Monica K. Sikka

Background: Rates of serious injection-related infections in persons who use drugs have increased. Resulting admissions are an opportunity for screening and vaccination of preventable infections such as hepatitis A virus (HAV), hepatitis B virus (HBV), and tetanus. Design and methods: We conducted a retrospective review of adults with documented substance use admitted for bacterial infection between July 2015 and March 2020. We evaluated HAV, HBV, and tetanus vaccination status at admission, along with screening for HAV and HBV infection and immunity. We identified the proportion of patients at risk for infection who received HAV, HBV, and tetanus vaccines during admission and patient-level factors associated with vaccination. Results: We identified 280 patients who met our inclusion criteria. Of the 198 (70.7%) patients at risk for HAV, infectious disease providers recommended vaccination for 21 (10.6%) and 15 (7.6%) received HAV vaccine. Of the 174 (62.1%) patients at risk for HBV, infectious disease providers recommended vaccination for 32 (18.3%) and 25 (14.4%) received HBV vaccine. A large proportion of patients (31.4%, 88) had no documentation of prior tetanus vaccination, and infectious disease providers recommended tetanus vaccination for three (1.1%) and five patients (1.8%) received a tetanus booster. Infectious disease consult vaccine recommendations were statistically significantly associated with HAV or HBV vaccination prior to discharge. Conclusion: Over 70% of our population is at risk for one or more of these preventable infections. Efforts are needed to maximize inpatient screening and vaccination for HAV, HBV, and tetanus in patients with barriers to care.

Background: Patients with substance use disorders admitted for severe bacterial infection are in a prime position to be screened for important co-infections. However, data suggest that standard screening for co-infections in this population during hospital admission can vary in frequency and type of testing. Methods: We performed a retrospective review of patients to evaluate screening for co-infections during admission, followed by a case–control analysis to determine factors associated with lack of any screening. Results: We identified 280 patients with 320 eligible admissions. Most were male and Caucasian with unstable housing. Only 67 (23.9%) patients had a primary-care provider. About 89% ( n = 250) of our cohort were screened for one or more co-infection during their first admission with one patient never screened despite subsequent admissions. Of those screened, the greatest proportion was HIV (219, 81.4% of those without history of HIV), HCV (94, 79.7% of those without a prior positive HCV antibody), syphilis (206, 73.6%), gonorrhea, and chlamydia (47, 16.8%) with new positive tests identified in 60 (21.4%) people. Screening for all five co-infections was only completed in 15 (14.0%) of the 107 patients who had screening indications. Overall, a high proportion of those screened had a new positive test, including three cases of neurosyphilis, highlighting the importance of screening and treatment initiation. One patient was prescribed HIV pre-exposure prophylaxis at discharge and only 37 (34.6%) of those eligible were referred for HCV treatment or follow-up. In multivariable case–control analysis, non-Medicaid insurance (OR 2.8, 95% CI: 1.2–6.6, p = 0.02), use of only 1 substance (OR 2.9, 95% CI: 1.3–6.5, p < 0.01), and no documented screening recommendations by the infectious disease team (OR 3.7, 95% CI: 1.5–8.8, p < 0.01), were statistically significantly associated with lack of screening for any co-infection during hospital admission. Conclusion: Our data suggest additional interventions are needed to improve inpatient screening for co-infections in this population.

Background: Patients with injection drug use (IDU)-associated infections traditionally experience prolonged hospitalizations, which often result in negative experiences and bad outcomes. Harm reduction approaches that value patient autonomy and shared decision-making regarding outpatient treatment options may improve outcomes. We sought to identify health care professionals (HCPs) perspectives on the barriers to offering four different options to hospitalized people who use drugs (PWUD): long-term hospitalization, oral antibiotics, long-acting antibiotics at an infusion center, and outpatient parenteral antibiotics. Methods: We recruited HCPs ( n = 19) from a single tertiary care center in Portland, Maine. We interviewed HCPs involved with discharge decision-making and other HCPs involved in the specialized care of PWUD. Semi-structured interviews elicited lead HCP values, preferences, and concerns about presenting outpatient antimicrobial treatment options to PWUD, while support HCPs provided contextual information. We used the iterative categorization approach to code and thematically analyze transcripts. Results: HCPs were willing to present outpatient treatment options for patients with IDU-associated infections, yet several factors contributed to reluctance. First, insufficient resources, such as transportation, may make these options impractical. However, HCPs may be unaware of existing community resources or viable treatment options. They also may believe the hospital protects patients, and that discharging patients into the community exposes them to structural harms. Some HCPs are concerned that patients with substance use disorder will not make ‘good’ decisions regarding outpatient antimicrobial options. Finally, there is uncertainty about how responsibility for offering outpatient treatment is shared across changing care teams. Conclusion: HCPs perceive many barriers to offering outpatient care for people with IDU-associated infections, but with appropriate interventions to address their concerns, may be open to considering more options. This study provides important insights and contextual information that can help inform specific harm reduction interventions aimed at improving care of people with IDU-associated infections.