1 00:00:12,570 --> 00:00:13,620 Sara Dong: Hi everyone. 2 00:00:13,680 --> 00:00:18,360 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:18,750 --> 00:00:25,050 We use consult questions to dive into ID clinical reasoning, diagnostics, and anti-microbial management. 4 00:00:25,650 --> 00:00:28,659 I'm Sara Dong, your host and a Med-Peds ID fellow. 5 00:00:29,259 --> 00:00:34,590 Here on Febrile, we use patient cases and chat with ID discussants to learn more about high-yield ID topics. 6 00:00:35,775 --> 00:00:37,665 I will first welcome our co-host today. 7 00:00:37,695 --> 00:00:37,995 Dr. 8 00:00:37,995 --> 00:00:39,015 Nathan Nolan. 9 00:00:39,495 --> 00:00:44,504 Nathan is a recent ID fellowship grad from the Washington University School of Medicine in St. 10 00:00:44,504 --> 00:00:48,525 Louis and currently is an instructor and a med ed fellow. 11 00:00:48,945 --> 00:00:54,825 He has a special focus on marginalized populations, including patients who use drugs and patients who are unhoused. 12 00:00:54,945 --> 00:00:56,925 Our guests discussant today is Dr. 13 00:00:56,925 --> 00:00:57,845 Raagini Jawa. 14 00:00:58,335 --> 00:00:58,695 Dr. 15 00:00:58,695 --> 00:01:05,265 Jawa is a clinical instructor at Boston University School of Medicine, where she practices Infectious Disease and Addiction Medicine. 16 00:01:05,504 --> 00:01:15,505 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. 17 00:01:16,294 --> 00:01:18,030 Welcome to the show, friends. 18 00:01:18,420 --> 00:01:19,200 Raagini Jawa: Thank you. 19 00:01:19,680 --> 00:01:20,020 Nathan Nolan: Hi. 20 00:01:20,220 --> 00:01:31,800 Sara Dong: 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. 21 00:01:32,010 --> 00:01:33,600 Raagini Jawa: Nathan, would you like to go first? 22 00:01:34,620 --> 00:01:35,250 Nathan Nolan: Sure. 23 00:01:35,610 --> 00:01:42,270 I don't know if this fits the normal definition that you have, but, uh, I recently was on vacation in Puerto Rico. 24 00:01:43,320 --> 00:01:49,980 And I got the opportunity to go to a bioluminescent bay, which is where they have the little plankton that light up. 25 00:01:50,580 --> 00:01:54,730 And it was one of the coolest experiences and it was just so beautiful. 26 00:01:54,730 --> 00:01:54,820 And. 27 00:01:55,589 --> 00:02:00,240 I would say, if you ever get an opportunity to go to Puerto Rico and do that, uh, you definitely should. 28 00:02:00,630 --> 00:02:05,429 Raagini Jawa: That sounds a very exciting, I am really jealous and I need to make a trip to Puerto Rico. 29 00:02:07,080 --> 00:02:14,470 I'm a photography junkie and I'm, I'm like waiting for something beautiful to just show up that I can photograph. 30 00:02:15,920 --> 00:02:18,060 New England winters are very dreary. 31 00:02:18,299 --> 00:02:20,310 Um, what brings me joy? 32 00:02:20,340 --> 00:02:25,310 I mean, right now, what brings me joy is TLC's 90 Day Fiancé. 33 00:02:25,980 --> 00:02:30,960 I will tell you, I am such a reality show junkie. 34 00:02:31,170 --> 00:02:38,310 There is nothing more relaxing than coming home from a long day of ID consults or HIV clinic or whatever. 35 00:02:38,610 --> 00:02:42,150 And then just being like, I'm going to watch 90 Day Fiancé re-runs. 36 00:02:42,480 --> 00:02:43,920 Um, it's fantastic. 37 00:02:43,920 --> 00:02:46,785 If you haven't enjoyed an episode. 38 00:02:46,785 --> 00:02:49,395 I highly encourage you do that. 39 00:02:49,425 --> 00:02:55,605 This is not sponsored by TLC but I, I, it's a really great show. 40 00:02:55,635 --> 00:03:00,390 It's sometimes mind numbing, but, um, that's my guilty pleasure. 41 00:03:00,450 --> 00:03:01,980 Sara Dong: Sometimes that's what you need though. 42 00:03:02,040 --> 00:03:05,070 A little bit of mind numbing at the end of the day, or at least I do. 43 00:03:06,390 --> 00:03:06,900 Awesome. 44 00:03:06,930 --> 00:03:08,760 Well, those are both great. 45 00:03:08,820 --> 00:03:14,550 Um, so today's consult question is about a 35 year old male who is admitted with fevers. 46 00:03:14,880 --> 00:03:16,830 So I will throw it over to Nathan. 47 00:03:17,280 --> 00:03:17,670 Nathan Nolan: Okay. 48 00:03:17,670 --> 00:03:23,970 So we have a 35 year old male patient who has a history of substance use disorder. 49 00:03:24,450 --> 00:03:26,990 And specifically he uses injection opioids. 50 00:03:27,510 --> 00:03:30,900 And he's admitted for fevers that have been ongoing for two weeks. 51 00:03:31,500 --> 00:03:34,650 He has a history of hepatitis C that has been untreated. 