Drug Use-related Infections Research Articles

Centering persons who use drugs: addressing social determinants of health among patients hospitalized with substance use disorders

ABSTRACT Social workers have emerged as leaders within Addiction Consult Services (ACS) due to their ability to provide a wide range of services, from crisis work and brief therapeutic interventions to connecting patients to community resources. Many hospitals have implemented ACS to address the overdose crisis and the sharp rise in drug use-related infections, including skin and soft tissue infections, osteomyelitis, and endocarditis; a result of unaddressed systemic social determinants of health (SDOH). Yet, despite social workers being at the forefront of inpatient substance use work, little guidance exists regarding social work’s role in leading person-centered addiction care and addressing SDOH in the hospital setting. The authors of this paper are licensed clinical social workers who have worked across five different health systems, engaging persons who use drugs (PWUD) in the context of an ACS. This paper examines five practice interventions of social work practice within hospitals that represent key points for innovation. Drawing on social work’s unique commitments to social justice, strengths, and person-in-environment, these interventions operate within eco-social approaches to help us grapple more effectively with ways that health – and disease – are socially and economically produced by multiple interacting factors. We provide a clinical roadmap of interventions for social workers in hospital settings with PWUD to demonstrate how social work leadership within inpatient care models can help us better address the impacts of various intersecting SDOH on the care of PWUD.

Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study

BackgroundHospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention.MethodsParticipants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs.ResultsImplementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team’s advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing.ConclusionIntegration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.

1984. Implementation of an integrated infectious disease and substance use disorder team for the treatment of severe injection-related infections

Abstract Background Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment team for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. In order to facilitate implementation of this team, we conducted a qualitative study of patients and providers to identify barriers and facilitators to the team’s success. Methods Participants were patients with history of SIRIs (n=7) at the Jackson Memorial Hospital (JMH) and healthcare providers (HCPs) (n=8) at JMH. Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Science (CFIR). Interviews were transcribed and double coded by study team members using determinants adapted from the CFIR. Results Key barriers to SIRI team success included: 1) complexity of SIRI and SUD care requiring multidisciplinary teams and resources; 2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; 3) stigma and lack of knowledge around addiction and medications for SUD; and 4) suspected understaffing and underfunding for the team. Facilitators of team success included: 1) holistic, integrated care being more efficient and effective than fragmented care; 2) the team’s advocacy for PWID as a means of institutional culture change; 3) provision of close post-hospital follow-up for an often-abandoned population; 4) non-judgmental, harm reduction-oriented approach; and 5) addressing diverse needs such as housing, insurance, and psychological wellbeing. Conclusion Integration of infectious disease and substance use disorder treatment is a promising approach to managing patients with SIRIs; however, success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction. Disclosures Susanne Doblecki-Lewis, MD, MSPH, Gilead Sciences: Grant/Research Support.

744. Infectious Diseases Providers Perspectives Around the Use of Outpatient Parenteral Antibiotic Therapy (OPAT) for Persons Who Inject Drugs (PWID), US, 2022

Abstract Background Injection drug use-related infections are life threatening and may require prolonged courses of antibiotic therapy. There is no consensus on best practices for serious infections when patients are stable for discharge. Outpatient parenteral antimicrobial therapy (OPAT) has been shown to be feasible for people who inject drugs (PWID) especially when paired with medication for opioid use disorder. We set out to determine the current practice patterns and attitudes of infectious diseases (ID) clinicians in the United States regarding the use of OPAT for PWID. Methods We surveyed ID clinicians between January 2022 and March 2022. Topics focused on PWID including OPAT access, barriers to inclusion in OPAT, and factors clinicians considered for OPAT success. Responses from those who perceived PWID were eligible for OPAT (PWID-E) were compared to those who believed PWID were ineligible (PWID-I) using the Pearson chi-squared test. Results Of 239 clinician respondents, 80% were MD, 6% DO, 5% NP, 2% PA, and 7% Pharmacists. 187 (78.2%) work at an academic practice and 179 (75%) work in an urban setting. 182 (76%) respondents have access to inpatient addiction medicine services and 206 (86%) reported availability of outpatient addiction treatment, but only 86 (36%) described patient access to outpatient services as “good” or “excellent.” Respondents were categorized as PWID-E (n=171, 72%) and PWID-I (n=68, 28%). Of the PWID-E group, only 48 (28%) have an institutional policy for determining eligibility. There was no significant difference in practice setting or access to addiction services between PWID-E and PWID-I. Access to inpatient and outpatient social work/case management was significantly higher for PWID-E. (Table 1). Clinicians reporting PWID-I were more likely to cite risk of tampering with PICC (76.5% vs 62.6%, p = 0.04) and medical-legal risk (47.1% vs 19.3%, p < 0.001) as barriers to OPAT. (Table 2). Conclusion A high proportion of respondents to this national survey offer OPAT for PWID, but only a minority have an institutional policy for eligibility. Guidelines that outline a framework for discharge decision making, education regarding medical and legal risk, and development of best practices may help to standardize care across settings. Disclosures Ellen Eaton, MD, MPH, Gilead HIV Research Scholar: Grant/Research Support|Gilead HIV research scholar: Grant/Research Support Monica K. Sikka, MD, F2G: Site research investigator.

