Drs. Nathan Nolan and Raagini Jawa discuss a case that traverses some of the intersections of ID and addiction medicine.

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Hi everyone.

Welcome to Febrile, a cultured podcast about all things infectious disease.

We use consult questions to dive into ID clinical reasoning, diagnostics, and anti-microbial management.

I'm Sara Dong, your host and a Med-Peds ID fellow.

Here on Febrile, we use patient cases and chat with ID discussants to learn more about high-yield ID topics.

I will first welcome our co-host today.

Dr.

Nathan Nolan.

Nathan is a recent ID fellowship grad from the Washington University School of Medicine in St.

Louis and currently is an instructor and a med ed fellow.

He has a special focus on marginalized populations, including patients who use drugs and patients who are unhoused.

Our guests discussant today is Dr.

Raagini Jawa.

Dr.

Jawa is a clinical instructor at Boston University School of Medicine, where she practices Infectious Disease and Addiction Medicine.

Her research has focused on the intersection of ID and addiction with a focus on harm reduction practices as a mechanism to reduce the rate of infectious complications occurring in people who inject drugs.

Welcome to the show, friends.

Thank you.

Hi.

Um, so before Nathan takes us to the case, we like to ask as everyone's favorite cultured podcast, if you could share a little piece of culture or something that brings you happiness.

Nathan, would you like to go first?

Sure.

I don't know if this fits the normal definition that you have, but, uh, I recently was on vacation in Puerto Rico.

And I got the opportunity to go to a bioluminescent bay, which is where they have the little plankton that light up.

And it was one of the coolest experiences and it was just so beautiful.

And.

I would say, if you ever get an opportunity to go to Puerto Rico and do that, uh, you definitely should.

That sounds a very exciting, I am really jealous and I need to make a trip to Puerto Rico.

I'm a photography junkie and I'm, I'm like waiting for something beautiful to just show up that I can photograph.

New England winters are very dreary.

Um, what brings me joy?

I mean, right now, what brings me joy is TLC's 90 Day Fiancé.

I will tell you, I am such a reality show junkie.

There is nothing more relaxing than coming home from a long day of ID consults or HIV clinic or whatever.

And then just being like, I'm going to watch 90 Day Fiancé re-runs.

Um, it's fantastic.

If you haven't enjoyed an episode.

I highly encourage you do that.

This is not sponsored by TLC but I, I, it's a really great show.

It's sometimes mind numbing, but, um, that's my guilty pleasure.

Sometimes that's what you need though.

A little bit of mind numbing at the end of the day, or at least I do.

Awesome.

Well, those are both great.

Um, so today's consult question is about a 35 year old male who is admitted with fevers.

So I will throw it over to Nathan.

Okay.

So we have a 35 year old male patient who has a history of substance use disorder.

And specifically he uses injection opioids.

And he's admitted for fevers that have been ongoing for two weeks.

He has a history of hepatitis C that has been untreated.

He uses fentanyl by way of injection and uses daily.

He tries to use new needles when able, but sometimes has to re-use his needles if he's not able to get new ones.

He does not routinely clean his skin before injection.

He lives within the city, but is unstably housed.

He describes his situation as couch surfing.

He has history of skin infections in the past, but has never had to be admitted to the hospital for any serious, uh, injection site related injury or infection for the last two weeks.

He has been noting night sweats and fevers.

He also reports low energy, low appetite, and progressive difficulty with his breathing today.

He had some more trouble with his breathing and decided to present to the emergency room.

He has no prior medical history, no history of any major surgery.

On the initial evaluation in the ER, he looks moderately ill and he's found to have a fever of 38.1 degrees Celsius.

His heart rate is 111 and his respiratory rate is 20.

He was breathing comfortably on room air and his blood pressure was stable.

His heart exam was significant for a systolic murmur heard best at the right sternal border.

He has lower extremity edema, which is 2+.

He has some faint crackles in the left lung.

And then his initial lab work comes back as a CBC with a white count of 18000 with 82% neutrophils with 3% bands.

His hemoglobin is 13.

His platelets are 180,000 and a metabolic panel demonstrates a sodium of 1 35, potassium of 4, chloride 101, bicarb 24, BUN 37, Cr 2 with an unknown baseline.

His glucose is 98.

AST is 93, ALT 92.

On chest x-ray, he has a peripheral opacity in the left lower lung field concerning for an infectious process.

So blood cultures are obtained and he's admitted to the hospital.

And so you're asked to see him as a consult.

Do you have any initial thoughts about this case or how you might approach a patient that you're seeing that may have injection related infection?

