New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use
Hospitalists are increasingly responsible for the management of infectious consequences of opioid use disorder (OUD), including increasing rates of hospitalization for injection drug use (IDU)-associated infective endocarditis, osteomyelitis, and soft tissue infections. Management of IDU-associated infections poses unique challenges: symptoms of the underlying addiction can interfere with care plans, patients often have difficult psychosocial circumstances in addition to their addiction, and they are often stigmatized by the healthcare system. Although there are few randomized trial data to support one particular approach to management, the literature suggests that successful treatment of IDU-associated infections requires appropriate antimicrobial and surgical interventions in addition to acknowledgment and treatment of the underlying OUD. In this narrative review, the best available evidence is used to answer several of the most commonly encountered questions in the management of IDU-associated infections. These data are used to develop a framework for hospitalists to approach the care of patients with IDU-associated infections.
© 2019 Society of Hospital Medicine
What Is the Role of Long Half-Life IV Antibiotics for Treating IDU-Associated Infections?
Dalbavancin and oritavancin are extremely long half-life IV glycopeptide antibiotics for gram-positive bacterial infections that require, at most, weekly administration. These agents allow IV-equivalent antibiotics to be delivered without the need for daily infusions or PICCs. Currently, both are approved by the United States Food and Drug Administration only for skin and skin structure infections, but there are increasing reports of successful use in more severe infections including osteomyelitis, bacteremia, and endocarditis.39-42
Is Surgical Placement of Prosthetic Material Safe in Patients With IDU-Associated Infections?
When surgery for an IDU-associated infection has the potential to be acutely lifesaving, it should be offered. There is a concern that surgical interventions that require placement of prosthetic material might serve as a nidus of future infection in the setting of ongoing IDU. Although treatments for many substance use disorders are effective—particularly medications to treat OUD—addiction is a relapsing chronic condition, and at least, some future drug use is an expected part of the course. Research comparing outcomes after valve surgery between IDU and non-IDU-associated endocarditis patients shows no difference in short-term outcomes,44 but longer-term data show increased mortality between 60 and 180 days postoperatively, higher rates of valve-related complications, and up to 53% reinfection rates.10,45,46 These studies are limited by the lack of a nonsurgically treated control group and little information on the rate of addiction treatment, which may be protective against these negative outcomes. In contrast, another study found that surgery was the strongest predictor of survival among patients with IDU-associated endocarditis after a median of 3.6 years follow-up.18 Another consideration is that patients with IDU-associated infection tend to be younger, and despite advancements, many modern prostheses have a finite lifespan. When multiple surgical options exist, a procedure that avoids prosthetic material is preferred. For example, in a meta-analysis of studies of tricuspid valve endocarditis (41% IDU-associated), there was no mortality difference between valve repair compared with valve replacement, but there was a significantly lower rate of recurrent endocarditis among those with a repair only.47 Decisions about surgery must be individualized and consider a patient’s engagement in OUD treatment, social support, prior success with treatment, treatment and relapse prevention resources, and access to harm reduction interventions such as sterile syringes.
What Are Appropriate Harm Reduction Interventions for Patients Hospitalized With Infections Due to IDU?
A prolonged admission for IDU-associated infections is an opportunity to provide patients with education, health maintenance services, and secondary prevention interventions for both infection and overdose. Based on epidemiologic risk, patients should be screened for HIV, HCV, hepatitis B, syphilis, gonorrhea, and chlamydia. Patients should be vaccinated against hepatitis A, influenza, and tetanus (and pneumococcus if indicated), if unvaccinated or without vaccination records. Patients positive for HIV should be evaluated by an infectious disease specialist with consideration of the rapid initiation of antiretroviral therapy. Patients positive for HCV or hepatitis B should be referred for treatment in the outpatient setting. Patients without HIV should be educated about HIV preexposure prophylaxis and referred to outpatient services.