52 00:03:35,220 --> 00:03:38,010 He uses fentanyl by way of injection and uses daily. 53 00:03:38,640 --> 00:03:44,430 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. 54 00:03:45,180 --> 00:03:47,790 He does not routinely clean his skin before injection. 55 00:03:48,720 --> 00:03:51,180 He lives within the city, but is unstably housed. 56 00:03:51,210 --> 00:03:53,340 He describes his situation as couch surfing. 57 00:03:54,105 --> 00:04:03,405 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. 58 00:04:03,405 --> 00:04:05,715 He has been noting night sweats and fevers. 59 00:04:05,745 --> 00:04:11,415 He also reports low energy, low appetite, and progressive difficulty with his breathing today. 60 00:04:11,415 --> 00:04:14,984 He had some more trouble with his breathing and decided to present to the emergency room. 61 00:04:15,704 --> 00:04:19,245 He has no prior medical history, no history of any major surgery. 62 00:04:20,724 --> 00:04:26,905 On the initial evaluation in the ER, he looks moderately ill and he's found to have a fever of 38.1 degrees Celsius. 63 00:04:27,445 --> 00:04:30,594 His heart rate is 111 and his respiratory rate is 20. 64 00:04:31,255 --> 00:04:34,435 He was breathing comfortably on room air and his blood pressure was stable. 65 00:04:35,125 --> 00:04:39,625 His heart exam was significant for a systolic murmur heard best at the right sternal border. 66 00:04:40,255 --> 00:04:42,965 He has lower extremity edema, which is 2+. 67 00:04:43,284 --> 00:04:46,225 He has some faint crackles in the left lung. 68 00:04:47,640 --> 00:04:55,980 And then his initial lab work comes back as a CBC with a white count of 18000 with 82% neutrophils with 3% bands. 69 00:04:56,520 --> 00:04:57,960 His hemoglobin is 13. 70 00:04:57,990 --> 00:05:12,300 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. 71 00:05:12,915 --> 00:05:14,415 His glucose is 98. 72 00:05:14,475 --> 00:05:17,415 AST is 93, ALT 92. 73 00:05:18,165 --> 00:05:24,405 On chest x-ray, he has a peripheral opacity in the left lower lung field concerning for an infectious process. 74 00:05:24,855 --> 00:05:28,605 So blood cultures are obtained and he's admitted to the hospital. 75 00:05:28,755 --> 00:05:30,825 And so you're asked to see him as a consult. 76 00:05:30,825 --> 00:05:39,300 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? 77 00:05:39,690 --> 00:05:40,120 Raagini Jawa: Yeah. 78 00:05:40,620 --> 00:05:47,280 Thanks for this case, Nathan, this clearly is a patient who is quite unwell. 79 00:05:47,610 --> 00:05:57,600 Um, he's young, he's coming in with symptoms for two weeks with SIRS and perhaps a pulmonary process. 80 00:05:58,080 --> 00:06:13,910 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. 81 00:06:14,150 --> 00:06:16,790 This patient has some sort of infection. 82 00:06:17,090 --> 00:06:29,070 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. 83 00:06:29,130 --> 00:06:43,409 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. 84 00:06:43,409 --> 00:06:50,549 So new systolic murmur, new lower extremity edema, some sort of left lower lobe infiltrate. 85 00:06:50,849 --> 00:06:51,120 So. 86 00:06:52,065 --> 00:06:56,505 I'm thinking, oh gosh, patient probably has a bacterial process. 87 00:06:56,865 --> 00:06:59,325 Pneumonia, maybe a cardiac process. 88 00:06:59,525 --> 00:07:06,135 Because of their homelessness, as an ID doc, I'd always be worried about something a little bit more insidious like TB. 89 00:07:06,585 --> 00:07:15,435 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. 90 00:07:16,140 --> 00:07:31,500 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. 91 00:07:32,969 --> 00:07:37,169 And I do think that that adds a new flare to our differential diagnosis. 92 00:07:37,760 --> 00:07:53,220 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. 93 00:07:53,220 --> 00:08:07,170 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. 94 00:08:07,560 --> 00:08:15,510 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. 95 00:08:16,110 --> 00:08:17,340 Um, so. 96 00:08:18,180 --> 00:08:32,610 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. 97 00:08:32,909 --> 00:08:33,210 Nathan Nolan: Wow. 98 00:08:33,240 --> 00:08:35,669 That was a really excellent discussion. 99 00:08:35,669 --> 00:08:36,600 Thank you for that. 100 00:08:37,020 --> 00:08:39,360 I can give you a little bit more of the case if you're ready. 101 00:08:39,570 --> 00:08:39,900 Raagini Jawa: Sure. 102 00:08:40,110 --> 00:08:46,380 Nathan Nolan: So the patient was admitted to the internal medicine service and he was empirically started on ceftriaxone and vancomycin. 