. [PMID: 35837678 DOI: 10.1080/21548331.2022.2102776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Opioid use disorder (OUD) has become increasingly prevalent among hospitalized patients in the United States and globally. As its prevalence increases, this provides a valuable opportunity for clinicians in the hospital setting to engage and initiate management and treatment of OUD. This article aims to provide hospitalists and other clinicians working in the hospital with a narrative review of the management of opioid withdrawal and the initiation of medications for opioid use disorder (MOUD) in the hospital and provide an update on a novel low dose approach to buprenorphine induction (also commonly referred to as the "microinduction" method). Management can initially include treating withdrawal symptoms with opioids as well as with a combination of non-opioid medications such as alpha 2 agonists, benzodiazepines, and/or antiemetics as needed. Besides simply managing withdrawal symptoms, clinicians can further improve the care of patients with OUD through initiating maintenance treatment with MOUD, ideally with opioids used in the initial management of withdrawal. Opioid detoxification is an inferior method of primary treatment and is associated with relapse and poor outcomes. In contrast, treatment with MOUD using methadone or buprenorphine is associated with superior treatment outcomes and reduced relapse compared to detoxification alone. Treatment with MOUD using methadone or buprenorphine can be successfully used in the hospital setting. A novel low dose approach to buprenorphine induction may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids, which makes this an attractive option in the hospital where patients are frequently on opioids for acutely painful conditions. The hospital setting also provides a valuable opportunity for clinicians to address harm reduction in patients with OUD. Finally, clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up.
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Affiliation(s)
- Nico Carswell
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Giselle Angermaier
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Christopher Castaneda
- Department of Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Fabrizzio Delgado
- Department of Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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36
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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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37
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Stockwell E, Rinehart K, Boes E, Pietrok A, Hewlett A, Hartman C, Streubel P. Outcomes of Orthopaedic Infections in Recreational Intravenous Drug Users Requiring Long-term Antibiotic Treatment. J Am Acad Orthop Surg Glob Res Rev 2022; 6:e22.00108. [PMID: 35696313 PMCID: PMC9191380 DOI: 10.5435/jaaosglobal-d-22-00108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/17/2022] [Indexed: 06/15/2023]
Abstract
Patients who participate in recreational injection drug use (RIVDU) have an increased risk of orthopaedic infections requiring prolonged treatment with intravenous antibiotics. This study reviews clinical outcomes and complications in RIVDU and have orthopaedic infections requiring long term antibiotic therapy (>4 weeks) and compares these outcomes to non-RIVDU patients. In this retrospective review, patients were divided into cohorts based on RIVDU history; the RIVDU cohort was further divided into subcohorts based on treatment location. Cohorts and subcohorts were compared to evaluate clinical outcomes. Between the two main cohorts, there was a statistically significant difference in treatment compliance (P = 0.0012) and no statistically significant differences for infection resolution at 6- or 12-month follow-up, hospital readmission, or mortality. At the 6-month follow-up, RIVDU patients who remained inpatient had 100% resolution of infection, which was significantly better than the resolution of all other cohorts (P = 0.0019). No differences were observed between the remaining subcohorts for resolution of infection by 12 months, catheter complications, or loss to follow-up. Our findings demonstrate an increased rate of failure in outpatient parenteral antibiotic therapy in RIVDU patients, and this population has better clinical outcomes when they remain inpatient for the duration of treatment.
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38
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Diagnosis and Management of Infective Endocarditis in People Who Inject Drugs: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:2037-2057. [PMID: 35589166 DOI: 10.1016/j.jacc.2022.03.349] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/16/2022]
Abstract
The incidence of injection drug use-associated infective endocarditis has been increasing rapidly over the last decade. Patients with drug use-associated infective endocarditis present an increasingly common clinical challenge with poor long-term outcomes and high reinfection and readmission rates. Their care raises issues unique to this population, including antibiotic selection and administration, indications for and ethical issues surrounding surgical intervention, and importantly management of the underlying substance use disorder to minimize the risk of reinfection. Successful treatment of these patients requires a broad understanding of these concerns. A multidisciplinary, collaborative approach providing a holistic approach to treating both the acute infection along with effectively addressing substance use disorder is needed to improve short-term and longer-term outcomes.