Yeah.

Thanks for this case, Nathan, this clearly is a patient who is quite unwell.

Um, he's young, he's coming in with symptoms for two weeks with SIRS and perhaps a pulmonary process.

And I think that the point of this podcast is really to not only sort of dispel myths about people with substance use disorders, but, but I think our differential as ID docs and medical docs is pretty much the same as any other patient.

This patient has some sort of infection.

And, um, I don't, I think that when I approached this sort of patient initially, um, my differential diagnosis, it's the same as a patient without addiction.

It's a homeless patient with two week long febrile illness, SIRS, leukocytosis with bandemia, AKI, transaminitis, and then all of these physical exam findings that are really concerning for some sort of pulmonary cardiac process.

So new systolic murmur, new lower extremity edema, some sort of left lower lobe infiltrate.

So.

I'm thinking, oh gosh, patient probably has a bacterial process.

Pneumonia, maybe a cardiac process.

Because of their homelessness, as an ID doc, I'd always be worried about something a little bit more insidious like TB.

Um, and so those would be the things highest on my differential that I hope like most of our medical colleagues would be keeping, um, highest on their differential.

But your question Nathan was really about, well, how do you sort of approach the fact that this patient is, is unlike others and has an additional past medical history of, uh, injection drug use specifically opioid use.

And I do think that that adds a new flare to our differential diagnosis.

And that really means that our differential diagnosis should have the typical, you know, pneumonia, cardiac process, TB, but we should have a higher index of suspicion for um, hematogenous introduced bacterial infections or fungal processes.

So this could be like endocarditis, osteomyelitis, septic arthritis, a serious skin and soft tissue infection that may be the patients not necessarily telling you about that could be concurrent with the thing that is causing him to have shortness of breath.

Um, and then the other things on the differential that probably don't fit with this illness script could be like an acute viral illness.

Um, so.

Differential is pretty much the same, but when you add injection drug use into the past medical history, it does make the index of suspicion higher for other hematogenously introduced bacterial and fungal processes.

Wow.

That was a really excellent discussion.

Thank you for that.

I can give you a little bit more of the case if you're ready.

Sure.

So the patient was admitted to the internal medicine service and he was empirically started on ceftriaxone and vancomycin.

Uh, shortly after admission, he becomes diaphoretic with severe abdominal cramps, nausea and diarrhea.

His blood pressure increases to 167/101 and his heart rate is now 120.

He appears agitated.

So I guess my question at this point is you talked about how there may be some other levels or other components of this presentation.

And I would say that my concern is, as a physician would be that this patient might have a secondary process on top of whatever their infection is that's ongoing and you know, this could be related to his opioid use disorder.

How do you go about, uh, addressing opioid withdrawal in patients like this who may be admitted with a unrelated processes?

So I think as any medical or specifically for infectious disease providers, it's important for us to think in our differential diagnosis, not just like the typical complications of drug use, but also the mimics of sepsis and sepsis like phenomena.

So opiate withdrawal and, and many drug withdrawal syndromes oftentimes can be mimicking sepsis and autonomic dysregulation.

And so for any patient with substance use disorder, I always like to ask, not only signs and symptoms that they're presenting with, but also when is the last time they used, um, What that means is what are they using?

And are they on any medications for their drug use?

Um, that could impact their risk of experiencing opiate withdrawal.

Uh, if it's not acutely managed in the hospital setting.

And yes, we go to medical school and get our bachelor's and get masters and, you know, get all these special degrees.

But for patients with addiction, when they're using drugs, they are the experts of their own bodies and they understand the keen pharmacokinetics and dynamics of the specific types of drugs that they're using.

So the questions that I like to ask my patients is.

Do you have any symptoms of withdrawal at this moment, from whatever substance that they're using, whether it be opiates, whether it be stimulants, whether it be alcohol, benzodiazepines.

The symptoms of opiate withdrawal are sort of at the same timeline that you told me about Nathan.

They start anywhere from 24 to 36 hours since the last time they use.

And again, that can vary depending on the potency and the type of opioid that patients are using.

So if their body is dependent on sort of longer acting opioid agonists, um, their withdrawal symptoms may not come for a little bit of time, but if they're using things like fentanyl which is very much, um, infiltrated into the drug supply, at least it has in New England, patients start experiencing withdrawal symptoms very quickly, sometimes even before the 24 hour period.

So they might start feeling sick in the emergency room bay and these symptoms can be very similar to sepsis, right?

They can be diaphoresis, dilated pupils, rhinorrhea, diarrhea, abdominal cramping, nausea, muscle spasms, anxiety, piloerection.

