(027) There's no place like home: A multidisciplinary approach to holistically manage addiction and intravenous drug use related infections requiring intravenous antibiotics

Abstract:

Background: The opioid epidemic has resulted in increasing intravenous drug use (IVDU) related infections. Patients who inject substances intravenously have traditionally been excluded from outpatient IV antibiotic therapy (OPAT) programs due to safety concerns leading to prolonged hospitalizations, Against Medical Advice (AMA) discharges, and readmissions (Rudasill, 2019). This study looks at outcomes from the implementation of a multidisciplinary team at Dartmouth-Hitchcock Medical Center for patients admitted with IVDU-related infections requiring long-term IV antibiotic therapy.

Methods: Using a multidisciplinary approach, we implemented early in-hospital medications for opioid use disorder (MOUD) with outpatient addiction care on discharge and identified patients who could be safely discharged on OPAT with close outpatient follow-up. While medically or surgically admitted for treatment of infectious or other complications of IVDU, patients were assessed by a proactive psychiatric consultative service who engaged with patients around motivational interventions, induction of MOUD, and outpatient treatment planning. A “tumor board” style case review incorporated team member feedback to arrive at a shared treatment plan for each patient.

Results: We compared 64 admissions and 57 individual patients with IVDU-related infections prior to our multidisciplinary intervention with 80 admissions and 64 patients post-intervention. Addiction was addressed in 77% (49/64) of admissions pre-intervention and in 99% (79/80) of admissions post-intervention. The rate of AMA discharges was 20% both pre- and post-intervention. Seven percent (4/57) of patients were discharged home on IV antibiotics pre-intervention versus 19% (12/64) post-intervention. The average length of stay was 21 days pre-intervention versus 12 days post-intervention. The readmission rate within 30 days was 8% pre-intervention versus 16% post-intervention. There were no substance use related complications among patients discharged on OPAT.

Conclusion/Implications: These results demonstrate that addiction was addressed in a higher percentage of admissions after our multidisciplinary intervention was implemented. Although there was no difference in AMA discharge rates and there was an increase in readmission rates post-intervention, our results show that more patients were discharged on outpatient IV antibiotic therapy with an overall decrease in average length of stay. These findings are promising given that we know starting buprenorphine in-hospital and linking patients to outpatient MOUD is more effective at retaining patients in treatment than compared to detoxification and referral (Liebschutz, 2014). In addition, by safely increasing access to OPAT for patients with IVDU, we can decrease lengths of hospital stay and, in turn, allow patients to return to their lives, reducing both institutional and patient costs.

References:

1. Rudasill SE, Sanaiha Y, Mardock AL, et al. Clinical Outcomes of Infective Endocarditis in Injection Drug Users. J Am Coll Cardiol. 2019;73(5):559-570. doi:10.1016/j.jacc.2018.10.082

2. Liebschutz JM, Crooks D, Herman D, et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-1376. doi:10.1001/jamainternmed.2014.2556