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Rivera CG, Beieler AM, Childs-Kean LM, Cortés-Penfield N, Idusuyi AM, Keller SC, Rajapakse NS, Ryan KL, Yoke LH, Mahoney MV. A Bundle of the Top 10 OPAT Publications in 2021. Open Forum Infect Dis 2022; 9:ofac242. [PMID: 35855003 PMCID: PMC9277647 DOI: 10.1093/ofid/ofac242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/07/2022] [Indexed: 11/16/2022] Open
Abstract
As outpatient parenteral antimicrobial therapy (OPAT) becomes more common, it may be difficult to stay current with recent related publications. A group of multidisciplinary OPAT clinicians reviewed and ranked all OPAT publications published in 2021. This article provides a high-level summary of the OPAT manuscripts that were voted the “top 10” publications of 2021.
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Affiliation(s)
- Christina G. Rivera
- Department of Pharmacy, Mayo Clinic, Rochester, MN, United States. Twitter: @MsSmallsO
| | - Alison M. Beieler
- Harborview Medical Center, Seattle, WA, United States. Twitter: @ABeieler
| | - Lindsey M. Childs-Kean
- College of Pharmacy, University of Florida, Gainesville, FL, United States. Twitter: @corevalues5
| | | | - Ann-Marie Idusuyi
- Department of Pharmacy, Infectious Diseases and Immunology Center, The Miriam Hospital, Providence RI, United States. Twitter: @AnnMarieI3
| | - Sara C. Keller
- Associate Professor, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, United States. Twitter: @SaraKellerMD1
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States
| | - Nipunie S. Rajapakse
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children’s Center, Rochester, MN, United States. Twitter: @nrajapakseMD
| | - Keenan L. Ryan
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, New Mexico, United States. Twitter: @keenanconazole
| | - Leah H. Yoke
- Vaccine and Infectious Disease Division, Fred Hutch Cancer Research Center; Allergy and Infectious Disease Division, University of Washington, United States. Twitter: @LeahYoke
| | - Monica V. Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, United States. Twitter: @mmPharmD
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Vyas DA, Marinacci L, Bearnot B, Wakeman SE, Sundt TM, Jassar AS, Triant VA, Nelson SB, Dudzinski DM, Paras ML. Creation of a Multidisciplinary Drug Use Endocarditis Treatment (DUET) Team: Initial Patient Characteristics, Outcomes, and Future Directions. Open Forum Infect Dis 2022; 9:ofac047. [PMID: 35252467 PMCID: PMC8890495 DOI: 10.1093/ofid/ofac047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background Consensus guidelines recommend multidisciplinary models to manage infective endocarditis, yet often do not address the unique challenges of treating people with drug use–associated infective endocarditis (DUA-IE). Our center is among the first to convene a Drug Use Endocarditis Treatment (DUET) team composed of specialists from Infectious Disease, Cardiothoracic Surgery, Cardiology, and Addiction Medicine. Methods The objective of this study was to describe the demographics, infectious characteristics, and clinical outcomes of the first cohort of patients cared for by the DUET team. This was a retrospective chart review of patients referred to the DUET team between August 2018 and May 2020 with DUA-IE. Results Fifty-seven patients were presented to the DUET team between August 2018 and May 2020. The cohort was young, with a median age of 35, and injected primarily opioids (82.5% heroin/fentanyl), cocaine (52.6%), and methamphetamine (15.8%). Overall, 14 individuals (24.6%) received cardiac surgery, and the remainder (75.4%) were managed with antimicrobial therapy alone. Nearly 65% of individuals were discharged on medication for opioid use disorder, though less than half (36.8%) were discharged with naloxone and only 1 patient was initiated on HIV pre-exposure prophylaxis. Overall, the cohort had a high rate of readmission (42.1%) within 90 days of discharge. Conclusions Multidisciplinary care models such as the DUET team can help integrate nuanced decision-making from numerous subspecialties. They can also increase the uptake of addiction medicine and harm reduction tools, but further efforts are needed to integrate harm reduction strategies and improve follow-up in future iterations of the DUET team model.
