Reimagining long‐term antibiotics in persons who inject drugs: Time to shift the status quo?

Abstract

In the United States, there are an estimated 744,000 individuals who have engaged in recent injection drug use (IDU) and 6.6 million individuals who have ever injected a drug. 1 The practice of IDU predisposes individuals to serious bacterial and fungal infections that often require long-term intravenous antibiotics. In individuals without IDU, these serious infections are often treated with outpatient parenteral antibiotic therapy (OPAT). However, a different standard exists for many persons who inject drugs (PWID)-the mandated completion of antibiotics in an inpatient setting.Though mandating inpatient antibiotic therapy for PWID is a widely adopted standard, this practice is not evidence based and may increase overall costs to the healthcare system. In 2012, in a qualityimprovement initiative, UKHealthCare established a protocol for treating appropriate PWID with OPAT. 2 They found very few inpatient providers willing to discharge PWID on OPAT, even with an established protocol.To better understand the reasons for the low adoption of this protocol, Fanucchi and colleagues developed a survey designed to "assess attitudes, practices, and mediating factors impacting the decision making about discharging PWID on OPAT." 2 The results of this survey are reported in this issue of the Journal of Hospital Medicine.The study found that 95% of inpatient providers use OPAT for patients without IDU, but only 29% would even consider OPAT in PWID. The most common barriers to discharging a patient with IDU on OPAT were socioeconomic factors, willingness of infectious diseases physicians to follow as an outpatient, and concerns for misuse of peripherally inserted central catheters and adherence with antibiotic treatment.At first glance, these reservations seem very reasonable. The presence of socioeconomic factors such as homelessness or lack of infectious diseases specialist follow-up would make the risks of discharge on OPAT significant. The concerns for misuse of peripherally inserted central catheters and adherence to antibiotic treatment suggest that inpatient providers have an overall goal of reducing drug misuse and improving treatment outcomes.Unfortunately, there are no data to suggest that completion of antibiotics in an inpatient setting reduces drug misuse or improves adherence to antibiotic treatments. Studies have found that at least 16% of PWID will misuse drugs during their hospitalization, 3 and 25% to 30% will be discharged against medical advice. 3,4 This may be in large part due to the fact that inpatient providers are historically poor at addressing substance use disorders, even in patients with serious infections associated with IDU. 5 Yet the provision of methadone during hospitalization has been associated with a significant reduction in discharges against medical advice. 4 Rather than focusing on placing restrictions on individuals with risky behaviors, patients may benefit more from minimizing these risks through prompt recognition and management of substance use disorder.Although limited, there is a...

Outpatient Parenteral Antimicrobial Therapy Among People Who Inject Drugs: A Review of the Literature

“…OPAT itself might also increase patient satisfaction among PWID and help to reduce rates of discharge AMA. Unfortunately, pharmacologic interventions to address substance use disorders remain rarely implemented during hospitalizations [ 37 , 38 ]. Further research is needed to examine the impact of addiction treatment for PWID who are being considered for OPAT.…”

“…Considering the prolonged duration in which PWID are kept in hospitals to complete the antibiotic regimen, there is interest in identifying the potential financial impact of implementing OPAT for this patient population [ 37 , 41 ]. The results from this review, although very preliminary, suggests cost savings in the range of $11 000 to $25 000 per episode of OPAT.…”