Rethinking Home-based Outpatient Parenteral Antibiotic Therapy for Persons Who Inject Drugs: An Opportunity for Change in the Time of COVID-19

Abstract

Outpatient parenteral antibiotic therapy (OPAT) refers to the monitored provision of intravenous antibiotics for complicated infections outside of a hospital setting, typically in a rehabilitation facility, an infusion center, or the home. Home-based OPAT allows for safe completion of prolonged courses of therapy while decreasing costs to the healthcare system, minimizing the risk of hospital-related infectious exposures for patients, and permitting patients to recover in a familiar environment. Amidst the COVID-19 pandemic, during which nursing facilities have been at the center of many outbreaks of the SARS-CoV-2 virus, completion of antimicrobial therapy in the home is an even more appealing option. Persons who inject drugs (PWID) frequently present with infectious complications of their injection drug use which require long courses of parenteral therapy. However, these individuals are frequently excluded from home-based OPAT on the basis of their addiction history. This commentary describes perceived challenges to establishing home-based OPAT for PWID, discusses ways in which this is discriminatory and unsupported by available data, highlights ways in which the COVID-19 pandemic has accentuated inequities in care, and proposes a multidisciplinary approach championed by Addiction specialists to increasing implementation of OPAT for appropriate patients with substance use disorders.

PICC Your Poison: Resident Beliefs and Attitudes Regarding Discharge Parenteral Antibiotics for Patients Who Inject Drugs

“…Respondents also noted that rehabilitation, nursing facility, and home nursing institutional policies are also likely to be barriers. Post-acute facilities do frequently reject patients with active or even historical drug use [ 8 ]; recently there have been attempts to file lawsuits against rehabilitation facilities for violating the Americans With Disabilities Act and discriminating against patients on MOUD [ 9 ], though the practice persists. Without specific training on this subject for residents, beliefs about barriers are likely culturally transmitted either attending to resident or resident to resident within institutions.…”

“…Providers may be concerned that PICC use may be complicated by secondary line infection, or have opposition to outpatient vascular access as a potential facilitator of further drug use [ 4–6 ]. These concerns are not limited to prescribers; skilled rehabilitation and nursing facilities, infusion companies, and visiting home nurse companies frequently decline service to people with active or even historical substance use disorders [ 7 , 8 ], a discriminatory action that has been challenged as in violation of the Americans With Disabilities Act in recent legal settlements [ 9 ]. The existence of these barriers, even if not uniformly applied, can have a strong influence on care plans for patients with SIRI.…”

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

“…In addition, some people requiring OPAT may be discharged to a facility because they are unjustly and illegally excluded from home OPAT due to their substance use. 19 Given the frequency that people with OUD and serious infections are treated in post-acute care facilities, approaches to improve OPAT completion are critical.…”

Outcomes of Partial Oral Antibiotic Treatment for Complicated Staphylococcus aureus Bacteremia in People Who Inject Drugs

“…The increasing movement for OPAT programs to support PWID will enhance patient access to SOC IV antibiotic treatment, and represents an important advancement in infectious diseases care for PWID [27][28][29]. However, it is likely that even at institutions with expanded access to OPAT, not all PWID may be eligible, either due to physician perceived barriers, lack of safe and stable housing, lack of health insurance, or limited access to outpatient follow-up [30,31]. For some patients there may also be benefits to avoiding the complexities of OPAT.…”