Complications Of Injection Drug Use Research Articles

1413. Regional variation in substance use associated infectious endocarditis in New York State: 2000-2014.

Abstract Background Injection drug use is a significant and growing public health concern in New York State (NYS). Infectious endocarditis (IE) is a serious complication of injection drug use, and is associated with significant morbidity and mortality, prolonged hospitalizations, and high healthcare costs. Methods Data was extracted from the Agency for Healthcare Research and Quality’s (AHRQ) Healthcare Cost and Utilization Project (HCUP)’s New York State Inpatient Database (SID) to determine incidence of IE in New York between 2000-2014. The HCUP-SID database includes inpatient discharge records from hospitals across the state regardless of payer and contains information on inpatient healthcare utilization. Regional incidence was then calculated using population values from the 2010 regional census. Cost of hospitalization was derived from the HCUP using the cost to charge ratio (CCR) file to estimate the cost of inpatient hospital stays. Results During the study interval the number of statewide substance use-associated IE cases fluctuated between a low of 262 cases in 2000, and a high of 362 cases in 2007. Approximately 70-80% of the patients with substance use-associated IE in NYS in this study were insured through public programs (Medicare or Medicaid). In-hospital mortality from substance use-associated IE appears to be decreasing slightly, however, there is an accompanying increase in hospital costs, in part due to long average length of hospital stays between 13 and 18 days. The mean cost of hospitalization rose notably from $51,934 to $134,325 over the course of our study. Over 10% of hospitalizations culminated in patient directed discharges. Over the study period New York City’s incidence rates appeared to decrease while other region’s incidence rates appeared to increase, specifically in the Capital District, Central New York, and Southern Tier regions. Trends in substance use associated infectious endocarditis in NYS This figure shows trends in endocarditis in the study period. It shows a rise in cases in substance use associated endocarditis in NYS in less urban areas. Conclusion Between 2000 and 2014 the rates of substance use-associated infective endocarditis in NYS fluctuated but remained fairly constant. Despite the relatively constant statewide rates, there was important regional variation, including decreasing incidence rates of SUIE in New York City and rising incidence rates in non-New York City counties. Disclosures Shashi Kapadia, MD, GIlead: Grant/Research Support.

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

BackgroundOver the past two decades, the United States has experienced a dramatic increase in the rate of injection drug use, injection associated infections, and overdose mortality. A hospital-based program for treating opioid use disorder in people who inject drugs presenting with invasive infections was initiated at an academic tertiary care center in 2020. The goal of this program was to improve care outcomes, enhance patient experiences, and facilitate transition from the hospital to longer term addiction care. The purpose of this study was to interview two cohorts of patients, those admitted before vs. after initiation of this program, to understand the program's impact on care from the patient's perspective and explore ways in which the program could be improved.MethodsThirty patients admitted to the hospital with infectious complications of injection drug use were interviewed using a semi-structured format. Interviews were transcribed and coded. Emergent themes were reported. Limited descriptive statistics were reported based on chart review.ResultsThirty interviews were completed; 16 participants were part of the program (admitted after program implementation) while 14 were not participants (admitted prior to implementation). Common themes associated with hospitalization included inadequate pain control, access to medications for opioid use disorder (MOUD), loss of freedom, stigma from healthcare personnel, and benefits of having an interprofessional team. Participants in the program were more likely to report adequate pain control and access to MOUD and many cited benefits from receiving care from an interprofessional team.ConclusionsPatients with opioid use disorder admitted with injection related infections reported improved experiences when receiving care from an interprofessional team focused on their addiction. However, perceived stigma from healthcare personnel and loss of freedom related to hospitalization were continued barriers to care before and after implementation of this program.

Effect of an Unsanctioned Safe Consumption Site in the United States on Syringe Sharing, Rushed Injections, and Isolated Injection Drug Use: A Longitudinal Cohort Analysis.

