Patients With Serious Injection Drug Use–Related Infections who Experience Patient-Directed Discharges on Oral Antibiotics Have High Rates of Antibiotic Adherence but Require Multidisciplinary Outpatient Support for Retention in Care

Abstract

Background Persons who inject drugs (PWID) are frequently admitted for serious injection related infections (SIRI). Outcomes and adherence to oral antibiotics for PWID with patient directed discharge (PDD) remain understudied. Methods We conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge, or immediately after discharge through an ID telemedicine clinic. Additional support services included health coaches, therapist, case manager, free clinic follow up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow up were compared between PWID with PDD on oral antibiotics and those that completed IV antibiotics, using an as treated approach. Results Of 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%) while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups (p=0.819). For PWID with a PDD on oral antibiotics, 7.6% had documented non-adherence to antibiotics, 67% had documented adherence and 23% were lost to follow-up. Factors protective against readmission included antibiotic and MOUD adherence, engagement with support team, and clinic follow up. Conclusions PWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics.

Medication for opioid use disorder at hospital discharge is not associated with intravenous antibiotic completion in post-acute care facilities

“…New treatment paradigms of oral or long-acting IV antibiotics can allow effective treatment without the issues related to prolonged IV access, including safety concerns, and possible requirement for treatment within a facility. 28 Prolonged antibiotic treatment of people with OUD requires careful coordination to continue the treatment of OUD during care transitions. These efforts may be aided by changes to the regulatory framework for MOUD.…”

Experiences Using a Multidisciplinary Model for Treating Injection Drug Use Associated Infections: A Qualitative Study

“…This qualitative analysis was undertaken to explore patient perceptions of a multidisciplinary program to address opioid use disorder (OUD) in the context of hospitalization for a serious injection-related infection. This program (called the bridge-to-health program) was designed to bridge the gap between hospitalization, early discharge and establishment of stable addiction care ( 19 ). When comparing interviews with patients admitted before and patients admitted after the initiation of this program, we found several perceived benefits, as well as areas of improvement.…”

“…The Washington University School of Medicine bridge-to-health program was initiated as a Centers for Disease Control and Prevention (CDC) funded program for treating opioid use disorder (OUD) in people who inject drugs (PWID) presenting to the hospital with invasive infections associated with injection drug use ( 19 ). Patients that are prospectively identified by infectious disease physicians, hospitalists, and social workers can be enrolled in the program, which provides access to a peer recovery coach, a dedicated program social worker, a clinical counselor, and physicians who can follow-up post discharge.…”

“…Upon hospital discharge, patients are followed in a bridge-to-health clinic, either in-person or via telemedicine, and continue to receive intensive social work and peer recovery resources for 90 days after discharge, followed by a handoff to community providers for continuation of their addiction care. The goal of this program is to provide supportive services for PWID presenting with injection related infections, decrease readmissions, and improve retention in outpatient infectious diseases and substance use disorder care ( 19 ).…”

Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association

“…36 Use could be considered for patients intolerant of other antibiotic regimens. For patients with unstable housing or other risk factors for extensive sun exposure, counseling on the increased risk of photosensitivity may be considered.For patients in whom oral absorption of medications is limited or there are other contraindications to oral antibiotics AHA indicates American Heart Association; DS, double strength; IE, infective endocarditis; MAOI, monoamine oxidase inhibitor; POET, Circulation.…”