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PICC Your Battles: Considering the Appropriateness of Peripherally Inserted Central Catheter (PICC) Lines for Outpatient Parenteral Antimicrobial Therapy (OPAT) in Injection Drug Users (IDUs)

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Abstract

Injection drug users (IDUs) requiring outpatient parenteral antibiotic therapy (OPAT) for injection-related infections are regularly de- nied the use of peripherally inserted central catheter (PICC) lines based on the assumption that they will use the port to inject illicit drugs, and that it will be used in a non-sterile/unclean fashion. While IDUs have higher rates of infective endocarditis, abscesses and septicemia, there is no substantial body of evidence that PICC lines in IDUs result in more serious infections, increased overdoses or increased morbidity or mortality. Successful transition of IDUs from inpatient treatment to OPAT requires appropriate patient selec- tion. Namely, housing status, mental health history, the presence of a support system, and a patient’s willingness to comply with treatment all play a significant role in OPAT success. Honest and straightforward conversations must be undertaken between patient and provider regarding the risks and benefits of a PICC line if injecting drugs. Close follow-up, a compassionate approach, provider education, and the expansion of respite programs all introduce novel spaces for ongoing harm reduction and good patient care. Finally, further research is needed to establish protocols, guidelines, screening criteria, transition of care, and to clarify best practices for OPAT in patients who inject drugs. RÉSUMÉ Les utilisateurs de drogues injectables (UDIs) ayant besoin d’une antibiothérapie par voie parentérale ambulatoire (APA) pour des infections associées aux injections se voient fréquemment refuser l’accès à un cathéter central à insertion périphérique (PICC, de l’anglais) puisqu’on présume qu’ils l’utiliseront pour s’injecter des drogues illicites, et que le cathéter sera utilisé de manière non stérile ou peu hygiénique. Bien que les UDIs présentent des taux plus élevés d’endocardite infectieuse, d’abcès et de septicémie, il n’existe pas de preuves substantielles qui démontrent que les PICCs chez les UDIs entraînent des infections plus sévères, ou une hausse de surdoses, de morbidité ou de mortalité. La transition réussie des UDIs d’un traitement hospitalier vers une APA exige une sélection at- tentive des patients. Notamment, la situation de logement, les antécédents de santé mentale, la présence d’un système de soutien et la volonté du patient de suivre le traitement contribuent tous au succès de l’APA. Des conversations honnêtes et directes doivent avoir lieu entre le patient et le fournisseur de soins quant aux risques et aux avantages d’un PICC et de l’utilisation de drogues injectables. Un suivi étroit, une approche compatissante, la formation appropriée des fournisseurs de soins, et l’expansion des programmes de répit constituent tous de nouvelles façons de réduire les méfaits et d’améliorer les soins aux patients. Finalement, plus de recherche est nécessaire afin de mettre en place des protocoles, des lignes directrices, des critères de dépistage et des transitions de soins, et pour clarifier les pratiques exemplaires quant à l’APA chez les patients qui utilisent des drogues injectables.
Page 18 | UOJM Volume 7 Issue 1 | May 2017
Les ulisateurs de drogues injectables (UDIs) ayant besoin d’une anbiothérapie par voie parentérale ambulatoire (APA) pour des
infecons associées aux injecons se voient fréquemment refuser l’accès à un cathéter central à inseron périphérique (PICC, de
l’anglais) puisqu’on présume qu’ils l’uliseront pour s’injecter des drogues illicites, et que le cathéter sera ulisé de manière non stérile
ou peu hygiénique. Bien que les UDIs présentent des taux plus élevés d’endocardite infeceuse, d’abcès et de sepcémie, il n’existe
pas de preuves substanelles qui démontrent que les PICCs chez les UDIs entraînent des infecons plus sévères, ou une hausse de
surdoses, de morbidité ou de mortalité. La transion réussie des UDIs d’un traitement hospitalier vers une APA exige une sélecon at-
tenve des paents. Notamment, la situaon de logement, les antécédents de santé mentale, la présence d’un système de souen et
la volonté du paent de suivre le traitement contribuent tous au succès de l’APA. Des conversaons honnêtes et directes doivent avoir
lieu entre le paent et le fournisseur de soins quant aux risques et aux avantages d’un PICC et de l’ulisaon de drogues injectables.