Program Adaptations to Provide Harm Reduction Services During the COVID-19 Pandemic: A Qualitative Study of Syringe Services Programs in the U.S.

Syringe services programs (SSPs) are essential to preventing injection drug use-related infections and overdose death among people who use drugs (PWUD). The novel coronavirus (COVID-19) pandemic initially impeded SSPs’ operations. To effectively support these programs, information is needed regarding SSPs’ experiences adapting their services and the challenges posed by COVID-19. We conducted qualitative interviews with leadership and staff from a sample of 31 U.S. SSPs. Respondents discussed urgent concerns including reduced reach of services, suspended HIV/hepatitis C testing, high COVID-19 risk among PWUD, and negative impacts of isolation on overdose and mental health. They also noted opportunities to improve future services for PWUD, including shifting to evidence-based distribution practices and maintaining regulatory changes that increased access to opioid use disorder medications post-pandemic. Findings can inform efforts to support SSPs in restoring and expanding services, and provide insight into SSPs’ role in engaging PWUD during the COVID-19 response and future emergencies.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10461-021-03332-7.

972. Infection and Overdose Prevention for Persons with Injection Drug Use-Related Infections: Evaluation of an Inpatient Quality Improvement Program

BackgroundHospitalizations for injection drug use-related infections (IDU-I) are increasing in North Carolina and nationally. Many IDU-I, such as endocarditis, bone, joint, and spine infections, require long antimicrobial courses and extended inpatient stays. These hospitalizations are opportunities to engage patients in overdose and infection prevention.MethodsA quality improvement (QI) program was piloted for inpatients with IDU-I. Eligible patients admitted to the inpatient pulmonary or infectious disease teams from 11/2019 to 01/2020 were referred to the QI team if they reported or were suspected to have injected drugs over the past year, or felt to benefit from drug-related infection prevention and overdose services. A checklist of recommendations to the care teams included: (1) screening for HIV, Hepatitis B (HBV) and C (HCV), (2) immunization for Hepatitis A (HAV), HBV, and tetanus, (3) prescription of naloxone at discharge, and (4) information on a syringe services program in or near their county. After review of the medical record, the QI team made recommendations on the appropriate taks from the checklist. The number of QI checklist tasks performed on the two inpatient teams during a 9-week pilot period (the above period excepting a two-week break) was reviewed. Baseline comparison data was not incorporated, owing to the challenges in retrospective identification of IDU-I.Results20 patients were included in the intervention. The median age was 32 years (IQR 27-38) and 70% were female. The most common diagnosis was endocarditis (40%) and the median length of stay was 11 days (IQR 5-42). HIV and HCV tests were each conducted in 95% of patients (Table). Screenings for HAV and HBV immunity were done in 90% of patients. HAV, HBV, and Tdap immunizations were given to 20%, 35%, and 50%, respectively. Naloxone was provided to 60% of patients at discharge and half of patients were referred to syringe programs. HCV was detected in 8 patients and HBV in 2 patients. No patients were diagnosed with HIV.Percentage of infection and overdose prevention services provided to eligible IDU-I patients during hospitalization. ConclusionIn a setting without comprehensive addiction consultation, a simple intervention provided guideline-concordant infection and overdose prevention services for persons hospitalized for IDU-I.Disclosures All Authors: No reported disclosures

The Deepening Opioid Crisis in North America: Historical Context and Current Solutions

The purpose of this review is to (1) detail the historical context behind the rise of opioid use disorder (OUD) and opioid-related harms in the United States (US) and Canada, (2) describe the epidemiology of OUD in these two countries, and (3) discuss current strategies being employed to address this public health emergency in North America. Opioid-related overdose has become a leading cause of unintentional injury related death in North America. Deaths have risen in parallel with opioid prescribing and the rising prevalence of unintentional exposure to highly potent synthetic opioids. At the same time, rates of injection drug use-related infections such as hepatitis C and endocarditis have also increased. Both Canada and the US have implemented policy changes and interventions at the national and local levels in an attempt to stem rising opioid attributable morbidity and mortality. In many settings, the collective goal has been to increase access to treatment of OUD, expand harm reduction interventions (including improved access to naloxone), and develop and disseminate guidelines on the safe prescribing of opioids for non-cancer pain and the management of OUD.