In the hospital, at least in my hospital, we have these inbuilt like COWS (Clinical Opiate Withdrawal Scale) scores, uh, which is an opiate withdrawal scale that our nursing colleagues can sort of score up patients.

But depending on the type of hospital or clinic system you might be in, you can always Google it and find out like, what are the typical signs and symptoms for opiate withdrawal?

And you can score your patient yourself, and then say, gosh, if they're scoring like an eight or a 10 on the COWS scale, then that probably means that they're experiencing withdrawal symptoms and that might be confounding or contributing to the worsened hemodynamics that the patient is currently going through.

So that's how I address the whole "is my patient going through opiate withdrawal at this moment?"

Now I will make this note.

Okay.

The first question should not just be, are you going through opiate withdrawals and what's your COWS scale?

The next question needs to be, well, what the heck am I going to do about it?

And you have so many tools to actually manage patients with opiate withdrawal, but, but your patient needs to be engaged and you need to have a conversation with your patient on how they think would be best to manage their withdrawal symptoms.

To help them feel comfortable and it sort of take the opiate withdrawal symptoms off of their plate when they're already feeling sick from a bacterial or fungal process.

And I think we, as clinical providers could do better in this realm.

I think sometimes we, we know like, oh, I'm going to ask.

Are they having withdrawals?

I know how to do the score.

And then we sort of feel like, oh gosh, I don't know what to do next.

Am I enabling the patient?

Am I making their drug use worse?

Am I going to make their hemodynamics worse?

And the answer is no.

Drugs have very typical pharmaco kinetics and dynamics patients withdraw.

And us as medical providers have a responsibility to manage the withdrawal in whatever setting in the outpatient setting or in the hospital.

What I would advise in this stage is once you've identified patient is withdrawing, is to work with the patient, ask them what their goals are for management of the opiate withdrawal symptoms short and long-term and use that hospital stay as a reachable moment.

Um, and there's a lot of literature on what reachable moments are.

But it's really your opportunity to reach out to the patient and say, Hey, I'm here to treat your infection.

I'm here to make you feel better.

And I also don't want you to withdraw and this sort of fosters a very respectful, trusting relationship and the go-to medications that you have in your armamentarium as a clinical provider are not only like the stigmatized medications, like methadone and buprenorphine that sometimes clinicians feel uncomfortable prescribing, but it's stuff that we like give all the time, like NSAIDs, like Tylenol, like hydroxizine, clonidine, Bentyl.

We can prescribe all of these medications to help our patients feel more comfortable.

You can also prescribe your patients short or long acting opioids and other medications for opiate use disorder, whether they be methadone and buprenorphine, both that are opioid agonists or partial opiate agonist.

I just want to make sure we take a quick pause here for you to tell us just a little bit about how to gather a history around IV drug use, because I think there are a lot of listeners who maybe aren't as familiar with what to ask.

And so specifically, what might be the types of questions you ask and how those are useful to you as you think about your patient.

Oh, of course.

So ID docs love histories, and I love this.

If I'm taking care of a patient with injection drug use, it is my responsibility to not only get a good social history, but, uh, specifically an injection drug use history.

And so I like to ask nitty gritties, what drugs are my patients injecting or using?

Cause it doesn't necessarily mean that my patients are going to be using an injection route of drugs.

Right?

They might be inhaling.

They might be smoking.

They might be taking oral medications or other routes of administration.

And I like to ask what drugs they're using.

So is it opioids only or is it opioids and stimulants?

And if it's stimulants then which stimulants, like, is it cocaine, crack, methamphetamine?

And the reason why is because not only will that guide you on their withdrawal syndrome, that will also potentially guide you on some of the risk taking behaviors they're engaging in and it will probably guide you on some of the injection drug use related complications they might be facing.

So for instance, things like methamphetamine, so stimulants are vasoconstricting.

And so those patients often tend to have a lot of ischemic, uh, skin infections.

Um, or if patients are engaging in methamphetamine with other substances there that's been associated with, uh, riskier injection drug use and sexual risk behaviors.

So the questions keep going.

Um, the questions you can ask are when was the last time they used, how are the patients injecting?

Um, and how frequently are your patients injecting?

And you might be surprised.

Some patients will say I live at home.

I inject in the bathroom maybe once a day.

Um, and that might not be the same type of patient who might be unstably housed, who might say I have no place to inject.

I'm injecting 10, 15 times a day.

Um, and then the obvious next questions would be.

Where are you getting your injection drug preparation equipment from, is it the local needle exchange?