Un suivi étroit, une approche compassante, la formaon appropriée des fournisseurs de soins, et l’expansion des programmes de
répit constuent tous de nouvelles façons de réduire les méfaits et d’améliorer les soins aux paents. Finalement, plus de recherche
est nécessaire an de mere en place des protocoles, des lignes directrices, des critères de dépistage et des transions de soins, et
pour clarier les praques exemplaires quant à l’APA chez les paents qui ulisent des drogues injectables.
Commentary
PICC Your Bales: Considering the Appropriateness of Peripherally
Inserted Central Catheter (PICC) Lines for Outpaent Parenteral
Anmicrobial Therapy (OPAT) in Injecon Drug Users (IDUs)
Maxime Jasmine Billick, BA1
1 Faculty of Medicine, McGill University
BT lay with her head cocked in the only comfortable posion, her
thin legs protruding below imsy hospital sheets. I was on a rota-
on in Infecous Diseases based at several Toronto-area hospi-
tals and she was not my rst intravenous (IV) drug-using paent.
She was, however, the rst paent I had seen who was unable to
move her head more than several millimeters in either direcon
since a paraspinal abscess precariously abued her spinal cord.
BT could be argumentave—she had yelled at several nurses and
oen refused to have her vital signs taken. She also told me she
was scared—she recognized that nding herself in this posion
was likely secondary to her IV drug use. Despite delivering aen-
ve care, some of the nurses rolled their eyes when talking about
Injecon drug users (IDUs) requiring outpaent parenteral anbioc therapy (OPAT) for injecon-related infecons are regularly de-
nied the use of peripherally inserted central catheter (PICC) lines based on the assumpon that they will use the port to inject illicit
drugs, and that it will be used in a non-sterile/unclean fashion. While IDUs have higher rates of infecve endocardis, abscesses and
sepcemia, there is no substanal body of evidence that PICC lines in IDUs result in more serious infecons, increased overdoses or
increased morbidity or mortality. Successful transion of IDUs from inpaent treatment to OPAT requires appropriate paent selec-
on. Namely, housing status, mental health history, the presence of a support system, and a paent’s willingness to comply with
treatment all play a signicant role in OPAT success. Honest and straighorward conversaons must be undertaken between paent
and provider regarding the risks and benets of a PICC line if injecng drugs. Close follow-up, a compassionate approach, provider
educaon, and the expansion of respite programs all introduce novel spaces for ongoing harm reducon and good paent care. Finally,
further research is needed to establish protocols, guidelines, screening criteria, transion of care, and to clarify best pracces for OPAT
in paents who inject drugs.
ABSTRACT
RÉSUMÉ
Keywords: Drug Users; PICC Placement; Abscess; Heroin Dependence;
Harm Reducon
BT, and the social worker said that the paent refused her entry
into the hospital room because she “didn’t like [her] face.
The senments I witnessed towards injecon drug users (IDUs)
are not unique to my clinical rotaon. A recent meta-analysis
sought to assess health professionals’ atudes regarding pa-
ents with substance use disorders and to examine the conse-
quences on healthcare delivery [1]. The analysis revealed that
health care workers generally held negave atudes toward
paents with substance use disorders, oen taking an avoidant
approach to healthcare provision [1]. This resulted in shorter vis-
its, diminished empathy, and lower personal engagement, pre-
sumed to result in subpar healthcare delivery [1]. Addionally,
Page 19 | UOJM Volume 7 Issue 1 | May 2017
Commentary
the negave atudes of health professionals add a signicant
barrier to paent recovery, since healthcare workers oen play a
crucial role in recognizing substance use problems, empowering
paents, and acng as gatekeepers to treatment [1].
BT required six weeks of anbioc therapy, most of which ne-
cessitated IV delivery via a peripherally inserted central catheter
(PICC) line. Numerous people on her immediate treang team
including nurses, aending surgeons, residents, and other con-
sultants were dismayed that an IDU would likely need a semi-
permanent PICC line.