Endocarditis due to gram-negative bacilli at a French teaching hospital over a 6-year period: clinical characteristics and outcome

Background: Infective endocarditis (IE) due to gram-negative bacilli (GNB) is rare. However, several studies described a change in the epidemiological profile of patients within the past few years. Methods: We reviewed all cases diagnosed and followed in the infectious diseases ward of a French teaching hospital in Paris between 2009 and 2014, inclusive. Results: Among the 17 patients with definite GNB-IE (11 male, mean age 54 years), 12 (70%) were due to non-HACEK GNB and 5 (30%) to HACEK group GNB. A prosthetic valve was involved in 10 cases (8 in non-HACEK and 2 in HACEK group). Escherichia coli (4/12 patients) and Pseudomonas aeruginosa (3/12 patients) were the most common pathogens in the first group; all the pathogens in the second group were Haemophilus spp. One-third of the patients with non-HACEK GNB had nosocomial IE, whereas injection drug use-related infections were rare (2/12). All patients with HACEK infection had at least one complication (intracardiac abscess, stroke or other systemic embolization). All patients were treated by antibiotic combination therapy during a median time of 42 days (interquartile range (IQR) = 42–42) and 10 (59%) underwent cardiac surgery. One death at 9 months was observed in the non-HACEK group. Conclusions: Regarding HACEK IE, this report supports the frequent association with vascular complications. Regarding non-HACEK GNB IE, this report supports the increasing proportion of nosocomial infections. We reported a high proportion of surgery in the therapeutic management of both HACEK and non-HACEK groups associated with no in-hospital mortality.

A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida.

BackgroundInfections related to injection drug use are common. Harm reduction strategies such as syringe exchange programs and skin care clinics aim to prevent these infections in injection drug users (IDUs). Syringe exchange programs are currently prohibited by law in Florida. The goal of this study was to estimate the mortality and cost of injection drug use-related bacterial infections over a 12-month period to the county safety-net hospital in Miami, Florida. Additionally, the prevalence of HIV and hepatitis C virus among this cohort of hospitalized IDUs was estimated.Methods and FindingsIDUs discharged from Jackson Memorial Hospital were identified using the International Classification of Diseases, Ninth Revision, codes for illicit drug abuse and endocarditis, bacteremia or sepsis, osteomyelitis and skin and soft tissue infections (SSTIs). 349 IDUs were identified for chart abstraction and 92% were either uninsured or had publicly funded insurance. SSTIs, the most common infection, were reported in 64% of IDUs. HIV seroprevalence was 17%. Seventeen patients (4.9%) died during their hospitalization. The total cost for treatment for injection drug use-related infections to Jackson Memorial Hospital over the 12-month period was $11.4 million.ConclusionsInjection drug use-related bacterial infections represent a significant morbidity for IDUs in Miami-Dade County and a substantial financial cost to the county hospital. Strategies aimed at reducing risk of infections associated with injection drug use could decrease morbidity and the cost associated with these common, yet preventable infections.

Risk factors and prevalence of tuberculosis, human immunodeficiency virus, syphilis, hepatitis B virus, and hepatitis C virus among prisoners in Pakistan

ObjectiveThe objective of this study was to evaluate the burden of sexual- and injection drug use-related infections in male prisoners in Karachi, Pakistan. MethodsWe administered a structured questionnaire in a cross-sectional survey of 365 randomly selected imprisoned men. We analyzed blood for the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) by ELISA, and for syphilis by rapid plasma reagin with Treponema pallidum hemagglutination assay confirmation. Subjects with possible tuberculosis (World Health Organization criteria) provided sputum samples for an acid-fast bacillus smear and culture. ResultsThe prevalence of tuberculosis was 2.2% (95% CI 0.71–3.8%). Of 357 of the randomly selected prisoners (eight refused to give blood), 2.0% (95% CI 0.6–3.4) were HIV-infected; syphilis was confirmed in 8.9% (95% CI 6.0–11.8%), HBV in 5.9% (95% CI 3.5–8.3%), and HCV in 15.2% (95% CI 11.7–18.8). By self-report, 59.2% had used any illicit drugs, among whom 11.8% (95% CI 8.5–15.0) had injected drugs. The median length of stay in the prison had been 3.2 (range 1–72) months. ConclusionsAll four infections were prevalent among the prisoners in Pakistan. Prisons are excellent venues for infectious disease screening and intervention given the conditions of poverty and drug addiction. Collaboration with community-based health providers is vital for post-discharge planning.

Dynamic Cost-Benefit Analysis of Drug Substitution Programs

This paper studies optimal spending for drug substitution programs in the context of a dynamic epidemic model of both drug use and drug use-related infections. Two types of costs are considered in addition to control costs: social costs resulting from individuals being dependent on drugs; additional costs due to drug users being vulnerable to infections like hepatitis C or HIV. Analysis of the model demonstrates that the long-run equilibrium is not necessarily unique. Instead, there may be multiple equilibria. Which of these equilibria is optimal depends on the initial conditions for the number of drug addicts and the number of those who are infected. So, for a given set of epidemic parameters, it may be optimal to spend a lot on substitution programs that reduce the number of drug addicts or to spend little and to accept a high level of drug use.

Fungal infections in drug users

Fungal infections may account for 5-50% of serious infections in intravenous drug users, and for 5-50 per 100,000 hospital admissions. The fungi most commonly encountered are Candida and Aspergillus spp. Candidosis may be disseminated, with lesions in superficial structures, the eye and the skeletal system, or limited to the eye, the heart (as endocarditis) or the central nervous system. Aspergillosis usually presents as endophthalmitis or as central nervous system infection. Mucormycosis is also met with occasionally, and various fungi may cause endophthalmitis or endocarditis. Antifungal therapy for intravenous drug use-related infections is no different from that for similar mycoses in other patients, but the management of intravenous drug users requires considerable clinical skill.