Is it the local pharmacy?

Are you reusing your injection drug preparation equipment or are you stealing it or are you taking it from one of your family members again?

Again, as an ID doc, all of those risk behaviors have implications for the type of infectious complications this patient might be having that I need to address, maybe not in that moment, but maybe down the stream in the hospital stay.

The other questions I ask it'll be, you know, how are you cooking your drugs?

That means are you using a flame to dissolve your drugs?

And where are you getting your solvents from?

Is it tap water?

Is it.

Uh, toilet water.

Is it spit?

Is it snow?

Um, balls?

And you'd be really surprised because all of those sources of, uh, solvents that our patients could be using may have different bacterial and fungal contaminants within them that could cause downstream complications.

And so the last few questions I like to ask is number of times they've reused or shared their injection equipment.

Um, if they have engaged in.

Uh, cotton shots.

And for those of you who are less familiar with cotton shots, cottons are typically filters that are used to take out any sort of.

Uh, contaminants and drug products, as you're sucking up the drug from your cooker, which is the receptacle on which your patient is probably cooking drugs and often cotton shots are the drug that's residually left behind that patients may or may not save or sell in order to, you know, uh, have it for a rainy day that when you're not able to, um, resource your drugs reliably, you still have something to prevent you from getting sick.

Um, because you know that that cotton is probably loaded with a little bit of drug products in it.

In my mind, if a patient is engaging in cotton shots, that's like a real red flag that this patient is really struggling.

We need to engage them.

They're high risk of bacterial and fungal complications.

Um, on the other stuff is like, uh, you know, we ask about past medical history.

So injection past medical history is going to be, are they having prior skin and soft tissue infections?

Have they had serious infection, infectious complications, like abscesses or endocarditis or osteomyelitis?

Have they had a prior immunocompromised infection like HIV?

Have they ever been on PrEP?

And then how are they supporting their habit?

Our patient is unstable housed.

It seems like this person's really struggling, maintaining their, you know, usual, uh, ability to do their day to day.

Um, how are they may, you know, supporting their habit?

Is it through, um, selling drugs or peddling or is it through transactional sex or other risky behaviors?

All of these questions should be in our background for talking to patients with injection drug use, um, and addiction.

And, and trust me while this hasn't been studied formally, I do think that if a clinician can have an open, honest conversation with a patient who's struggling with injection drug use and ask them all of these history, uh, uh, questions.

Your patient will very naturally open up.

You might not even have to prompt these questions.

They will just tell you because it might be one of the first times that that patient is heard an empathetic provider actually ask them what they're doing and how they're feeling.

Um, uh, it stinks guys, like there's so much stigma around patients with addiction.

And while I'd love to think that the medical environment is immune to that stigma.

I think we're getting there, but it's taking some time and it's going to need some champions like you all to sort of break those barriers, um, and, and help this patient population feel more.

That the hospital is a welcoming environment.

Yeah.

Thanks so much.

I really wanted to make sure we outlined those questions explicitly.

And I totally agree with you.

I think it makes a huge difference when you have these conversations with our patients, uh, to try to develop that trust.

But also I think to make sure we're continuing to model that to others around you in the healthcare setting.

So I do a lot of harm reduction research among learners, and, uh, if you teach trainees on having safe injection practice discussions with patients, it actually has shown to be associated with increased compassion satisfaction towards caring for this patient population.

And that has implications, right?

Like if we feel compassionate to someone suffering, we also provide them better care.

And I think that oftentimes, like these questions are not taught in medical school.

And so we can only model it through these podcasts and model it through champions, local champions who are taking care of these patients.

Uh, but I really do hope that there is a culture change over the years.

Well, our patients are coming in more and more with infectious complications.

They're more and more in your hospital words as you're being seen by hospitalists, by seeing by internal medicine, med peds trainees, family medicine, surgical trainees, um, and, and this dialogue needs to be part of our conversation guide.

So that was a really great explanation.

And, uh, I appreciate you talking about also the use of, of short acting opioids in, uh, treating withdrawal.

You know, oftentimes we have patients that come in that, uh, like you said, trying to meet a patient where they're at.

They may not be ready to be on some sort of agonist therapy, or maybe they have a procedure that's going to happen and they may need, um, analgesia more than what might be provided with something like buprenorphine.

So, uh, we'll move on with the case.

Um, the patient has started on buprenorphine.

This improves his symptoms of withdrawal.

He is also provided with symptomatic relief, including loperamide and Clonidine.

On hospital day two, his blood cultures turned positive for Gram positive cocci in chains.