HIV and other medical complications of drug use, including overdose, are rising among people who inject drugs in the United States (US). Risk of complications and mortality increase with injection behaviors such as syringe sharing, rushing injections, and injecting in isolated places. Studies suggest safe consumption sites (SCS) reduce high-risk injection behaviors by offering sterile syringes and a safe, supervised space to consume drugs, although this has yet to be evaluated in the US. An unsanctioned SCS in an undisclosed US location. From 2018 to 2019, we recruited people who inject drugs using targeted sampling methods (N = 494) and conducted interviews at baseline, 6-, and 12-months. We sought to determine associations of past-month SCS use with past-month receptive syringe sharing, rushed injections, and injections in isolated places. We analyzed data using inverse probability of treatment weighted Poisson regression models. Generalized estimating equations accounted for repeated measures. Fifty-two (11%) participants had past-month SCS use. Participants with past-month SCS use had decreased rates of receptive syringe sharing (Incident rate ratio [IRR] 0.17, 95% CI: 0.03 to 1.02) and injecting in an isolated location (IRR 0.77, 95% CI: 0.54 to 1.27) compared with those without past-month SCS use, although results were not statistically conclusive. Rate of rushed injections was only slightly lower (IRR 0.94, 95% CI: 0.70 to 1.30). SCS may show benefit in reducing high-risk injection practices, and legal sanctioning of an SCS may offer further advantages. SCS implementation should be considered to help reduce the spread of HIV, overdose mortality, and prevent other medical complications of injection drug use.

Injection Drug Use Associated Infections are a Major Determinant of Maternal Morbidity in Pregnant Persons with Opiate Use Disorder

Infectious complications of injection drug use constitute a major medical morbidity underrecognized in the setting of the opioid epidemic. Persons who inject drugs are at risk for acquiring invasive bacterial infections and these infections are increasing in parallel to the opioid epidemic. National attention has been drawn to the opioid epidemic in pregnant people and the development of neonatal abstinence syndrome, yet these life-threatening infectious complications have not been characterized.

1362. Adding Insult to Injury: Association of Stigmatizing Language and Suboptimal Outcomes in People Who Inject Drugs

Abstract Background The National Academy of Medicine has identified stigma surrounding substance use disorders (SUDs) and infectious diseases (ID) as a key barrier to integration of opioid use disorder (OUD) and ID services. Prior literature on stigmatizing language in OUD clinical care focuses on surveys and theoretical scenarios rather than real-world data. As part of a larger study of patients admitted for infectious complications of injection drug use (CHOICE), we sought to determine how inpatient physicians describe persons with OUD, as well as associations of this language with outcomes along the OUD continuum of care. Methods CHOICE is a retrospective review of adults hospitalized with an infectious complication of OUD and IDU at four academic medical centers. Included patients were hospitalized between 1/1/2018-12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data was abstracted regarding demographics, inpatient interventions, transitions of care, and outcomes 1 year after admission. Potentially stigmatizing language was identified based on the discharge summary. “Abuse” and “misuse” were considered potentially stigmatizing; “use disorder” was considered best practice. Associations of language and outcomes were analyzed via logistic generalized estimating equations. Results A total of 287 subjects met inclusion criteria; 119 (42%) were female and the median age was 40 years (IQR: 32 – 52). The most common terms used to describe OUD were “abuse” (190, 66%) and “IVDU” (119, 42%). “Use disorder” was noted in only 72 (25%) charts. In a regression analysis, any mention of “use disorder” was associated with not leaving against medical advice (OR 2.48, 95% CI 1.24 – 4.95), a plan for ongoing OUD treatment (OR 5.17, 95% CI 2.05-13.0), and addiction-specific follow up (OR 2.94, 95% CI 2.34-3.68). Conclusion In this multicenter retrospective study, inpatient physicians commonly referred to patients with OUD using stigmatizing language. When NIH-preferred language was used this was associated with improved outcomes along the OUD continuum of care, possibly reflecting increased awareness of best practices for treating patients with OUD. Disclosures Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

690. High Mortality and Over-representation of Young Women Amongst People Who Inject Drugs Admitted with Infective Endocarditis in Saskatchewan, Canada from 2013-2018

