A 42-year-old female with a history of intravenous (IV) drug use presents with severe neck pain, gait instability, and bilateral C5 motor weakness. A cervical MRI shows inflammation consistent with infection of her cervical spine at C5 and C6 and significant boney destruction. The patient undergoes kyphoplasty and debridement of her cervical spine. Operative cultures are significant for Pseudomonas aeruginosa. Infectious disease consultants recommend parenteral ceftriaxone for six weeks. The patient has no insurance, and efforts to obtain long-term placement are unsuccessful. The patient states that her last use of IV drugs was three months ago, and she insists that she will abstain from illicit IV drug abuse going forward.
Outpatient parenteral antibiotic treatment (OPAT) has proven to be a cost-effective and relatively safe treatment option for most patients.1 For these reasons, it has been encouraged for use among a wide a variety of clinical situations. Intravenous drug users (IDUs) are often underinsured and have few options other than costly treatment in an inpatient acute-care facility.
A history of illicit injection drug use frequently raises questions about the appropriateness of OPAT. Some of our most vulnerable patients are those who abuse illicit drugs. Due to psychiatric, social, and financial factors, their ability to adequately transition to outpatient care may be limited. They are often underinsured, and appropriate options for inpatient post-acute care may not exist. Hospitalists often feel pressure to discharge these patients despite the lack of optimal follow-up care, and they must weigh the risks and benefits in each case.
The enrollment of IDUs into an OPAT service using a peripherally inserted central catheter (PICC) is controversial and often avoided. No clear-cut guidelines concerning the use of OPAT in IDUs by national medical societies exist.2 Consultants are often reluctant to recommend options that deviate from the typical standard of inpatient or directly observed care. The obvious risk is that a PICC line provides easy and tempting access to veins for continued drug abuse. In addition, there is an increased risk of infection and/or thrombosis if the PICC is abused.3
The safety and efficacy of PICC line use for OPAT in IDUs are unknown, and studies addressing these issues are limited. In one study at the National University Hospital of Singapore, 29 IDU patients received OPAT without complications.4 Patients were closely monitored, including by use of a tamper-proof security seal on the PICC. Infective endocarditis was the primary diagnosis in 42% of the cases studied. There were no deaths or cases of PICC abuse reported. In another abstract presentation, 39 IDU patients at Henry Ford Health System in Detroit were discharged to outpatient therapy with a PICC line and demonstrated a high cure rate (73.3%). Nine patients were lost to follow-up.5
No studies have compared OPAT therapy to inpatient therapy in IDU patients.
Back to the Case
Despite multiple attempts and due to financial considerations, no long-term care facility is able to admit the patient for therapy. The frequency of required antibiotics makes outpatient therapy in an infusion center problematic. The primary service is reluctant to discharge the patient home with a PICC line in place due to the potential of abuse and complications. A “Goals of Care” committee, consisting of several physicians from multiple specialties, legal counsel, and case management, is convened to review the case. The committee concludes that, in this particular case, it would be a reasonable option to discharge the patient to home with a PICC line in place to complete OPAT. A patient agreement document is drafted; it describes the complications of PICC line abuse and stipulates that the patient agrees to drug testing throughout the duration of her treatment. A similar agreement is required by the home infusion company. Both documents are signed by the patient, and she is subsequently discharged home.
Our strategy is to deal with each of these cases as unique situations because no policies, procedures, protocols, or guidelines currently exist. One of the guiding principles should be, despite financial pressures, that the primary focus is on appropriate care of this vulnerable population. A type of “Goals of Care” committee (or organizational equivalent) can be utilized to offer assistance in decision making. Unfortunately, the safety and efficacy of OPAT in IDU patients are uncertain, and there is a lack of studies to support definitive protocols. In select cases, OPAT in IDU patients may be considered, but signed consent of the risks and the patient’s responsibilities concerning OPAT should be clearly documented in the medical record by the discharging team. TH
Dr. Conrad is a hospitalist with Ochsner Health System in New Orleans.
- Tice AD, Hoaglund PA, Nolet B, McKinnon PS, Mozaffari E. Cost perspectives for outpatient intravenous antimicrobial therapy. Pharmacotherapy. 2002;22(2, pt 2):63S-70S.
- Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651-1672.
- Chemaly R, de Parres JB, Rehm SJ, et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179-1183.
- Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrobial Chemotherapy. 2010;65(12):2641-2644.
- Papalekas E, Patel N, Neph A, Moreno D, Zervos M, Reyes K. Outpatient parenteral antimicrobial therapy (OPAT) in intravenous drug users (IVDUs): epidemiology and outcomes. Oral abstract presented at: IDWeek; October 2014; Philadelphia.