Terary care hospitals throughout Canada arrange outpaent
parenteral anmicrobial therapy (OPAT) for paents requiring
long-term IV anbioc delivery. OPAT has demonstrated cost-
eecveness benets when compared to a full in-hospital IV
anbioc treatment course [2]. A recent analysis of a 334-per-
son cohort in the UK esmated a yearly cost of approximately
£300,000 (including pre-clinical set-up costs), whereas the mini-
mum theorecal in-paent cost was more than three mes high-
er at £1,005,676 [3]. Hospitalizing people solely for IV anmicro-
bial treatment is not cost eecve. Moreover, an addional bed
is occupied, which could be given to a paent in need [3]. Despite
this, many physicians connue to believe IDUs should not be dis-
charged with a PICC line under any circumstances [4]. During my
clinical training, common beliefs I noted among medical profes-
sionals included infecon of the line itself, and that the resulng
infecon would inherently be more serious than one acquired by
self-injecon. Others surmised that the individual may use the
port to inject drugs.
Fundamentally, there is no consensus in the literature that sup-
ports these statements. People who use IV drugs do have higher
rates of infecve endocardis, abscesses and sepcemia [5-7].
However, there is no meaningful body of evidence that PICC lines
in IDUs result in more serious infecons, increased overdoses, or
increased morbidity and mortality. In fact, the few studies that
have examined PICC line complicaons concluded that complica-
on rates were similar amongst IDUs and non-users [8]. More-
over, improvement and recovery rates were high among IDUs
with PICC lines (73.3% cure rate, 23.3% readmission rate, 3.3%
relapse rate), and no deaths, serious misadventures or line tam-
pering were reported [9,10].
Physicians’ own discomfort with discussing IV drug use may be
reected in the paucity of paent-physician conversaons. In a
study conducted by the Naonal Center on Addicon and Drug
Abuse at Columbia University, less than 20% of primary care doc-
tors described themselves as “very prepared” to idenfy alcohol-
ism and illegal drug use, and over 50% of paents with substance
use disorders said their primary care physician did not address
their substance abuse [11]. Honest and straighorward conver-
saons must be held between paents and providers regarding
the importance of keeping the PICC line as clean as possible, giv-
en its indwelling nature and the increased risk of endocardis in
IDUs. If paents plan or believe they might use the PICC line for
injecng drugs, oral anbioc alternaves may be tried with the
understanding that they may be less eecve [6,8,12]. Paents
can also be encouraged to inject more safely by cleaning the
site adequately, using sterile water to mix with their drugs, us-
ing new needles each me, and not sharing paraphernalia [13].
Addionally, appointments with paents at one-week intervals,
repeat blood tests and cultures, and close follow-up for symp-
toms or signs of infecon is essenal (Dr. Isaac Bogoch MD MPH,
personal communicaon, October 18, 2016). Ulmately, the goal
of the treatment is not to cure someone of their substance use
disorder, but rather to cure their infecon and act as a liaison to
further care should the paent desire.
Successful transion of IDUs from inpaent treatment to OPAT
has been documented in several case reports and studies,
however eecve transion requires careful paent selecon
[10,14]. Ho et al. demonstrated that paents straed by pre-
dened criteria can be safely and successfully treated with OPAT
[10]. Paents signed a contract asserng they would comply with
daily OPAT visits, they would not access the PICC line for drug
injecon, and they would not take drugs unless prescribed by a
hospital physician [10]. Formal drug counselling was provided at
the onset and as needed [10]. Intermient IV drug use was not
a denite dismissal from the program as long as the PICC line
was not used [10]. PICC lines were inspected by nurses for breach
of security seals (sckers) prior to anbioc administraon [10].
With these condions in place, the invesgators obtained similar
rates of readmission and PICC line infecons between IDUs and
non-IDUs [10].