BackgroundThe province of Saskatchewan has had the highest rates of HIV and Hepatitis C in Canada for over 10 years, the majority of which is related to People who inject drugs (PWID) and with higher proportion of young women. However, the most severe complications of injection drug use (IDU) are infective endocarditis (IE) and its associated sequelae. While high rates of IE have been noted, no data exists to show the burden of infective endocarditis and its clinical outcomes. Thus, we looked to determine the mortality and impact of IE amongst PWID and also establish the epidemiology while comparing to non-PWID IE. MethodsThis is a retrospective chart review of consecutive adult patients (age > 18) admitted for IE, as defined by Duke’s IE Criteria, at tertiary care hospitals in Regina, the capital city of Saskatchewan, between January 1, 2013 and December 31, 2018. PWID were identified through chart documentation of self-reported IV drug use. Outcomes included 1-year mortality, surgical intervention and referral to addiction services. ResultsOf the total 227 patients in our cohort, 130 (57.3%) were female, and the 1-year mortality was 39.2%. PWID related IE comprised 132 (58.1%) of the cohort. In comparison to non-PWID related IE, PWID were younger (median age 38.0, compared to 68.0 for non-PWID), more likely to be female (RR 2.06; 95% CI [1.44-3.04]; p< 0.001), to suffer right-sided disease (RR 9.14; 95% CI [4.74-15.14]; p< 0.001) and less likely to receive surgical management (RR 0.30; 95% CI [0.27-0.77]; p< 0.001). Surgical management was associated with lower mortality (RR 0.40; 95% CI [0.11-0.65]; p< 0.001). Addiction support and treatment also was protective (RR 0.89; 95% CI [0.34-1.21]; p=0.051). ConclusionThis cohort study of IE episodes shows for the first time the devastating impact of IDU in Saskatchewan and identifies PWID as having a 39% mortality at 1 year, which coupled with their younger age translates into an enormous years of life lost. Additionally, the over-representation of young women amongst PWID IE is consistent with the higher percentage of young women with HIV and HCV infections, and identifies them as a group that is particularly vulnerable to complications of IDU. Targeted programs for PWID, particularly towards young women at risk are urgently needed. Disclosures All Authors: No reported disclosures

A community-based study of abscess self-treatment and barriers to medical care among people who inject drugs in the United States.

Skin and soft tissue infections (SSTIs) are the most common medical complication of injection drug use in the United States, though little work has been done assessing SSTI treatment among people who inject drugs (PWID). We examined past-3-month abscess characteristics, treatment utilization, and barriers to medical treatment among N=494 community-recruited PWID. We used descriptive statistics to determine the frequencies of self-treatment and medical treatment for their most recent past-3-month abscess as well as barriers to seeking medical treatment. We then used bivariate and multivariate logistic regression to identify factors associated with having an abscess in the past 3months. Overall, 67% of participating PWID ever had an abscess and 23% had one in the past 3months. Only 29% got medical treatment for their most recent abscess whereas 79% self-treated. Methods for self-treatment included pressing the pus out (81%), applying a hot compress (79%), and applying hydrogen peroxide (67%). Most (91%) self-treated abscesses healed without further intervention. Barriers to medical treatment included long wait times (56%), being afraid to go (49%), and not wanting to be identified as a PWID (46%). Factors associated independently with having an abscess in the past 3months were injecting purposely into muscle tissue (adjusted odds ratio [AOR]=2.64), having difficulty finding a vein (AOR=2.08), and sharing injection preparation equipment (AOR=1.74). Our findings emphasize the importance of expanding community-based access to SSTI education and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking resources.

Unexpected Hepatitis B Virus Infection After Liver Transplantation - United States, 2014-2019.

Unexpected donor-derived hepatitis B virus (HBV) infection is defined as a new HBV infection in a recipient of a transplanted organ from a donor who tested negative for total antihepatitis B core antibody (total anti-HBc), hepatitis B surface antigen (HBsAg), and HBV DNA* before organ procurement. Such infections are rare and are associated with injection drug use among deceased donors (1). During 2014-2019, CDC received 20 reports of HBV infection among recipients of livers from donors who had no evidence of past or current HBV infection. Investigation included review of laboratory data and medical records. Fourteen of these new HBV infections were detected during 2019 alone; infections were detected a median of 38 (range = 5-116) weeks after transplantation. Of the 14 donors, 13 were hepatitis C virus (HCV)-seropositive† and had a history of injection drug use within the year preceding death, a positive toxicology result, or both. Because injection drug use is the most commonly reported risk factor for hepatitis C,§ providers caring for recipients of organs from donors who are HCV-seropositive or recently injected drugs should maintain awareness of infectious complications of injection drug use and monitor recipients accordingly (2). In addition to testing for HBV DNA at 4-6 weeks after transplantation, clinicians caring for liver transplant recipients should consider testing for HBV DNA 1 year after transplantation or at any time if signs and symptoms of viral hepatitis develop, even if previous tests were negative (2).