Uh, repeat blood cultures are obtained and the transthoracic echocardiogram is performed.

This demonstrates a three centimeter vegetation on the tricuspid valve on hospital day three.

The organism is identified as Streptococcus mitis.

And so given this information, is there anything you would do different in regards to this patient's management?

So Nathan, I'm going to probe you and say, what do you mean by the patient's management?

Do you mean the antibiotic management, the medication for opiate use disorder management or harm reduction management?

Potentially all of the above, but I think in this moment you have new microbiologic data, so probably would be the management of the actual infection itself.

Totally.

So for a Strep mitis species that is typically, uh, uh, very sensitive pathogen.

I think that narrowing the antibiotics is probably most appropriate in this case.

Typically Strep mitis is, is a if I don't remember if you said it's penicillin susceptible.

So I would, I would narrow it down to the most susceptible type of agent, um, to simplify the patient's antibiotic regimen.

In terms of the medications for opioid use disorder management seems like the patient was started on buprenorphine for, or opioid withdrawal.

And I think that this would be an appropriate time to check in on the patient and see how are those symptoms going?

Is the patient's withdrawal being managed appropriately on the current dose and or does that dose need to be titrated further?

Typically buprenorphine is dosed either once or twice or thrice a day.

Um, and the questions to ask your patient for any medication for opioid use disorder, there's actually three goals.

Um, this goes for methadone and for buprenorphine, the first goal, uh, of titrating a medication, um, like an MOUD is managing the opiod withdrawal syndrome symptoms.

The second goal is to prevent cravings.

And the third goal is if you were to use drugs on top, that there'll be like a blocking dose that you wouldn't actually be able to have, uh, an intoxication syndrome, um, if you were to use.

And so that's really the goals that you should be trying to achieve even in the hospital, stay.

For a patient who is newly started on a medication for opioid use disorder, so I think the management here would be checking in on the patient, seeing how they're doing on their withdrawal symptoms.

If those are managed, you're a rock star, then see if there you're being able to do.

You know, the goal number two or three, are there cravings managed?

Because being in the hospital is no joke.

It stinks.

And especially for patients who are struggling with a substance use disorder and unstable housing, being in a closed hospital, there is nothing worse.

It feels like jail.

And so patients will often have cravings as they're feeling better.

And.

Right.

Um, and they might want to go out and use and treat themselves.

And so your role would be to check in to see if we need to do dose titration.

And then as an ID doc, the pathogens that are isolated are the biggest hint for me, just to figure out what the risk behavior was for a patient who's using drugs.

Um, one of my favorite patients had Serratia marcescens, uh, isolated and her blood cultures who had a history of injection drug use.

And for those of you who are less familiar with this type of pathogen, it's a pink tinged bacteria that typically colonizes the outside of like your faucets, um, and your sinks.

And so when I asked her, I was like, so how are you injecting?

And she's like, Hey Doctor Jawa, you know, I, uh, inject tap water because I think that's the safest.

And that's where this pathogen was introduced.

And so similarly, this patient is coming in with Strep mitis, which is typically an oral flora.

And so that is a hint to me to say, you know, you have bacteria in your blood, by the way, the bacteria that was found in your blood is actually a mouth bacteria.

Talk to me again about how you're injecting and, and you might realize that the patient will say, Hey, you know what?

I am licking my needles before I inject, because I want to make sure that the potency of the drug that I'm injecting is good.

Or I lick the needle after I inject to make sure that I don't waste the drug, or I lick my skin after I'm bleeding from my injection site, so as to help with the coagulation of the blood or, I spit as my solvent when I'm mixing my drugs or I'm sharing my injection drug preparation equipment.

So the pathogen is key in engaging your patient in a conversation.

Once you've identified the pathogen, it like blows their world.

I kid you not, like it really helps, um, patients identify like, oh, I have an infection.

I think now I understand where it came from.

And this also then leads to the next step of you partnering with the patient to identify realistic risk mitigation strategies.

So let's say the patient says I'm licking my skin before or after I inject, maybe you can talk to them about, well, maybe we can think about other ways, like maybe using an alcohol swab or soap water or, um, if the patient is saying I'm having to resort to using spit to solubilize my drug saying like, Hey, let me help you find the local needle exchanges, or maybe I can prescribe you those ampules of saline or water at the time of discharge.

Again, it's, it's giving, um, tools for your patient to keep them safe.

In HIV, we do this all the time.

Um, and, and frankly, in anything, we do this all the time.

Like for our diabetic patients, we teach our patients how to inject insulin.

