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

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.

Program-wide review and follow-up of erythema Induratum of Bazin and tuberculosis-associated ocular inflammation management in a TB low-incidence setting: need for improved treatment candidate selection, therapy standardization, and care collaboration

BACKGROUND

Erythema induratum of Bazin (EIB) - nodular vasculitis associated with Mycobacterium tuberculosis (TB) - and Tuberculosis-Associated Ocular Inflammation (TB-AOI) represent uncommon manifestations of TB. There is limited data and a lack of diagnostic and treatment standards for these conditions.

METHODS

Eleven-year retrospective review of EIB and TB-AOI cases managed in a provincial TB program with prospective phone-based follow-up of anti-tubercular therapy (ATT) recipients. Presumptive TB-AOI and EIB diagnoses were determined by ophthalmologist or dermatologist assessments correlated with positive tuberculin skin test and/or QuantiFERON-TB Gold, along with pathologic criteria in EIB cases.

RESULTS

Of 21 EIB and 20 TB-AOI cases that received ATT, 13 and 11, respectively, were reached for follow-up. The majority of EIB and TB-AOI cases were female and immigrated from TB high-burden countries. Median durations of pre-diagnosis symptoms were 2 and 0.8 years (IQR 2.5 & 1.1) for EIB and TB-AOI cases, respectively. Overall, 14 different ATT regimens were used for a median duration of 6 months (range 5-9). ATT related adverse events resulting in treatment discontinuation occurred in 14% of EIB and 10% of TB-AOI cases. On last follow-up, 76% of EIB and 42% of TB-AOI had improvement or resolution of disease.

CONCLUSION

EIB and TB-AOI were uncommon presentations receiving variable therapy. While treatment response was modest for EIB cases, TB-AOI cases had sub-optimal treatment outcomes. The unique diagnostic and management challenges presented by these conditions in TB low-incidence settings highlight a need for improved treatment candidate selection, therapy standardization, and cross-specialty medical collaboration.

Homeless shelter context and tuberculosis illness experiences during a large outbreak in Atlanta, Georgia

Setting: Persons experiencing homelessness (PEH) represent a population at high risk for tuberculosis (TB). While quantitative studies have characterized some important features of this key group, less has been captured directly from PEH about how they experience TB illness itself and the prevention and control measures implemented in response to an outbreak. This qualitative study aimed to explore PEH's TB disease experiences in the context of a large TB outbreak involving homeless shelters in Atlanta, Georgia, USA. Design: This was a qualitative cross-sectional study involving in-depth interviews with 10 PEH with active TB disease. Key themes were identified through coded data analysis. Results: The central theme to emerge was that stressful social environments of homeless shelters shape illness experiences and health care seeking behaviors, and limit the influence of shelter-based prevention and control measures implemented in response to a TB outbreak. Despite availability, shelter-based latent tuberculous infection (LTBI) testing and education services were minimally engaged. Furthermore, hardships inherent to homelessness were interrelated with disease normalization and symptom minimization. Conclusions: Homeless shelter-related stress may have important implications for the prevention and control of TB outbreaks in this setting. This stress may hinder case finding; a model of supplemental TB education and testing for LTBI at proximal community venues is necessary.

Healthcare contacts among patients lost to follow-up in HIV care: review of a large regional cohort utilizing electronic health records

In the United States 40% of HIV patients are lost to follow-up (LTFU) following linkage to HIV care and an estimated 30-61% of new HIV transmissions are attributed to this group. To characterize those LTFU and healthcare contacts they make, we retrospectively analyzed a large regional HIV cohort in Calgary, Canada, utilizing a province-wide electronic health record. Adults engaged in HIV care between January 2010 and August 2014 who had >12 months without HIV clinic contact were identified as LTFU. Of 1928 individuals engaged in care, 176 became LTFU with 64% having no healthcare contacts, 20% receiving HIV care elsewhere, and 16% making non-HIV healthcare contacts. Those LTFU making non-HIV healthcare contacts did so a median of six times (interquartile range 2-8), 76% attending emergency departments (ED). Compared to those retained in care, LTFU patients were younger (median age 43 versus 47 years), had lower CD4⁺ cell counts (median 420 versus 500 × 10⁶/l) and more commonly resided outside of the centralized HIV clinic's city (odds ratio 4.58) (all p < 0.01). Our finding that a majority of those LTFU did not make healthcare contacts suggests that community and HIV clinic-based relinkage programs are needed. For those LTFU who make healthcare contacts enhanced ED-based relinkage programs could engage a majority.