HIV detection by an emergency department HIV screening program during a regional outbreak among people who inject drugs.

ObjectiveMultiple HIV outbreaks among persons who inject drugs (PWID) have occurred in the US since 2015. Emergency departments (EDs), recognized as essential venues for HIV screening, may play a unique role in identifying undiagnosed HIV among PWID, who frequently present for complications of injection drug use (IDU). Our objective was to describe changes in HIV diagnoses among PWID detected by an ED HIV screening program and estimate the program’s contribution to HIV diagnoses among PWID county-wide during the emergence of a regional HIV outbreak.MethodsThis was a retrospective study of electronically queried clinical records from an urban, safety-net ED’s HIV screening program and publicly available HIV surveillance data for its surrounding county, Hamilton County, Ohio. Outcomes included the change in number of HIV diagnoses and the ED’s contribution to case identification county-wide, overall and for PWID during 2014–2018.ResultsDuring 2014–2018, the annual number of HIV diagnoses made by the ED program increased from 20 to 42 overall, and from 1 to 18 for PWID. We estimated that the ED contributed 18% of HIV diagnoses in the county and 22% of diagnoses among PWID.ConclusionsThe ED program contributed 1 in 5 new HIV diagnoses among PWID county-wide, further illustrating the importance of ED HIV screening programs in identifying undiagnosed HIV infections. In areas experiencing increasing IDU, HIV screening in EDs can provide an early indication of increasing HIV diagnoses among PWID and can substantially contribute to case-finding during an HIV outbreak.

Hospital admissions and mortality due to complications of injection drug use in two hospitals in Regina, Canada: retrospective chart review

BackgroundInfectious complications of injection drug use (IDU) often require lengthy inpatient treatment. Our objective was to identify the number of admissions related to IDU in Regina, Canada, as well as describe patient demographics and comorbidities, yearly mortality, readmission rate, and cumulative cost of these hospitalizations between January 1 and December 31, 2018. Additionally, we sought to identify factors that increased risk of death or readmission.MethodsThis study is a retrospective chart review conducted at the two hospitals in Regina. Eligible study cases were identified by querying the discharge database for predetermined International Classification of Diseases code combinations. Electronic medical records were reviewed to assess whether each admission met inclusion criteria, and hospitalization and patient data were subsequently extracted for all included admissions. Mortality data were gleaned from hospital and Ministry of Health databases. Data were analyzed using Excel and IBM SPSS Statistics to identify common comorbidities, admission diagnoses, and costs, as well as to compare patients with a single admission during the study period to those with multiple admissions. Logistic regression analysis was used to identify the relationship between individual variables and in- and out-of-hospital annual mortality.ResultsOne hundred and forty-nine admissions were included, with 102 unique patients identified. Common comorbidities included hepatitis C (47%), human immunodeficiency virus (HIV) (25%), and comorbid psychiatric disorders (19%). In 23% of all admissions, patients left hospital prior to treatment completion, and 27% of patients experienced multiple admissions. Female patients and those with chronic pain were more likely to be readmitted (p = 0.024 and p = 0.029, respectively). Patients admitted with infective endocarditis were more likely to die during hospitalization (p = 0.0001). The overall mortality was 15% in our cohort. The estimated cumulative cost of inpatient treatment of complications of IDU in Regina was $3.7 million CAD in 2018.ConclusionPatients with history of IDU and hospital admission experience high mortality rates in Regina, a city with paucity of inpatient supports for persons who use injection drugs. Needle syringe programs, opioid agonist therapy, and safe consumption sites have been shown to improve outcomes as well as reduce healthcare costs for this patient population. We will use our findings to advocate for increased access to these harm reduction strategies in Regina, particularly for inpatients.

The Dynamics of Infectious Diseases Associated With Injection Drug Use in Lawrence and Lowell, Massachusetts.

BackgroundThere are a wide variety of infectious complications of injection drug use. Understanding the trajectory of these complications might inform the development of an early warning system for human immunodeficiency virus (HIV) outbreaks that occur regularly among people who inject drugs (PWID).MethodsA distributed lag Poisson regression model in the Bayesian setting was used to examine temporal patterns in the incidence of injection-associated infectious diseases and their association with HIV cases in Lawrence and Lowell, Massachusetts between 2005 and 2018.ResultsCurrent-month HIV counts are associated with fatal overdoses approximately 8 months prior, cases of infective endocarditis 10 months prior, and cases of skin and soft tissue infections and incision and drainage procedures associated with these infections 12 months prior.ConclusionsCollecting data on these other complications associated with injection drug use by public health departments may be important to consider because these complications may serve as input to a sentinel system to trigger early intervention and avert potential outbreaks of HIV.