More recently, the importance of appropriate paent selecon
for OPAT was also highlighted by Beieler et al [14]. The invesga-
tors examined the implementaon of OPAT at a medical respite
facility and found that rates of adverse events with IDUs (13%)
were similar to that of non-IDUs (3-10%), and the readmission
rate of IDUs was comparable to current literature of non-IDUs
(30% compared to 9-26%, respecvely) [14]. The invesgators
parally aributed OPAT success to the close examinaon of pa-
ents’ social behaviours throughout the selecon process [14].
Notably, IV drug use alone may be not be reecve of future
OPAT success or failure. Rather, housing status, mental health
history, the presence of a support system and a paent’s willing-
ness to comply with treatment all play a signicant role [14-16].
The balance between paent autonomy and physician benevo-
lence may appear tenuous when considering candidates for OPAT
who inject drugs. Nonetheless, healthcare providers must pro-
vide adequate informaon and support to IDUs with the capacity
Page 20 | UOJM Volume 7 Issue 1 | May 2017
to consent in order to help them to make informed decisions.
Care must be tailored to the individual; some IV drug users may
be appropriate and reliable candidates for OPAT, while others
may not be. In addion to appropriate paent selecon when
considering IDUs requiring OPAT, close follow-up, a compassion-
ate approach, provider educaon, and expansion of respite pro-
grams all introduce novel spaces for ongoing harm reducon and
good paent care. Further research is needed to clarify best prac-
ces regarding OPAT for IDUs, and to establish screening criteria
and guidelines for treatment in this populaon.
ACKNOWLEDGEMENTS
I would like to thank Dr. Isaac Bogoch for his guidance and sup-
port during both the clinical component and wring process of
this manuscript, and Marta Cybulsky for her ongoing feedback.
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Commentary
... Conversely, people who inject drugs (PWID) often remain hospitalized for the duration of their treatment due to concerns that unstable housing or ongoing drug use may inhibit treatment adherence and that patients will inject drugs and/or diverted medications into these devices [9][10][11]. However, there is a lack of empirical evidence on the prevalence and health risks associated with injecting drugs into VADs among either outpatient or hospitalized PWID [12][13][14][15]. Nevertheless, clinical guidance in many jurisdictions advises inpatient hospitalization and close monitoring as the primary strategy to prevent VAD complications for this patient population [9][10][11]. ...
... Harm Reduction Journal (2022) 19:54 opioid use disorders evidence-based medication treatment or harm reduction interventions [49]. Clinicians therefore should be educated and encouraged to engage patients with previous or active injection drug use in non-stigmatizing and factual conversations about reducing harms associated with drug use, including the potential risks of injecting into VADs [15,50]. Research to quantify VAD injecting risks is urgently needed to facilitate such factual discussions. ...
... In cases where education and available supports have not deterred VAD injecting, staff might consider supervising patients injecting into their VADs from within their hospital room (in jurisdictions where this is permissible) [64], or demonstrating how to more safely and sterilely inject into VADs, requesting patients avoid certain VADs, and establishing a non-punitive system for patients to report to hospital staff after use [15,57]. However, more research is needed to evaluate the effectiveness of these harm reduction strategies for reducing health harms of VAD injecting for hospitalized PWID. ...
Article
Full-text available
Background Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians’ concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms. Methods Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually. Results A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms. Conclusions VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.
... PICCs can either be valved (pressure-sensitive slits) or nonvalved, with valves keeping the exterior tube of the PICC closed, unless it is being used to transfer fluids into or out of the body ( Gonzalez & Cassaro, 2020 ;Quinte Health Care, 2016 ). PICCs are used to deliver a range of medications (e.g., antibiotics and antifungals) and treatments (e.g., chemotherapy) in hospital and community (e.g., outpatient parenteral antimicrobial therapy (OPAT)) ( Billick, 2017 ;Suzuki et al., 2018 ). PICCs can be used to administer fluids and treatments and collect blood samples, thus offering two-way access ( Duwadi, Zhao, & Budal, 2019 ). ...
