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Les ulisateurs de drogues injectables (UDIs) ayant besoin d’une anbiothérapie par voie parentérale ambulatoire (APA) pour des
infecons associées aux injecons se voient fréquemment refuser l’accès à un cathéter central à inseron périphérique (PICC, de
l’anglais) puisqu’on présume qu’ils l’uliseront pour s’injecter des drogues illicites, et que le cathéter sera ulisé de manière non stérile
ou peu hygiénique. Bien que les UDIs présentent des taux plus élevés d’endocardite infeceuse, d’abcès et de sepcémie, il n’existe
pas de preuves substanelles qui démontrent que les PICCs chez les UDIs entraînent des infecons plus sévères, ou une hausse de
surdoses, de morbidité ou de mortalité. La transion réussie des UDIs d’un traitement hospitalier vers une APA exige une sélecon at-
tenve des paents. Notamment, la situaon de logement, les antécédents de santé mentale, la présence d’un système de souen et
la volonté du paent de suivre le traitement contribuent tous au succès de l’APA. Des conversaons honnêtes et directes doivent avoir
lieu entre le paent et le fournisseur de soins quant aux risques et aux avantages d’un PICC et de l’ulisaon de drogues injectables.
Un suivi étroit, une approche compassante, la formaon appropriée des fournisseurs de soins, et l’expansion des programmes de
répit constuent tous de nouvelles façons de réduire les méfaits et d’améliorer les soins aux paents. Finalement, plus de recherche
est nécessaire an de mere en place des protocoles, des lignes directrices, des critères de dépistage et des transions de soins, et
pour clarier les praques exemplaires quant à l’APA chez les paents qui ulisent des drogues injectables.
PICC Your Bales: Considering the Appropriateness of Peripherally
Inserted Central Catheter (PICC) Lines for Outpaent Parenteral
Anmicrobial Therapy (OPAT) in Injecon Drug Users (IDUs)
Maxime Jasmine Billick, BA1
1 Faculty of Medicine, McGill University
BT lay with her head cocked in the only comfortable posion, her
thin legs protruding below imsy hospital sheets. I was on a rota-
on in Infecous Diseases based at several Toronto-area hospi-
tals and she was not my rst intravenous (IV) drug-using paent.
She was, however, the rst paent I had seen who was unable to
move her head more than several millimeters in either direcon
since a paraspinal abscess precariously abued her spinal cord.
BT could be argumentave—she had yelled at several nurses and
oen refused to have her vital signs taken. She also told me she
was scared—she recognized that nding herself in this posion
was likely secondary to her IV drug use. Despite delivering aen-
ve care, some of the nurses rolled their eyes when talking about
Injecon drug users (IDUs) requiring outpaent parenteral anbioc therapy (OPAT) for injecon-related infecons are regularly de-
nied the use of peripherally inserted central catheter (PICC) lines based on the assumpon 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 infecve endocardis, abscesses and
sepcemia, there is no substanal body of evidence that PICC lines in IDUs result in more serious infecons, increased overdoses or
increased morbidity or mortality. Successful transion of IDUs from inpaent treatment to OPAT requires appropriate paent selec-
on. Namely, housing status, mental health history, the presence of a support system, and a paent’s willingness to comply with
treatment all play a signicant role in OPAT success. Honest and straighorward conversaons must be undertaken between paent
and provider regarding the risks and benets of a PICC line if injecng drugs. Close follow-up, a compassionate approach, provider
educaon, and the expansion of respite programs all introduce novel spaces for ongoing harm reducon and good paent care. Finally,
further research is needed to establish protocols, guidelines, screening criteria, transion of care, and to clarify best pracces for OPAT
in paents who inject drugs.
Keywords: Drug Users; PICC Placement; Abscess; Heroin Dependence;
BT, and the social worker said that the paent refused her entry
into the hospital room because she “didn’t like [her] face.”
The senments I witnessed towards injecon drug users (IDUs)
are not unique to my clinical rotaon. A recent meta-analysis
sought to assess health professionals’ atudes regarding pa-
ents with substance use disorders and to examine the conse-
quences on healthcare delivery . The analysis revealed that
health care workers generally held negave atudes toward
paents with substance use disorders, oen taking an avoidant
approach to healthcare provision . This resulted in shorter vis-
its, diminished empathy, and lower personal engagement, pre-
sumed to result in subpar healthcare delivery . Addionally,
Page 19 | UOJM Volume 7 Issue 1 | May 2017
the negave atudes of health professionals add a signicant
barrier to paent recovery, since healthcare workers oen play a
crucial role in recognizing substance use problems, empowering
paents, and acng as gatekeepers to treatment .