Impact of medications for opioid use disorder among persons hospitalized for drug use-associated skin and soft tissue infections

BackgroundSkin and soft tissue infections (SSTI) are common complications of injection drug use. We aimed to determine if rehospitalization and recurrent SSTI differ among persons with opioid use disorder (OUD) hospitalized for SSTI who are initiated on MOUD within 30 days of discharge and those who are not. MethodsWe performed a retrospective analysis of commercially insured adults aged 18 years and older in the U.S. with OUD and hospitalization for injection-related SSTI from 2010–2017. The primary exposure was initiation of MOUD in the 30 days following hospitalization for SSTI. The primary outcomes included 30-day and 1-year 1) all-cause rehospitalization and 2) recurrent SSTI. We calculated the incidence rates for the two groups: MOUD group and no MOUD group for the primary outcomes. We developed Cox models to determine if rehospitalization and recurrent SSTI differ between the two groups. ResultsOnly 5.5 % (357/6538) of people received MOUD in the month following their index SSTI hospitalization. 30-day rehospitalization incidence was higher in the MOUD group compared to no MOUD (35.9 vs 27.5 per 100 person-30 days) and one-year SSTI recurrence was lower (10.3 vs 18.7 per 100 person-years). In multivariable modeling, the MOUD group remained at significantly higher risk of 30-day rehospitalization compared to the no MOUD group and at lower risk for one-year SSTI recurrence. ConclusionsMOUD receipt following SSTI hospitalization decreases risk of recurrent SSTI among persons with OUD. Further expansion of these in-hospital services could provide an effective tool in the U.S. response to the opioid epidemic.

Clinical ultrasonography in patients who inject drugs (the CUPID protocol): an illustrated case series.

In 2017, there were ≈47,600 opioid overdose‐related deaths in the United States. US emergency department (ED) visits for suspected opioid overdose increased by 30% between July 2016 and September 2017.2 The current US opioid epidemic makes it critical for emergency physicians to be aware of common and uncommon infectious and non‐infectious complications of injection drug use. Point‐of‐care ultrasound has become a widely available, non‐invasive diagnostic tool in EDs across the United States and worldwide. The increasing population of injection drug use patients is at risk for serious morbidity and mortality from an array of disease states amenable to ultrasound‐based diagnosis. We propose a protocol for clinical ultrasonography in patients who inject drugs (the CUPID protocol), a focused, 3‐system point‐of‐care ultrasound approach emphasizing cardiovascular, thoracic, and musculoskeletal imaging. The protocol is a screening tool, designed to detect high risk infectious and noninfectious complications of injection drug use.

Rural-Urban Differences in Hospitalizations for Opioid Use-Associated Infective Endocarditis in the United States, 2003-2016.

BackgroundThe incidence of infective endocarditis, a serious heart infection that can result from injection drug use, has increased in step with the opioid epidemic. Harm reduction services aimed at decreasing infectious complications of injection drug use are limited in rural areas; however, it is unknown whether the burden of opioid use–associated infective endocarditis varies between rural and urban populations.MethodsWe used 2003–2016 National (Nationwide) Inpatient Sample data and joinpoint regression to compare trends in hospitalization for opioid use–associated infective endocarditis between rural and urban populations.ResultsRates of US hospitalizations for opioid use–associated infective endocarditis increased from 0.28 to 3.86 per 100 000 rural residents, as compared with 1.26 to 3.49 for urban residents (overall difference in annual percent change P < .01). We observed 2 distinct trend periods, with a period of little change between 2003 and 2009/2010 (annual percent change, 0.0% rural vs –0.08% urban) followed by a large increase in hospitalization rates between 2009/2010 and 2016 (annual percent change, 0.35% rural vs 0.36% urban). Over the study period, opioid use–associated infective endocarditis hospitalizations shifted toward younger age groups for both rural and urban residents, and rural resident hospitalizations increasingly occurred at urban teaching hospitals. For both groups, Medicaid was the most common payer.ConclusionsThe increase in US hospitalizations for opioid use–associated infective endocarditis over the past decade supports the importance of public health efforts to reduce injection-related infections in both urban and rural areas. Future studies should examine factors affecting the higher increase in rate of these hospitalizations in rural areas.