We also give them glucose tablets along with the insulin to keep themselves safe.

And so when you have a patient with injection drug use, you've isolated the pathogen, you are empowered to say, okay, let's come up with a strategy that works for you.

And like, here are the tools.

And that tool might be cleaning your skin.

That tool might be finding the local needle exchange.

That tool might be something else like cooking your works for like two minutes so that you can try to sterilize the bacteria that's in your cooker.

So, yeah, the other thing is a Strep mitis in the mouth, and so from a physical exam perspective, you should always examine your patient's mouth.

Oftentimes patients may have non-optimal dental hygiene and, and, and you can have odontogenic infections that can lead to hematogenous infections.

And so, you know, they might have a broken tooth or whatever that could have led to the, this bacteria going into their bloodstream.

So, yeah.

I hope by my conversation about this, your role is more than just like, here's how I narrow the antibiotics based off of what microbiology told me.

And I empower you to say, not only can I do that, but I can manage their MOUD, their medication for opiate use disorder.

I can check on them for their cravings and I can partner them with how to reduce their risk, um, of injection drug use.

Excellent.

All right.

So that was a really, uh, great and robust discussion on harm reduction and how we might further tailor our care for this patient.

Thank you for that.

Um, ultimately the patient is improving on antibiotics and he did have a consultation with cardiothoracic surgery, but they didn't feel like he needed any kind of surgical intervention.

Susceptibility testing revealed that the Strep mitis was highly susceptible to penicillin.

The PICC line was placed and he has started on ceftriaxone with a plan for a four week course of IV antibiotics.

His medical teams, uh, deems that he is not a candidate for outpatient parental antibiotics.

So, I guess in this moment, my question for you, Dr.

Jawa is when you're seeing patients in the hospital for complications of their injection drug use, um, you essentially kind of have a captive audience or, or patients that are there for what you were referring to as a reachable moment.

Um, what other screenings or interventions would you do while they're in the hospital?

For example, would you screen them for STI or, uh, bloodborne viruses?

And then I guess on top of that, um, you know, this is a patient that his team has said, you know, he, uh, is seemingly not safe to discharge with a PICC line or on outpatient, IV antibiotics.

Um, What do you do in that circumstance?

Do you preemptively make a plan for that patient in case they need to discharge a prematurely?

Um, excellent questions.

So yes, you have a captive audience.

When does this ever happen?

And so yes, to all of the above, you can do anything and everything.

And this is also the opportunity for you to sort of change the dynamic of the experience that the patient has had traditionally in the health facility.

Right?

So these patients are often very stigmatized against the health systems.

They don't even want to come to see you.

They will come only when they are so sick that they probably can't function.

And so you can provide the clinical intervention.

Um, like STI screenings and, um, discussions about pre-exposure prophylaxis and initiation of pre-exposure and post-exposure prophylaxis, depending on if your patient is engaging in injection drugs.

Uh, engaging and sharing of injection drug use preparation equipment, um, or engaging in transactional sex, which many of your patients may disclose to you that they are.

And again, pre-exposure prophylaxis is a, uh, an indication for PrEP.

So you can do all of those things.

So what I like to do is I screened for the hepatitides.

I screened for STIs.

I vaccinate my patients for the Hep B hepatitis B, if they need boosters, also have, uh, vaccinate them for COVID.

If they haven't already received that, discuss with them about pre-exposure and post-exposure prophylaxis.

For our female patients who are injecting drugs, oftentimes who are of childbearing age, you can also discuss with them contraception and initiate them on contraception, whether it be some sort of, uh, uh, you know, implanon or whatever.

Um, and all of those interventions you can do in the hospital, uh, The other critical thing you can do while your patient is in the hospital is see what are their outpatient linkages?

So do they have a primary care doctor?

Do they have any social worker who can help them with like, uh, paperwork or housing?

Because oftentimes this patient is probably unlinked to medical care, and this is your opportunity to sort of wrap your arms around them and say, how can I help you?

Um, In terms of the ID questions is can we come up with a preemptive plan?

Well, I challenge us to say, can we come up with a preemptive ID and an addiction plan?

So for a patient on buprenorphine, um, who might be, uh, you know, not necessarily linked to an outpatient buprenorphine clinic, then the preemptive plan to leave to, you know, your night float residents is if this patient was to leave as a patient directed discharge for whatever reason, then from an addiction standpoint, they should be getting a bridge script of buprenorphine.

So several days of buprenorphine, a prescription so that they don't go into withdrawal, they need an appointment the next day, um, to some sort of bridge clinic or primary care provider or urgent care that can continue prescribing them this medication.