Acute dental infections managed in an outpatient parenteral antibiotic program setting: prospective analysis and public health implications

BACKGROUND

The number of Acute Dental Infections (ADI) presenting for emergency department (ED) care are steadily increasing. Outpatient Parenteral Antibiotic Therapy (OPAT) programs are increasingly utilized as an alternative cost-effective approach to the management of serious infectious diseases but their role in the management of severe ADI is not established. This study aims to address this knowledge gap through evaluation of ADI referrals to a regional OPAT program in a large Canadian center.

METHODS

All adult ED and OPAT program ADI referrals from four acute care adult hospitals in Calgary, Alberta, were quantified using ICD diagnosis codes in a regional reporting system. Citywide OPAT program referrals were prospectively enrolled over a five-month period from February to June 2014. Participants completed a questionnaire and OPAT medical records were reviewed upon completion of care.

RESULTS

Of 704 adults presenting to acute care facilities with dental infections during the study period 343 (49%) were referred to OPAT for ADI treatment and 110 were included in the study. Participant mean age was 44 years, 55% were women, and a majority of participants had dental insurance (65%), had seen a dentist in the past six months (65%) and reported prior dental infections (77%), 36% reporting the current ADI as a recurrence. Median length of parenteral antibiotic therapy was 3 days, average total course of antibiotics was 15-days, with a cumulative 1326 antibiotic days over the study period. There was no difference in total duration of antibiotics between broad and narrow spectrum regimes. Conservative cost estimate of OPAT care was $120,096, a cost savings of $597,434 (83%) compared with hospitalization.

CONCLUSIONS

ADI represent a common preventable cause of recurrent morbidity. Although OPAT programs may offer short-term cost savings compared with hospitalization, risks associated with extended antibiotic exposures and delayed definitive dental management must also be gauged.

Requirement for a growth substrate during lignin decomposition by two wood-rotting fungi

Decomposition of C-labeled lignin to CO(2) by the lignin-decomposing fungi Phanerochaete chrysosporium and Coriolus versicolor required a growth substrate such as cellulose or glucose. Growth with lignin as sole carbon addition to an otherwise complete medium was negligible.

Microbial decomposition of synthetic C-labeled lignins in nature: lignin biodegradation in a variety of natural materials

Lignin biodegradation in a variety of natural materials was examined using specifically labeled synthetic C-lignins. Natural materials included soils, sediments, silage, steer bedding, and rumen contents. Both aerobic and anaerobic incubations were used. No C-labeled lignin biodegradation to labeled gaseous products under anaerobic conditions was observed. Aerobic C-labeled lignin mineralization varied with respect to type of natural material used, site, soil type and horizon, and temperature. The greatest observed degradation occurred in a soil from Yellowstone National Park and amounted to over 42% conversion of total radioactivity to CO(2) during 78 days of incubation. Amounts of C-labeled lignin mineralization in Wisconsin soils and sediments were significantly correlated with organic carbon, organic nitrogen, nitrate nitrogen, exchangeable calcium, and exchangeable potassium.

Preparation and microbial decomposition of synthetic [14C]ligins

A definitive assay for microbiological and biochemical research on the biodegradation of lignin was developed using radioactive synthetic lignins specifically labeled in the side chains, aromatic rings or in the methoxyl groups. The [14C]lignins were prepared by oxidative polymerization with peroxidase and H2O2 Of specifically labeled coniferyl alcohol (4-hydroxy-3-methyoxycinnamyl alcohol). The synthetic polymers were shown by spectroscopic and chemical methods to contain the same intermonomer linkages found in natural lignins. Incubation of the [14C]lignins with known lignin-degrading fungi and with a forest soil resulted in 14CO2 evolution.