... Despite reported efficacy and decades of routine use in clinical and community settings, there continues to be widespread controversy about offering PICCs to patients with a history of injection drug use ( Billick, 2017 ;Suzuki et al., 2018 ). This concern stems from PICCs being indicated in situations where the substance being injected is too caustic for regular intravenous injection (bypassing smaller veins and going directly to the heart), the healthcare team is unable to access the patient's veins (e.g., for infants), and if there is a need for frequent access (e.g., for daily medication and frequent blood draws). ...
... This concern stems from PICCs being indicated in situations where the substance being injected is too caustic for regular intravenous injection (bypassing smaller veins and going directly to the heart), the healthcare team is unable to access the patient's veins (e.g., for infants), and if there is a need for frequent access (e.g., for daily medication and frequent blood draws). With these benefits for both patients and providers in mind, there is concern about PICCs being 'misused' (e.g., being used to inject illicit drugs by patients who are unable to access their veins because of damage caused by past injecting), non-compliance with care instructions (especially in outpatient programs where patients are returning to their homes and may not be able to follow disinfection protocols), patient and staff safety, and perceived legal liability in cases where the patient has a documented history of injection drug use ( Billick, 2017 ;Suzuki et al., 2018 ;Tan, 2017 ). Despite these concerns, Billick (2017) has stated that "While [injection drug users (IDU)] have higher rates of infective endocarditis, abscesses and septicemia, there is no substantial body of evidence that PICC lines in IDUs result in more serious infections, increased overdoses or increased morbidity or mortality. ...
Article
Full-text available
Background People who use drugs (PWUD), and especially those who inject drugs, are at increased risk of acquiring bloodborne infections (e.g., HIV and HCV), experiencing drug-related harms (e.g., abscesses and overdose), and being hospitalized and requiring inpatient parenteral antibiotic therapy delivered through a peripherally inserted central catheter (PICC). The use of PICC lines with PWUD is understood to be a source of tension in hospital settings but has not been well researched. Drawing on theoretical and analytic insights from ”new materialism,” we consider the assemblage of sociomaterial elements that inform the use of PICCs. Methods This paper draws on n = 50 interviews conducted across two related qualitative research projects within a program of research about the impact of substance use on hospital admissions from the perspective of healthcare providers (HCPs) and people living with HIV/HCV who use drugs. This paper focuses on data about PICC lines collected in both studies. Results The decision to provide, maintain, or remove a PICC is based on a complex assemblage of factors (e.g., infections, bodies, drugs, memories, relations, spaces, temporalities, and contingencies) beyond whether parenteral intravenous antibiotic therapy is clinically indicated. HCPs expressed concerns about the risk posed by past, current, and future drug use, and contact with non-clinical spaces (e.g., patient's homes and the surrounding community), with some opting for second-line treatments and removing PICCs. The majority of PWUD described being subjected to threats of discharge and increased monitoring despite being too ill to use their PICC lines during past hospital admissions. A subset of PWUD reported using their PICC lines to inject drugs as a harm reduction strategy, and a subset of HCPs reported providing harm reduction-centred care. Conclusion Our analysis has implications for theorizing the role of PICC lines in the care of PWUD and identifies practical guidance for engaging them in productive and non-judgemental discussions about the risks of injecting into a PICC line, how to do it safely, and about medically supported alternatives.
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Background The use of injectable drugs and alcohol increased during the months of lockdown and continual uncertainty of the worldwide response to the COVID-19 virus and its variants. As the world adjusts to living with multiple transmissible viruses, the health care system needs a comprehensive approach to care for people who inject drugs. Although the problem of injectable drug use is wide-ranging, this article will focus on the intersection of the person who injects drugs and the health care system. Methods & Findings After an initial case involving a person who injects drugs requiring 42 days of intravenous antibiotics, the hospital began to develop plans to care for this patient population. Finding gaps in the research, a team at the hospital developed a Substance Use Risk Reduction Program that included a risk assessment scale, an interprofessional communication plan, and a set of protocols, then trialed these components between 2017 and 2019. The program successfully screened and collaborated care for patients with a history of injectable drug use. The goals to increase safety were addressed through the protocols that included tamper-evident technology and frequent observations by the staff. The risks of blood stream infection and overdose while a patient was in the hospital were reduced by using the risk reduction protocols. In addition, repudiated costs were decreased by thousands of dollars because of early planning for transfer from inpatient to outpatient, skilled nursing facility, or long-term acute care for the completion of intravenous therapy.