And then in terms of the ID plan, well, this patient has a really sensitive pathogen Strep mitis, which is penicillin susceptible.

There are probably many other agents that you can give orally, um, that will have as good, uh, sort of penetration into tissue that you could give, um, for the duration of their four week course that you know, the data for partial oral antibiotics, we can sort of discuss later.

Um, but, but I think that, um, when you have a captive audience, you have a reachable moment to change the dialogue on how we provide care for this patient population to engage them into primary care and addiction care as an outpatient.

And have contingencies on, if there was to be a patient direct discharge contact the ID fellow, and then they can provide you whatever the, the institutional, uh, oral equivalent antibiotic would be for this patient.

Alright, so our patients now, uh, about two weeks into treatment, um, he's doing well on his, uh, dosing of buprenorphine.

He's not having any withdrawal symptoms.

He feels pretty well.

In fact, he's, uh, getting a little bit stir crazy, doing laps around the hospital ward.

And he's asking you if he can leave the hospital and not have to stay there for another two weeks to finish out his week course.

And you know, this is something I think, as ID physicians, we're faced with a lot where we're trying to make, uh, decisions, um, both what's best for our patient, but then taking our patient's values and their thoughts into consideration.

I was wondering in, in this type of situation, how do you have that conversation with patients about whether or not they're eligible for IV antibiotics in the outpatient setting or whether or not they might be good candidates for partial oral antibiotic treatment?

If they don't feel that they can stay in the home.

So, this is such an important question and there is so much variability on eligibility of out outpatient parenteral antibiotic treatment via a PICC line.

Um, particularly among patients who inject drugs and I've written about this with some of my colleagues in, um, as a commentary, just sort of looking at data on what are the previously cited barriers to home-based OPAT for people who use drugs and the typical barriers for home-based OPAT it could be anything like unstable housing, lack of transportation, not living with a responsible adult who can support infusions this whole, uh, idea that patients who use drugs are at risk for misusing their PICC line, um, and, uh, you know, having, uh, an access to the PICC line and this risk of litigation.

If the patient misuses the PICC line and gets a PICC line associated infection or some other adverse, uh, clinical symptom.

Um, and then this, the other side of barriers are this need for mental health and substance use disorder treatment, lack of data on outcomes for OPAT, with people who inject drugs and inadequate Medicare coverage for non home bound patients and this lack of existing care models.

So you can imagine that in the United States, why isn't it standard of care for patients who use drugs, to be discharged, um, on OPAT after the two week mark, which is typically what we do for every other patient who is not doesn't have like the stamp of patient who uses drugs.

Um, it's because of a lot of systemic, um, variability and some stigma and some lack of infrastructural support that exists for patients.

So while some institutions have figured out avenues to support patients who use drugs with PICC lines in their homes, others have not.

So am I surprised that the initial team deemed this patient not eligible?

No but do I, would I challenge them?

Absolutely.

Uh, because I think as with any other medical syndrome, that is someone is, uh, admitted for, um, Antibiotic outpatient antibiotic and addiction plans need to be dictated by the patient's clinical stability for both the ID realm and the addiction realm and really their needs.

Right?

Like it is a shared decision making venture.

We can't be, uh, paternalistic about the.

That, oh, this patient has an addiction and I can't discharge them on a PICC line because I could get sued.

No, the patient has a cat or whatever that they need to take care of.

They have work, they have kids, they have the same responsibilities that other patients with the past medical history of substance use disorder also have.

Um, and, and we can't insert our morals or our own stigma into the clinical decisions that we make for this patient population.

So I think that your, what w what kind of plan should we make?

Well it should really be dictated by the patient and their clinical ID and addiction optimization.

And my colleague, Dr.

Ayesha Appa, who's also an infectious disease and addiction medicine provider.

Um, from UCSF she summarized, uh, in the New England Journal Curbside Consult, uh, a fair amount of evidence about this, that while patients who use drugs face a lot of discrimination, um, on being discharged with pic lines, um, uh, again, I am an OPAT provider.

Uh, for people who use drugs, I manage numerous patients with IV antibiotics and I don't see any contra-indication to discharge.

Um, and this is not just because Doctor Jawa said, so this is actually evidence-based.

Um, Dr.

Laura Marks has shown that patients who are hospitalized with serious, um, invasive, bacterial infections who had patient directed discharges, who are on PO antibiotics, had high antibiotic adherence rates.

So if they took their PO antibiotics, don't you think that also take their IV antibiotics?

Like no one wins.

