New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use

Harm reduction involves meeting patients where they are and providing services they are willing to accept to improve their health or prevent negative outcomes. One important strategy for reducing harm involves maintaining patients in care for their addiction and infection as much as possible, ideally avoiding AMA discharge. In one cohort of patients admitted with IDU-associated infections and OUD, 49% of those without an addiction medicine consult left AMA.¹² If a patient plans to leave AMA, all efforts should be made to provide them with oral antibiotics that might be effective, even if suboptimal, for their infection. Hospitalists should consider documenting an oral “antibiotic contingency plan” that can be rapidly enacted if a patient is imminently leaving the hospital. They should be provided with outpatient follow-up appointments with infectious disease or primary care. All patients with IDU-associated infections should be discharged with naloxone, overdose prevention education, and community resources for addiction treatment and syringe exchange programs.

Management of IDU-associated infection should be organized around a multidisciplinary framework with careful attention to infection treatment, OUD treatment, and harm reduction interventions (Figure 2). The first step in managing IDU-associated infections is recognizing addiction in the acute care setting. Substance use disorders, including OUD, are often unrecognized in patients presenting with IDU-associated infections.⁴⁸ The Rapid Opioid Dependence Screen, a validated screening tool for OUD, can be quickly administered for all patients who present with endocarditis, bacteremia, skin and soft tissue infections, vertebral and epidural infections, and HIV and HCV infections.⁴⁹ In addition to directly questioning patients about substance use, Figure 2 lists epidemiologic, physical exam, and laboratory findings that might suggest to the provider that OUD may be present.

The approach to infection management is similar to non-IDU-associated infections, including identifying a source, evaluating for complications and need for source control procedures, and administering antimicrobials. Management of the substance use disorder includes treatment of acute withdrawal, control of pain, initiation of MOUD when appropriate, and linkage to outpatient addiction treatment services in addition to harm reduction interventions.

Hospital admissions for infectious complications of IDU are increasingly common and are difficult experiences for both patients and providers. However, these hospitalizations serve as a “reachable moment” to engage patients with OUD into medical care and initiate holistic treatment of their infection and underlying substance use disorder.^28,50Significant systems-level barriers remain to comprehensive management of the overlapping infectious disease and opioid epidemics. Nevertheless, it is critical to acknowledge that the infections are a symptom of an underlying substance use disorder, a key first step in improving the care of patients hospitalized with infectious complications of OUD. Just like the many acute exacerbations of chronic illness managed by hospitalists, treatment of these episodes of “acute decompensated addiction” require evidence-based management of the underlying disease and its infectious consequences using a harm reduction approach.

Disclosures

The authors both report no conflict of interest.