Patient-Directed Discharges Among Persons Who Use Drugs Hospitalized with Invasive Staphylococcus aureus Infections: Opportunities for Improvement

Appa, Ayesha; Adamo, Meredith; Le, Stephenie; Davis, J. Lucian; Winston, Lisa G; Doernberg, Sarah B; Chambers, Henry F.; Martin, Marlene; Hills, Nancy K.; Coffin, Phillip O.; Jain, Vivek

doi:10.1016/j.amjmed.2021.08.007

Cited by 15 publications

(16 citation statements)

References 32 publications

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“…We identified contributing factors to PDD, similar to published observations [ 3 , 20 , 21 ]. As PDD is associated with worse outcomes [ 22 , 23 ], a standardized proactive approach can prevent PDD [ 20 ], which should include substance withdrawal treatment and pain control; compassionate, nonjudgmental communication; and proactive management of physical symptoms and concerns related to personal belongings and other obligations. Fortunately, only 8 (11%) of 74 patients in the partial-oral group received oral antibiotics in the setting of PDD, and only 2 of them were truly loss to follow-up.…”

Section: Discussionmentioning

confidence: 99%

Partial-Oral Antibiotic Therapy for Bone and Joint Infections in People With Recent Injection Drug Use

Yang

Dombrowski

Glick

et al. 2023

Open Forum Infectious Diseases

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Background Limited outcome data exists regarding partial-oral antibiotic therapy, defined as oral antibiotics as part of a patient’s treatment, for bone and joint infections (BJI) in people who inject drugs (PWID). Methods We conducted a retrospective study of all PWID reporting drug use within three months and BJI requiring six or more weeks of antibiotics in an urban safety-net hospital between February 1, 2019 and February 1, 2021. Treatment outcomes were assessed by chart review. Rates of failure, defined as death, symptoms or signs concerning for worsening or recurrent infections, were assessed 90 and 180 days after completion of antibiotics. Univariate logistic regression was used to explore the association between covariates and failure. Results Of 705 patients with BJI, 88 (13%) were PWID. Eighty-six patients were included in the final cohort. Forty-four (51%) were homeless; 50 (58%) had spine infection; 68 (79%) had surgery; and 32 of 68 (47%) had postoperatively retained hardware. Twelve (14%) of 86 patients received exclusively intravenous (IV) antibiotics, and 74 (86%) received partial-oral antibiotics. Twelve (14%) of 86 patients had patient-directed discharge. In those received partial-oral antibiotics, the failure rate was 20% at 90 days, and 21% at 180 days after completion of intended treatment. Discharge to a medical respite and follow-up with infectious diseases (ID) or surgery were negatively associated with odds of failure. Conclusions Partial-oral treatment of BJI in PWID was a common practice and often successful when paired with medical respite and follow-up with ID or surgery.

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Section: Discussionmentioning

confidence: 99%

Partial-Oral Antibiotic Therapy for Bone and Joint Infections in People With Recent Injection Drug Use

Yang

Dombrowski

Glick

et al. 2023

Open Forum Infectious Diseases

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“… 26 , 27 Many clinicians may still consider IV antibiotics as first-line therapy, but this approach may be based on personal experience, rather than evidence-based practice. 28 Addressing knowledge gaps in PICC misuse and educating HCPs on new and current antimicrobial research are important for facilitating a harm reduction approach to discharge decision-making. Also, addressing knowledge gaps on factors that facilitate outpatient treatment, such as home health policies and community resources, would further allow HCPs to expand treatment options for patients.…”

Section: Discussionmentioning

confidence: 99%

“… 12 Stigmatization is a key contributor to self-directed discharge, and studies show that odds of hospital readmission for infections in PWUD who have undergone self-directed discharge were almost fourfold higher than standard discharge. 28 The most fundamental aspect of a harm reduction approach is recognizing that a medical encounter is not an isolated event, but part of a series of events that shape how a patient thinks about, experiences, and interacts with the medical system. Addressing stigmatization and mistreatment may reduce traumatizing hospital experiences for PWUD, allowing them to stay in the hospital long enough to create a patient-centered treatment and discharge plan through shared decision-making.…”

Section: Discussionmentioning

confidence: 99%

Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections

Moore

Kohut

Stoddard

et al. 2022

Therapeutic Advances in Infection

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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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“…7 Moreover, patients with housing instability and SUDs have low rates of infection treatment completion compared with those with only one or neither of these risk factors. 8,9 Mortality rates are also higher in patients with unplanned or premature discharges. 10 Serious bacterial infections are commonly treated with long courses of intravenous (IV) antibiotics, and although outpatient parenteral antimicrobial therapy (OPAT) has been successful in PWID, application is limited.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Description and outcomes of patients with substance use disorder with serious bacterial infections who had a multidisciplinary care conference

Conte

Schneider

Varley

et al. 2022

Therapeutic Advances in Infection

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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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Patient-Directed Discharges Among Persons Who Use Drugs Hospitalized with Invasive Staphylococcus aureus Infections: Opportunities for Improvement

Cited by 15 publications

References 32 publications

Partial-Oral Antibiotic Therapy for Bone and Joint Infections in People With Recent Injection Drug Use

Partial-Oral Antibiotic Therapy for Bone and Joint Infections in People With Recent Injection Drug Use

Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections

Description and outcomes of patients with substance use disorder with serious bacterial infections who had a multidisciplinary care conference

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