If, if you don't take your medication and, and so that's really getting to the point that.

It's not that patients at substance use disorder are a nonadherent.

They also want to get better.

And so, uh, they might just need a little bit more multidisciplinary, outpatient support.

And then in terms of the literature that's shown.

PICC line complications among people who use drugs while that's been mixed.

And the data is like a lot of retrospective studies.

And, um, and while some studies have shown increased vascular complications in this group of patients, there's really no significant difference between secondary line infections for patients who use drugs, who get home-based OPAT versus in-hospital OPAT.

What all of these, you know, studies really show us is that.

While there's a lot of variability in PICC line eligibility.

Oftentimes it's dictated by what the institutional norm is.

And sometimes the institutional norm is no that we will not.

Um, but as medical providers who are providing evidence-based practices, I urge you to look at the most recent literature to guide some of your management and engage your patients in shared decision-making.

Um, because there really isn't any negative outcome.

It does require a fair amount of case management VNA buy-in, um, an outpatient sort of support for this patient population.

But your clinic.

Uh, decisions for this patient's outpatient management should not be dictated by anything except for, is this person optimized from their addiction?

Yes or no.

Is this person optimized for their infection?

Yes or no.

And then do they have like a stable way to get their IV antibiotics?

Um, and that's it.

And, you know, we can think about like tamper proof pick lines and all of these other sort of innovative ways to, uh, Prevent patients from utilizing their picks.

But when you look at some of the qualitative literature that asks patients who use drugs on whether or not they inject in their pics, I mean, these patients are expert phlebotomist.

They would not inject in their PICC and they say that they recognize the complications of injecting their PICCs are quite large.

Um, they have other ways of injecting if they really needed to inject and if a patient wants to use, they will.

Um, and I certainly have had a fair amount of patients who have triggers.

They have cravings, they use, um, they perhaps use from a different route, they might use from a different arm, but that really, um, is your role to say, okay, that's still should not be a contraindication for them to get out of outpatient antibiotics.

Um, that being said, I don't think that.

IV antibiotics is necessarily the best route for everyone.

Um, it is less optimal if you're not stably housed in the commentary that we wrote in Journal of Addiction Medicine, looking at the literature, there are some proposed criteria for consideration of

outpatient antibiotics for people who inject drugs.

It includes that the patient is willing to engage in close, follow up, that they, the patient has safe and stable housing.

Even if this patient that we have in this case is not stable housed.

Maybe they have a family member who's really engaged in their recovery that can house them that as a responsible adult.

And then we'll continue to help.

Administer the antibiotics and get them to appointments, et cetera.

And I think that that should be included in the conversations that you have with your patients.

I think that there's a lot of gray zones and, um, I encourage you all to have conversations with your patients.

And Nathan, the other question you asked is, well, have antibiotics.

In this day and age, our IV antibiotics really needed after two weeks.

And we have data from POET really suggesting that for certain types of pathogens that you can do like a two week upfront IV antibiotic course, and it can be followed with a chaser of PO antibiotics.

And, and this patient is lucky because they don't have a methicillin-resistant staph or is.

Um, but you know, the POET trial didn't really include a lot of patients with substance use disorders.

That being said the outcomes for, from the more sensitive pathogens was probably fine.

Um, so I really think it's dependent on what your ID consultants in your institution are comfortable doing.

There are other trials about long-acting lipo, um, glycopeptides and whatnot that can help.

Um, facilitate patients being able to go home earlier, uh, that, uh, yeah, uh, I think the world is our oyster.

Um, the way we provide care to this patient population is very much changing and, and it should change because, uh, there's really no reason for these patients to not get standards of care that we provide to every other patient who doesn't have the past medical history stamp of an addiction.

Um, I will tout this, this a paper that came out in JAMA Open Network, we simulated the cost-effectiveness and long-term clinical outcomes of addiction care and antibiotic therapy strategies for patients with injection drug use associated endocarditis.

And if you model, if this is a cost-effective strategy to discharge patients on partial oral antibiotics, um, and outpatient IV antibiotics with a combination of addiction care.

It is a cost-effective strategy.

And so if you're getting a lot of pushback from your hospital systems or your VNH or your case management saying like, I don't feel comfortable, this isn't a good idea.

This might be a waste of our money.

Well there's data that suggests that it might actually be a cost saving venture for the hospital system.

And ha heck, it'll be a real, real benefit for our patients.

Patients who inject drugs are just like every other patient that we take care of.

They should be getting the same standard of care and should not be discriminated against, um, forgetting serious bacterial and fungal infections.

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