767. Can Integration of Addiction Treatment Facilitate Safe Discharge on OPAT for Patients with Infectious Complications of Injection Drug Use?

BackgroundWhile there is a growing body of evidence that suggests outpatient parental antibiotic treatment (OPAT) for people who inject drugs (PWID) may be safe, research on integrating OPAT with addiction treatment for PWID has been limited.MethodsAdults hospitalized for infectious complications of injection drug use (IDU) requiring prolonged IV antibiotics were included in this study. The suitability for OPAT was determined by the infectious disease and addiction consultation services. Eligibility criteria included safe housing, attendance at infectious disease (ID) clinic visits, and engagement with addiction treatment. Demographic and clinical outcomes were summarized, and compared with patients without any IDU history enrolled in OPAT during the same time at the same institution.ResultsEighteen OPAT episodes among 17 individuals were included, with 9 (50.0%) males. Mean age was 38.4 (SD 9.5). Types of infection included endocarditis (38.9%), epidural abscess (38.9%), and bone/joint infections (33.3%). Opioid use disorders (OUD) were most common (94.4%), followed by cocaine (33.3%) and benzodiazepines (16.7%). All individuals completed the recommended course of IV antibiotics. All OUD patients received buprenorphine (52.9%) or methadone (47.1%). Two (11.1%) relapsed to drug use during OPAT, but no instances of line tampering, thrombosis, line infection or line dislodgement were identified. No deaths or overdoses were reported. Collectively, 504 inpatient days were avoided. Compared with 390 individuals without any history of IDU, those with IDU history were significantly younger (38.4 vs. 59.0, P < 0.0001), had fewer episodes of endocarditis (38.9% vs. 43.6%) and bone/joint infections (33.3% vs. 41.8%), but more epidural abscesses (38.9% vs. 3.1%). There were no statistical differences in rates of readmission (22.2% vs. 11.3%), line complications (0% vs. 3.5%), mortality (0% vs. 1.0%), ID clinic visit attendance (100.0% vs. 82.0%), or number of days on OPAT (28.0 vs. 30.1).ConclusionResults add further evidence of OPAT’s safety among PWID and that integration of addiction treatment may be feasible. OPAT outcomes were similar to those without any IDU history. More research is needed to study the impact of integrating addiction treatment with OPAT for PWID. Disclosures All authors: No reported disclosures.

140. Trends of Infective Endocarditis at a Northern New England Academic Medical Center, From 2011 to 2017: A Case for Improved Methods to Reliably Identify Associated Substance Use

BackgroundInfective endocarditis (IE) is a morbid and often lethal complication of injection drug use. There is an urgent need for accurate surveillance for IE related to substance use (SU) to support control strategies.MethodsWe conducted a retrospective comparative analysis of 3 datasets evaluating patients aged ≥16 years admitted to an academic medical center in New England with an ICD-9/10 discharge diagnosis of IE from April 2011 to December 2017. The 3 datasets included the hospital’s electronic medical record (EMR); the hospital’s Outpatient Parenteral Antibiotic Therapy (OPAT) program dataset; and the New Hampshire Uniform Hospital Discharge Data Set (UHDDS). We analyzed the number of admissions for IE per year, stratified by SU. We developed a SU composite measure by incorporating multiple sources of data from the EMR, and then verified accuracy of both the SU and IE diagnoses through manual chart review.ResultsThe EMR documented 472 hospital admissions for IE, representing 385 unique patients. The median age was 56 years and 59% were men. Admissions increased 67%, from 56 in 2012 to 84 in 2017. SU was coded as a discharge diagnosis in 27% of these admissions; however, based on our composite measure of SU, 45% IE admissions were possibly associated with SU. The proportion of IE patients who had evidence of SU increased from 20% in 2011 to 49% in 2017 (P = 0.002). Patients with SU compared with those without were younger (40.5 vs. 65.2 years, P < 0.001) and more likely to be on Medicaid (59% vs. 8%, P < 0.001). They had higher average charges ($146,633 vs. $107,223, P = 0.002) and lengths of stay (19.1 vs. 13.4 days, P < 0.001). The UHDDS and EMR datasets identified a similar numbers of patients with a diagnosis of IE; however, manual chart review revealed that IE was over-coded in ~one-fifth of admissions.ConclusionThe rate of IE in our hospital increased dramatically between 2011 and 2017, with a rising proportion associated with SU. Despite these trends, we found that discharge diagnosis coding alone substantially underestimated associated SU and overestimated IE disease burden. Our findings suggest public health administrative datasets, such as the UHDDS, can contribute to surveillance of IE disease burden with consideration of these important limitations, especially for assessing disease trends.Disclosures All authors: No reported disclosures.