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We report a case of an intravenous drug user (IVDU) patient who had 4 episodes of endocarditis within a 2-year time period in rural Georgia. The institutional cost was approximately $380,000. The lack of an established transitional care plan for an IVDUs to an outpatient care is a common phenomenon at institutions. Guidelines are essential to optimize the quality of care rendered to IVDU with such infections, assist providers in utilizing limited resources, and limit the cost to the institutions.
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The role of oral antibiotic therapy in treating infective endocarditis (IE) is not well established. We searched MEDLINE, EMBASE and Scopus for studies in which oral antibiotic therapy was used for the treatment of IE. Seven observational studies evaluating the use oral beta-lactams (five), oral ciprofloxacin in combination with rifampin (one), and linezolid (one) for the treatment of IE caused by susceptible bacteria reported cure rates between 77% and 100%. Two other observational studies using aureomycin or sulfonamide, however, had failure rates >75%. One clinical trial comparing oral amoxicillinversus intravenous ceftriaxone for streptococcal IE reported 100% cure in both arms but its reporting had serious methodological limitations. One small clinical trial (n = 85) comparing oral ciprofloxacin and rifampin versus conventional intravenous antibiotic therapy for uncomplicated right-sided S. aureus IE in intravenous drug users (IVDUs) reported cure rates of 89% and 90% in each arm, respectively (P =0.9); however, drug toxicities were more common in the latter group (62% versus 3%; P <0.01). Major limitations of this trial were lack of allocation concealment and blinding at the delivery of the study drug(s) and assessment of outcomes. Reported cure rates for IE treated with oral antibiotic regimens vary widely. The use of oral ciprofloxacin in combination with rifampin for uncomplicated right-sided S. aureus IE in IVDUs is supported by one small clinical trial of relatively good quality and could be considered when conventional IV antibiotic therapy is not possible.
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Background: Outpatient parenteral antimicrobial therapy (OPAT) is a safe way to administer intravenous (IV) antimicrobial therapy to patients with the potential to decrease hospital length of stay (LOS). Often, homeless patients with complex infections, who could otherwise be treated as an outpatient, remain in the hospital for the duration of IV antibiotic treatment. Injection drug use (IDU) is a barrier to OPAT. Objective: To evaluate our experience with administering OPAT to homeless patients at a medical respite facility and determine if patients could complete a successful course of antibiotics. Design: Using retrospective chart review, demographics, diagnosis, and comorbidities including mental illness, current IDU, and remote IDU (>3 months ago) were recorded. Surgical, microbiologic, and antimicrobial therapy including route (IV or oral), duration of therapy, and adverse events were abstracted. Participants: Homeless patients >18 years old who received OPAT at medical respite after discharge, no exclusions. Main measurements: Primary outcome was successful completion of OPAT at medical respite. Secondary outcome was successful antimicrobial course completion for a specific diagnosis. Results: Forty-six (87%) patients successfully completed a defined course of antibiotic therapy. Thirty-four (64%) patients were successfully treated with OPAT at medical respite. Readmission rate was 30%. The average length of OPAT was 22 days. The cost savings to our institution (using 1500/dayinpatientcost)was1500/day inpatient cost) was 25,000 per episode of OPAT. Conclusions: OPAT can be successful in a supervised medical respite setting for homeless patients with the help of a multidisciplinary team, and can decrease inpatient LOS resulting in cost savings. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.