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Affiliation(s)
- Darshali A Vyas
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lucas Marinacci
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Benjamin Bearnot
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah E Wakeman
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thoralf M Sundt
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arminder S Jassar
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Virginia A Triant
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sandra B Nelson
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David M Dudzinski
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Molly L Paras
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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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] [MESH Headings] [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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Adams JW, Savinkina A, Hudspeth JC, Gai MJ, Jawa R, Marks LR, Linas BP, Hill A, Flood J, Kimmel S, Barocas JA. Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use-Associated Infective Endocarditis. JAMA Netw Open 2022; 5:e220541. [PMID: 35226078 PMCID: PMC8886538 DOI: 10.1001/jamanetworkopen.2022.0541] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/10/2022] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Emerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use-associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown. OBJECTIVE To compare the added value of inpatient addiction care services and the cost-effectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE. DESIGN, SETTING, AND PARTICIPANTS This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Cost-effectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty. INTERVENTIONS The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy). MAIN OUTCOMES AND MEASURES Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs). RESULTS All modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416 570 per person, with 77.6% of hospitalized patients completing treatment. Life expectancy was extended by each alternative strategy. The partial oral antibiotic strategy yielded the highest treatment completion rate (80.3%) compared with the OPAT strategy (78.8%) and the usual care/addiction care strategy (77.6%). The OPAT strategy was the least expensive at $412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163 370 per LY. Increasing IDU-IE treatment uptake and decreasing treatment discontinuation made the partial oral antibiotic strategy more cost-effective compared with the OPAT strategy. When assuming that all patients with IDU-IE were eligible to receive partial oral antibiotic therapy, the strategy was cost-saving and resulted in 0.0247 additional discounted LYs. When treatment discontinuation was decreased from 3.30% to 2.65% per week, the partial oral antibiotic strategy was cost-effective compared with OPAT at the $100 000 per LY threshold. CONCLUSIONS AND RELEVANCE In this decision analytical modeling study, incorporation of OPAT or partial oral antibiotic approaches along with addiction care services for the treatment of patients with IDU-IE was associated with increases in the number of people completing treatment, decreases in mortality, and savings in cost compared with the usual care strategy of providing inpatient IV antibiotic therapy alone.
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Affiliation(s)
- Joëlla W. Adams
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- RTI International, Research Triangle Park, North Carolina
| | - Alexandra Savinkina
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - James C. Hudspeth
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Mam Jarra Gai
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Raagini Jawa
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Laura R. Marks
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Benjamin P. Linas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Alison Hill
- Population Health Analytics Division, Boston Medical Center, Boston, Massachusetts
| | - Jason Flood
- Population Health Analytics Division, Boston Medical Center, Boston, Massachusetts
| | - Simeon Kimmel
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Section of General Medicine, Boston Medical Center, Boston, Massachusetts
| | - Joshua A. Barocas
- Division of General Internal Medicine, Anschutz Medical Campus, University of Colorado, Aurora
- Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado, 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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Marks LR, Nolan NS, Liang SY, Durkin MJ, Weimer MB. Infectious Complications of Injection Drug Use. Med Clin North Am 2022; 106:187-200. [PMID: 34823730 DOI: 10.1016/j.mcna.2021.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The opioid overdose epidemic is one of the leading causes of death in adults. Its devastating effects have included not only a burgeoning overdose crisis but also multiple converging infectious diseases epidemics. The use of both opioids and other substances through intravenous (IV) administration places individuals at increased risks of infectious diseases ranging from invasive bacterial and fungal infections to human immunodeficiency virus (HIV) and viral hepatitis. In 2012, there were 530,000 opioid use disorder (OUD)-related hospitalizations in the United States (US), with $700 million in costs associated with OUD-related infections. The scale of the crisis has continued to increase since that time, with hospitalizations for injection drug use-related infective endocarditis (IDU-IE) increasing by as much as 12-fold from 2010 to 2015. Deaths from IDU-IE alone are estimated to result in over 7,260,000 years of potential life lost over the next 10 years. There have been high-profile injection-related HIV outbreaks, and injection drug use (IDU) is now the most common risk factor for hepatitis C virus (HCV). As this epidemic continues to grow, clinicians in all aspects of medical care are increasingly confronted with infectious complications of IDU. This review will describe the pathogenesis, clinical syndromes, epidemiology, and models of treatment for common infectious complications among persons who inject drugs (PWIDs).