BT required six weeks of anbioc therapy, most of which ne-
cessitated IV delivery via a peripherally inserted central catheter
(PICC) line. Numerous people on her immediate treang team
including nurses, aending surgeons, residents, and other con-
sultants were dismayed that an IDU would likely need a semi-
permanent PICC line.
Terary care hospitals throughout Canada arrange outpaent
parenteral anmicrobial therapy (OPAT) for paents requiring
long-term IV anbioc delivery. OPAT has demonstrated cost-
eecveness benets when compared to a full in-hospital IV
anbioc treatment course . A recent analysis of a 334-per-
son cohort in the UK esmated a yearly cost of approximately
£300,000 (including pre-clinical set-up costs), whereas the mini-
mum theorecal in-paent cost was more than three mes high-
er at £1,005,676 . Hospitalizing people solely for IV anmicro-
bial treatment is not cost eecve. Moreover, an addional bed
is occupied, which could be given to a paent in need . Despite
this, many physicians connue to believe IDUs should not be dis-
charged with a PICC line under any circumstances . During my
clinical training, common beliefs I noted among medical profes-
sionals included infecon of the line itself, and that the resulng
infecon would inherently be more serious than one acquired by
self-injecon. 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 infecve endocardis, abscesses and sepcemia [5-7].
However, there is no meaningful body of evidence that PICC lines
in IDUs result in more serious infecons, increased overdoses, or
increased morbidity and mortality. In fact, the few studies that
have examined PICC line complicaons concluded that complica-
on rates were similar amongst IDUs and non-users . 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
reected in the paucity of paent-physician conversaons. In a
study conducted by the Naonal Center on Addicon and Drug
Abuse at Columbia University, less than 20% of primary care doc-
tors described themselves as “very prepared” to idenfy alcohol-
ism and illegal drug use, and over 50% of paents with substance
use disorders said their primary care physician did not address
their substance abuse . Honest and straighorward conver-
saons must be held between paents and providers regarding
the importance of keeping the PICC line as clean as possible, giv-
en its indwelling nature and the increased risk of endocardis in
IDUs. If paents plan or believe they might use the PICC line for
injecng drugs, oral anbioc alternaves may be tried with the
understanding that they may be less eecve [6,8,12]. Paents
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 .
Addionally, appointments with paents at one-week intervals,
repeat blood tests and cultures, and close follow-up for symp-
toms or signs of infecon is essenal (Dr. Isaac Bogoch MD MPH,
personal communicaon, October 18, 2016). Ulmately, the goal
of the treatment is not to cure someone of their substance use
disorder, but rather to cure their infecon and act as a liaison to
further care should the paent desire.
Successful transion of IDUs from inpaent treatment to OPAT
has been documented in several case reports and studies,
however eecve transion requires careful paent selecon
[10,14]. Ho et al. demonstrated that paents straed by pre-
dened criteria can be safely and successfully treated with OPAT
. Paents signed a contract asserng they would comply with
daily OPAT visits, they would not access the PICC line for drug
injecon, and they would not take drugs unless prescribed by a
hospital physician . Formal drug counselling was provided at
the onset and as needed . Intermient IV drug use was not
a denite dismissal from the program as long as the PICC line
was not used . PICC lines were inspected by nurses for breach
of security seals (sckers) prior to anbioc administraon .
With these condions in place, the invesgators obtained similar
rates of readmission and PICC line infecons between IDUs and
More recently, the importance of appropriate paent selecon
for OPAT was also highlighted by Beieler et al . The invesga-
tors examined the implementaon 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%, respecvely) . The invesgators
parally aributed OPAT success to the close examinaon of pa-
ents’ social behaviours throughout the selecon process .
Notably, IV drug use alone may be not be reecve of future
OPAT success or failure. Rather, housing status, mental health
history, the presence of a support system and a paent’s willing-
ness to comply with treatment all play a signicant role [14-16].
The balance between paent autonomy and physician benevo-
lence may appear tenuous when considering candidates for OPAT
who inject drugs. Nonetheless, healthcare providers must pro-
vide adequate informaon 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 addion to appropriate paent selecon when
considering IDUs requiring OPAT, close follow-up, a compassion-
ate approach, provider educaon, and expansion of respite pro-
grams all introduce novel spaces for ongoing harm reducon and
good paent 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 populaon.
I would like to thank Dr. Isaac Bogoch for his guidance and sup-
port during both the clinical component and wring process of
this manuscript, and Marta Cybulsky for her ongoing feedback.
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