Conference Paper
In a retrospective review from 2002 to 2004 of 181 IVDU admissions for IV antibiotics to Vancouver General and St. Paul’s hospitals in Vancouver, 89 (49%) had incomplete treatment courses. In an attempt to improve care, the VCH piloted a 12-bed street-based live-in clinic in Vancouver’s downtown core area for IV therapy of infections in IVDU’s, 24 of whom have been enrolled to date. We compared their treatment course to 63 non-IVDU’s enrolled in the VCH home IV antibiotic program (NIVDU). Compliance, infection type, course duration, complications of PICC lines, were recorded. Median days of inpatient treatment inpatients were 17, and 13, and as outpatients 19 and 28, for IVDU and NIVDU respectively. Infections in IVDU vs NIVDU included: endocarditis 5/24 (21%) vs 14/63 (22%); osteomyelitis 13/24 (54%) vs 43/63 (68%); septic arthritis 6/24 (25%) vs 6/63 (17%). The causative organism in 16 of 24 (67%) IVDU’s was Staphylococcus aureus, with 75% of these being MRSA. In 42 NIVDU’s who had positive cultures, 14/42 (33%) were S. aureus (8 MSSA, 6 MRSA), and 19/42 (45%) were streptococci. In the IVDU group, antibiotics used were vancomycin in 12/24 (50%), β-lactam in 11/24 (46%). In the NIVDU group, 24/63 (38%) received vancomycin, and 39/63 (62%) received a β-lactam. PICC line problems occurred in 11/24 (46%) IVDU’s and in 15/63 (24%) (with 1 line infection) NIVDU’s. Replacement was required in 3/24(13%) and 9/63 (14%) respectively. Completed treatment was achieved in 21/24 IVDU’s (86%) (2 left AMA), and 50/63 NIVDU’s (79%) (2 left AMA). Readmissions for infection were 3/24 IVDU’s (13%), 1 with a relapse (osteomyelitis), and 4/63 NIVDU’s (6%) (all relapses of osteomyelitis). In conclusion, IV antibiotic therapy at a street-based live-in clinic for IVDU’s is feasible, and results in good compliance and outcomes, with acceptable rates of PICC complications.
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Addiction is defined as the need for and use of a habit-forming substance despite knowledge the substance is harmful. Addicted persons experience toler-ance (more and more of the sub-stance is required to achieve the same effect) and in the absence of the drug, they experience withdraw-al symptoms (Merriam-Webster, 2009). Addictions of all kinds (e.g., drugs, alcohol, nicotine, gambling, and eating disorders) result in sub-stantial costs to individuals, fami-lies, and society. They may lead to crime and violence, and they cost employers and taxpayers approxi-mately $590 billion annually in lost productivity and medical treatment (Addiction Treatment Magazine, 2012). While significant, however, these financial costs do not begin to approach the personal costs to indi-viduals and families who struggle with addiction. The Harm Reduction Coalition (n.d.a), a national advocacy group for persons affected by drug use, has noted that social inequality affects persons from different groups in dif-ferent ways, and works to insure even those with drug addictions have their rights honored, including the right to health care. Nurses and other health care professionals can play a vital role in the care of per-sons with addiction. When persons with addiction are approached by providers with disdain and rejec-tion, no matter how subtly, they may reject the care offered by these providers. In fact, negative behav-iors such as these may result in a missed opportunity for the addicted person to learn about important treatments. Incorporating harm reduction strategies and evidence-based interventions in working with persons with addiction yields the best opportunities for helping them get the care and treatment they need (Copenhaver, Lee, Margolin, Bruce, & Altice, 2011; Dutta, Wirtz, Baral, Beyrer, & Cleghorn, 2012). In this article, the science of addiction will be reviewed, with discussion of how nurses can be helpful to per-sons with addiction by taking a compassionate approach to their care.
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The enrollment of intravenous drug users (IVDUs) into an outpatient parenteral antibiotic treatment (OPAT) service using a peripherally inserted central catheter (PICC) is controversial and often avoided. The National University Hospital in Singapore has a policy of permitting OPAT-based treatment of IVDU patients with appropriate medical indications. We report on our experiences. A prospective observational study was conducted on IVDU patients requiring parenteral antibiotics via an OPAT service from January 2005 to December 2009. Clinically appropriate patients were screened using pre-defined criteria and enrolled into our service, where standardized measures were enforced to prevent and detect PICC abuse and optimize treatment. Outcomes measured included mortality, completion of therapy, PICC abuse, and readmission for infective or treatment-related complications during OPAT and a 30 day follow-up period. Twenty-nine IVDU patients received treatment in our OPAT service (total 675 patient-days). The median duration of therapy was 18 days (range 1-85). Infective endocarditis was the primary diagnosis in 42% of cases. Two patients (7%) had recrudescent infection after absconding during their inpatient stay. These two patients subsequently completed treatment in OPAT. There were no deaths or cases of PICC abuse. Five patients (17%) during OPAT and one patient (3%) during the 30-day follow-up period required readmission for infective or treatment-related complications. Appropriately selected, counselled and monitored patients with a history of being an IVDU can be treated safely and successfully via OPAT centres. It is likely that some will respond better to treatment in an outpatient setting.