167. Deep Space Infections in Injection Drug Users (IDU)

BackgroundThe opioid epidemic in the US has increased attention to infectious complications of injection drug use (IDU). The goal of our study was to ascertain the impact of these infections on the health of our community and institutional burden considering that our institution does not discharge patients with IDU for outpatient IV antibiotic treatments due to lack of safe environment and compliance concerns.MethodsThis retrospective study reviewed IDU-associated deep space infections in an 1100 -bed medical center from 2010 through 2014. Pathogens, site of infection, mortality rates and, length of stay (LOS), 3- month readmission (inpatient + observation), leaving against medical advice (AMA) rates for those alive at discharge, were evaluated. ICD-9/10 coding identified admissions related to opioid use and deep infections (endocarditis, diskitis/osteomyelitis, sepsis/bacteremia, empyema). Only the most severe infection was counted for each patient. Charts were reviewed to determine whether IDU was associated with the entree infections.ResultsA total of 505 patients met criteria for deep space infections associated with IDU over 5 years. Of those, 305 (60%) were male, 146 (29%) black, 335 (66%) white, 271 (54%) were on Medicaid, 246 (49%) had sepsis/bacteremia, 67 (13%) had endocarditis,143 (28%) discitis/osteomyelitis, 22 (4%) empyema and 27 (5%) other. Mean age was 46 ± 12 years. LOS varied by disease state. The overall median was 10 days, from 8 days for bacteremia/sepsis up to 27 for endocarditis. There were 43 (9%) hospital deaths; 30 (6%) patients left AMA and 209 (45%) patients were readmitted within 3 months.ConclusionDeep space infections in IDU patients result in long LOS, high mortality and high rates of readmissions and departures AMA. Improved algorithms for management that include psychosocial models and incorporate cost-effective and safe antibiotic administration need to be developed.Disclosures All authors: No reported disclosures.

Implementation facilitation to promote emergency department-initiated buprenorphine for opioid use disorder: protocol for a hybrid type III effectiveness-implementation study (Project ED HEALTH)

BackgroundPatients with opioid use disorder (OUD) frequently present to the emergency department (ED) after overdose, or seeking treatment for general medical conditions, their addiction, withdrawal symptoms, or complications of injection drug use, such as soft tissue infections. ED-initiated buprenorphine has been shown to be effective in increasing patient engagement in treatment compared with brief intervention with a facilitated referral or referral alone. However, adoption into practice has lagged behind need. To address this implementation challenge, we are evaluating the impact of implementation facilitation (IF) on the adoption of ED-initiated buprenorphine for OUD into practice.MethodsThis protocol describes a study that is being conducted through the National Institute on Drug Abuse’s Center for the Clinical Trials Network. A hybrid type III effectiveness-implementation study design is used to evaluate the effectiveness of a standard educational dissemination strategy versus IF on implementation (primary) and effectiveness (secondary) outcomes in four urban, academic EDs. Sites start with a standard 60-min “Grand Rounds” educational intervention describing the prevalence of ED patients with OUD, the evidence for opioid agonist treatment and for innovative interventions with ED-initiated buprenorphine; followed by a 1-year baseline evaluation period. Using a modified stepped wedge design, sites are randomly assigned to the IF intervention which is guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess evidence, context, and facilitation-related factors impacting the adoption of ED-initiated buprenorphine. During the 6 months of IF through the 1-year IF evaluation period, external facilitators work with local stakeholders to tailor and refine a bundle of activities to meet the site’s needs. The primary analyses compare the baseline evaluation period to the IF evaluation period (n = 120 patients with untreated OUD enrolled during each period) on (1) rates of provision of ED-initiated buprenorphine by ED providers with referral for ongoing medication (implementation outcome) and (2) rates of patient engagement in addiction treatment on the 30th day after the ED visit (effectiveness outcome). Finally, we will perform a cost-effectiveness analysis (CEA) to determine if the effectiveness benefits are worth the additional costs.DiscussionResults will generate novel information regarding the impact of IF as a strategy to promote ED-initiated buprenorphine.Trial registrationClinicalTrials.gov NCT03023930 first posted 1/10/2017, https://clinicaltrials.gov/ct2/show/NCT03023930?term=0069&rank=1