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Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110-1093, USA.
| | - Nathanial S Nolan
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110-1093, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110-1093, USA; Division of Emergency Medicine, Washington University in St. Louis School of Medicine
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110-1093, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, E.S. Harkness Memorial Building A, 367 Cedar Street, Suite 417A, New Haven, CT 06510, 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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Fanucchi LC, Murphy SM, Surratt H, Kapadia SN, Walsh SL, Grubbs JA, Thornton AC, Nuzzo P, Lofwall MR. Design and protocol of the Buprenorphine plus Outpatient Parenteral Antimicrobial Therapy (B-OPAT) study: a randomized clinical trial of integrated outpatient treatment of opioid use disorder and severe, injection-related infections. Ther Adv Infect Dis 2022; 9:20499361221108005. [PMID: 35847566 PMCID: PMC9277431 DOI: 10.1177/20499361221108005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/01/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction A marked increase in hospitalizations for severe, injection-related infections (SIRI) has been associated with the opioid epidemic. Outpatient parenteral antibiotic therapy (OPAT) is typically not offered to persons with opioid use disorder (OUD) and SIRI, though increasing evidence suggests it may be feasible and safe. This study evaluates the efficacy and cost-effectiveness of an integrated care model combining Buprenorphine treatment of OUD with OPAT for SIRI (B-OPAT) compared with treatment as usual on key OUD, infectious disease, and health economic outcomes. B-OPAT expands and incorporates key elements of established clinical models, including inpatient initiation of buprenorphine for OUD, inpatient infectious disease consultation for SIRI, office-based treatment of OUD, and OPAT, and includes more frequent clinical outpatient visits than standard OPAT. A qualitative evaluation is included to contextualize effectiveness outcomes and identify barriers and facilitators to intervention adoption and implementation. Methods B-OPAT is a single-site, randomized, parallel-group, superiority trial recruiting 90 adult inpatients hospitalized with OUD and SIRI who require at least 2 weeks of intravenous (IV) antibiotic therapy. After screening, eligible participants are randomized 1:1 to either discharge once medically stable to an integrated outpatient treatment care model combining Buprenorphine and OPAT (B-OPAT) or to Treatment As Usual (TAU). The primary outcome measure is the proportion of urine samples negative for illicit opioids in the 12 weeks after discharge from the hospital. Key secondary OUD outcomes include self-reported number of days of illicit opioid abstinence and 12-week retention in buprenorphine treatment. The infection outcomes are completion of recommended IV antibiotic therapy, peripherally inserted central catheter (PICC) complications, and readmission related to primary SIRI. Conclusions The B-OPAT study will help address the important question of whether it is clinically effective and cost-effective to discharge persons with OUD and SIRI to an integrated outpatient care model combining OUD treatment with OPAT relative to TAU (Clinicaltrials.gov Identifier: NCT04677114).
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Affiliation(s)
- Laura C. Fanucchi
- Division of Infectious Diseases, College of
Medicine, University of Kentucky, 845 Angliana Ave., Lexington, KY, 40508,
USA
- Center on Drug and Alcohol Research, College of
Medicine, University of Kentucky, Lexington, KY, USA
| | - Sean M. Murphy
- Department of Population Health Sciences, Weill
Cornell Medicine, New York, NY, USA
| | - Hilary Surratt
- Center on Drug and Alcohol Research, College of
Medicine, University of Kentucky, Lexington, KY, USA
- Department of Behavioral Science, College of
Medicine, University of Kentucky, Lexington, KY, USA
| | - Shashi N. Kapadia
- Department of Population Health Sciences, Weill
Cornell Medicine, New York, NY, USA
- Division of Infectious Diseases, Weill Cornell
Medicine, New York, NY, USA
| | - Sharon L. Walsh
- Center on Drug and Alcohol Research, College of
Medicine, University of Kentucky, Lexington, KY, USA
- Departments of Behavioral Science and
Psychiatry, College of Medicine, University of Kentucky, Lexington, KY,
USA
- Department of Pharmaceutical Sciences, College
of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - James A. Grubbs
- Division of Infectious Diseases, College of
Medicine, University of Kentucky, Lexington, KY, USA
| | - Alice C. Thornton
- Division of Infectious Diseases, College of
Medicine, University of Kentucky, Lexington, KY, USA
| | - Paul Nuzzo
- Center on Drug and Alcohol Research, College