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To provide a brief history of community syringe exchange programs (SEPs), describe the clinical profile of those who attend them, identify factors interfering with the transition of SEP participants to more comprehensive substance abuse treatment services, review studies designed to improve rates of treatment seeking, and offer practical suggestions to facilitate links between SEPs and substance abuse treatment. Relevant articles were identified using a PubMed literature search of English-language journals from 1997 to 2007. Studies were included that evaluated the effectiveness of SEPs or methods for increasing treatment enrolment in SEP participants or other out-of-treatment intravenous drug users. Relevant articles prior to 1997 were identified using reference lists of identified articles. SEPs have little impact on rates of drug use or injections. Substance abuse treatment reduces human immunodeficiency virus transmission through drug use reduction and psychosocial functioning improvement, yet SEP participants only infrequently engage in treatment. Psychological and pharmacological interventions delivered at the SEP setting can improve treatment seeking in SEP participants. Use of SEPs by substance abuse treatment programs can improve harm-reduction efforts at these settings. Efforts to improve the link between SEPs and substance abuse treatment should include interventions to enhance cooperation across programs, motivate treatment enrolment and SEP use, and expand access to treatment. A more fluent and bidirectional continuum of services can enhance the public health benefits of both of these health care delivery settings.
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Outpatient parenteral antibiotic therapy (OPAT) programmes have become prevalent over the past 2 decades. From the US perspective, these programmes have been shown to reduce healthcare costs. No comprehensive analysis has been published from the Canadian perspective. To describe a Canadian OPAT programme for the 3-year period since its inception and to conduct a treatment cost analysis. Demographics and resource utilisation data (health professional labour, laboratory and diagnostic tests, antimicrobials, delivery, home nursing care, catheters and catheter placement) were prospectively collected for enrollees in the OPAT programme over the evaluation period. Avoided hospital resource utilisation was estimated via retrospective chart review by the investigators. Costs were retrospectively assigned to each resource and total cost avoidance by the OPAT programme was determined from each perspective. A teaching hospital and a provincial Ministry of Health (MOH). 140 treatment courses were initiated for 117 adult patients (mean age 54 years) who were enrolled into the programme. Mean pre-OPAT length of hospital stay was 12 days, and mean OPAT duration was 22.5 days. Bone/joint (39%), skin and soft tissue (16%), cardiac (13%) and respiratory tract (12%) infections were the most common infections managed. The most commonly used antimicrobials were vancomycin (29%), cloxacillin +/- gentamicin (22%) and ceftriaxone +/- gentamicin (11%) 85% of enrollees successfully completed their planned antimicrobial treatment regimens. Premature discontinuation of antimicrobial therapy for various reasons occurred in the remaining 15% of courses. The mean cost per treatment course of OPAT was 1910 Canadian dollars (Can)fromthehospitalperspectiveandCan) from the hospital perspective and Can6326 from the MOH perspective. Assuming that patients would have otherwise completed their antimicrobial therapy in hospital, the mean cost per treatment course was estimated to be Can14,271.TheoverallcostavoidanceoftheOPATprogrammewasCan14,271. The overall cost avoidance of the OPAT programme was Can1,730,520 (hospital perspective) and $Can1,009,450 (MOH perspective) over the 3-year assessment period. Sensitivity analyses revealed the results to be robust to plausible changes. This analysis supports the premise that an adult OPAT programme can substantially reduce healthcare costs in the Canadian healthcare setting.