1020. Injection Drug Use-Associated Staphylococcus aureus Bacteremia in a Large Urban Hospital in Atlanta, Georgia

BackgroundInfectious complications of injection drug use (IDU) have increased with the expanding opioid epidemic in the southeast. We assessed the incidence, clinical presentation, and treatment outcomes of IDU-associated Staphylococcus aureus (SA) bacteremia (SAB).MethodsWe created a retrospective cohort of all adults with community acquired (CA) SAB over 5 years presenting to Grady Memorial Hospital, a 1,000-bed urban county hospital in Atlanta, GA. Charts were reviewed by infectious diseases physicians to obtain clinical and laboratory characteristics, including substance use disorder (SUD), and determine if SAB was IDU-associated. The study period was divided into three periods (P1 = March 2012–January 2014, P2 = January 2014–December 2015, P3 = December 2015–November 2017) to evaluate changes in the incidence of IDU-SAB over time using Poisson regression.ResultsAmong 321 patients with a first episode of CA-SAB, 24 (7%) were IDU-SAB. The number of IDU-SAB cases in each period increased (P1 = 4, P2 = 7, and P3 = 13 [P = 0.07 for trend]). The median age of IDU-SAB patients was 38 (IQR 31–57), 11 (46%) were black, and 15 (63%) had chronic hepatitis C virus infection. Heroin was the most common injected drug (92%) followed by cocaine (25%); multiple drugs were injected in 29%. All but two patients (92%) had a complication of SAB, most commonly endocarditis (50%) and septic pulmonary emboli (38%). The median hospitalization was 23 days (IQR 19.5–37.5) and 5 patients (12%) left the hospital against medical advice (AMA). Readmission for persistent or recurrent SA infection during the study period was common (42%), and three (13%) died ≤6 months from initial presentation, including two with prior discharge AMA. Half of the discharge summaries did not mention SUD as a hospital problem. Outpatient SUD treatment was recommended to eight (33%) patients and a recommendation of abstinence was the intervention for 12 (50%).ConclusionIncreasing IDU-SAB was observed over 5 years in our urban Atlanta hospital, primarily due to heroin use. Most cases were associated with complications of SAB with a long length of stay and frequent readmission, but few patients received treatment or harm reduction interventions for their SUD. These data will raise awareness and direct resources to expanding evidence-based opioid use disorder treatment for patients with infectious complications of IDU.Disclosures All authors: No reported disclosures.

Access to Syringe Services Programs - Kentucky, North Carolina, and West Virginia, 2013-2017.

The Appalachian region of the United States is experiencing a large increase in hepatitis C virus (HCV) infections related to injection drug use (IDU) (1). Syringe services programs (SSPs) providing sufficient access to safe injection equipment can reduce hepatitis C transmission by 56%; combined SSPs and medication-assisted treatment can reduce transmission by 74% (2). However, access to SSPs has been limited in the United States, especially in rural areas and southern and midwestern states (3). This report describes the expansion of SSPs in Kentucky, North Carolina, and West Virginia during 2013-August 1, 2017. State-level data on the number of SSPs, client visits, and services offered were collected by each state through surveys of SSPs and aggregated in a standard format for this report. In 2013, one SSP operated in a free clinic in West Virginia, and SSPs were illegal in Kentucky and North Carolina; by August 2017, SSPs had been legalized in Kentucky and North Carolina, and 53 SSPs operated in the three states. In many cases, SSPs provide integrated services to address hepatitis and human immunodeficiency virus (HIV) infection, overdose, addiction, unintended pregnancy, neonatal abstinence syndrome, and other complications of IDU. Prioritizing development of SSPs with sufficient capacity, particularly in states with counties vulnerable to epidemics of hepatitis and HIV infection related to IDU, can expand access to care for populations at risk.