of Medicine, University of Kentucky, Lexington, KY, USA
| | - Michelle R. Lofwall
- Center on Drug and Alcohol Research, College
of Medicine, University of Kentucky, Lexington, KY, USA
- Departments of Behavioral Science and
Psychiatry, College of Medicine, University of Kentucky, Lexington, KY,
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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Assessment of risk factors associated with outpatient parenteral antimicrobial therapy (OPAT) complications: A retrospective cohort study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e183. [PMID: 36406163 PMCID: PMC9672913 DOI: 10.1017/ash.2022.313] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022]
Abstract
Objective: To characterize factors associated with increased risk of outpatient parenteral antimicrobial therapy (OPAT) complication. Design: Retrospective cohort study. Setting: Four hospitals within NYU Langone Health (NYULH). Patients: All patients aged ≥18 years with OPAT episodes who were admitted to an acute-care facility at NYULH between January 1, 2017, and December 31, 2020, who had an infectious diseases consultation during admission. Results: Overall, 8.45% of OPAT patients suffered a vascular complication and 6.04% suffered an antimicrobial complication. Among these patients, 19.95% had a 30-day readmission and 3.35% had OPAT-related readmission. Also, 1.58% of patients developed a catheter-related bloodstream infection (CRBSI). After adjusting for key confounders, we found that patients discharged to a subacute rehabilitation center (SARC) were more likely to develop a CRBSI (odds ratio [OR], 4.75; P = .005) and to be readmitted for OPAT complications (OR, 2.89; P = .002). Loss to follow-up with the infectious diseases service was associated with increased risks of CRBSI (OR, 3.78; P = .007) and 30-day readmission (OR, 2.59; P < .001). Conclusions: Discharge to an SARC is strongly associated with increased risks of readmission for OPAT-related complications and CRBSI. Loss to follow-up with the infectious diseases service is strongly associated with increased risk of readmission and CRBSI. CRBSI prevention during SARC admission is a critically needed public health intervention. Further work must be done for patients undergoing OPAT to improve their follow-up retention with the infectious diseases service.
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Pineo T, Goldman JD, Swartzentruber G, Kanderi T, Qurashi H, Dimech C. An observational study on the use of long acting buprenorphine ( Sublocade) and a Tamper resistant PICC for Outpatient IV antibiotic administration in Patients with serious infections and Opioid Use Disorder; The STOP OUD project. DRUG AND ALCOHOL DEPENDENCE REPORTS 2021; 2:100020. [PMID: 36845901 PMCID: PMC9948820 DOI: 10.1016/j.dadr.2021.100020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022]
Abstract
What is STOP OUD? The STOP OUD project is an observational study on the use of long-acting buprenorphine (Sublocade) and a Tamper resistant PICC clamp for Outpatient IV antibiotic administration in Patients with serious infections and Opioid Use Disorder (STOP OUD). Background The US opioid crisis is driving up serious infections related to intravenous drug use. These infections require prolonged courses of antibiotics, often resulting in lengthy hospital stays. Extended hospitalizations for monitored parenteral antibiotics for patients with opioid use disorder are challenging for patients, reduce bed capacity, and are associated with significant cost. This observational study reviews the administration of intravenous (IV) antibiotics in a monitored outpatient setting using long-acting injectable buprenorphine (Sublocade, Indivior Inc., North Chesterfield, VA) and a tamper resistant clamp in patients with opioid use disorder . Methods Long-acting buprenorphine and a tamper resistant clamp were used to treat patients with serious infections and opioid use disorder as outpatients. Results Hospital days avoided were 30-days per STOP OUD project participant. Eleven of thirteen STOP OUD project participants completed their antibiotic courses as prescribed, there was no evidence of peripherally inserted central catheter (PICC) tampering, and they rated their care as a mean of 4.9/5 (SD 0.4). Institutional savings per STOP OUD patient was $33,000. Outpatient infusion costs were $9,300 for a net savings of $23,700 per STOP OUD project participant. Infections resolved in all participants. Conclusions The STOP OUD project reduced hospital length of stay for patients with opioid use disorder and serious infections, and had a favorable financial impact.
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Affiliation(s)
- Thomas Pineo
- Hospitalist, UPMC Central PA, Harrisburg Pennsylvania,Corresponding author.
| | - John D. Goldman
- Infectious Disease, UPMC Central PA, Harrisburg Pennsylvania
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