103 00:08:47,035 --> 00:08:53,065 Uh, shortly after admission, he becomes diaphoretic with severe abdominal cramps, nausea and diarrhea. 104 00:08:53,665 --> 00:08:59,815 His blood pressure increases to 167/101 and his heart rate is now 120. 105 00:09:00,025 --> 00:09:01,345 He appears agitated. 106 00:09:01,615 --> 00:09:09,565 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. 107 00:09:09,685 --> 00:09:24,540 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. 108 00:09:25,365 --> 00:09:33,765 How do you go about, uh, addressing opioid withdrawal in patients like this who may be admitted with a unrelated processes? 109 00:09:34,005 --> 00:09:52,380 Raagini Jawa: 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. 110 00:09:52,380 --> 00:10:04,170 So opiate withdrawal and, and many drug withdrawal syndromes oftentimes can be mimicking sepsis and autonomic dysregulation. 111 00:10:04,170 --> 00:10:19,724 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? 112 00:10:20,084 --> 00:10:23,354 And are they on any medications for their drug use? 113 00:10:23,685 --> 00:10:28,425 Um, that could impact their risk of experiencing opiate withdrawal. 114 00:10:28,814 --> 00:10:31,245 Uh, if it's not acutely managed in the hospital setting. 115 00:10:31,905 --> 00:10:40,160 And yes, we go to medical school and get our bachelor's and get masters and, you know, get all these special degrees. 116 00:10:40,400 --> 00:10:52,760 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. 117 00:10:53,210 --> 00:10:56,300 So the questions that I like to ask my patients is. 118 00:10:56,915 --> 00:11:06,185 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. 119 00:11:06,845 --> 00:11:13,115 The symptoms of opiate withdrawal are sort of at the same timeline that you told me about Nathan. 120 00:11:14,170 --> 00:11:18,430 They start anywhere from 24 to 36 hours since the last time they use. 121 00:11:18,460 --> 00:11:24,880 And again, that can vary depending on the potency and the type of opioid that patients are using. 122 00:11:24,880 --> 00:11:47,645 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. 123 00:11:47,855 --> 00:11:55,325 So they might start feeling sick in the emergency room bay and these symptoms can be very similar to sepsis, right? 124 00:11:55,355 --> 00:12:03,665 They can be diaphoresis, dilated pupils, rhinorrhea, diarrhea, abdominal cramping, nausea, muscle spasms, anxiety, piloerection. 125 00:12:05,069 --> 00:12:17,160 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. 126 00:12:17,370 --> 00:12:26,339 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? 127 00:12:26,569 --> 00:12:45,324 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. 128 00:12:45,595 --> 00:12:52,074 So that's how I address the whole "is my patient going through opiate withdrawal at this moment?" 129 00:12:52,675 --> 00:12:54,715 Now I will make this note. 130 00:12:54,895 --> 00:12:54,985 Okay. 131 00:12:56,100 --> 00:13:00,600 The first question should not just be, are you going through opiate withdrawals and what's your COWS scale? 132 00:13:00,900 --> 00:13:03,960 The next question needs to be, well, what the heck am I going to do about it? 133 00:13:04,320 --> 00:13:18,630 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. 134 00:13:19,359 --> 00:13:27,790 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. 135 00:13:28,359 --> 00:13:33,459 And I think we, as clinical providers could do better in this realm. 136 00:13:33,819 --> 00:13:37,329 I think sometimes we, we know like, oh, I'm going to ask. 137 00:13:38,020 --> 00:13:39,160 Are they having withdrawals? 138 00:13:39,430 --> 00:13:40,660 I know how to do the score. 139 00:13:40,930 --> 00:13:44,020 And then we sort of feel like, oh gosh, I don't know what to do next. 140 00:13:44,050 --> 00:13:45,370 Am I enabling the patient? 141 00:13:45,400 --> 00:13:47,140 Am I making their drug use worse? 142 00:13:47,560 --> 00:13:49,750 Am I going to make their hemodynamics worse? 143 00:13:50,020 --> 00:13:51,190 And the answer is no. 144 00:13:51,400 --> 00:13:56,230 Drugs have very typical pharmaco kinetics and dynamics patients withdraw. 145 00:13:56,290 --> 00:14:03,670 And us as medical providers have a responsibility to manage the withdrawal in whatever setting in the outpatient setting or in the hospital. 146 00:14:04,375 --> 00:14:19,944 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. 147 00:14:20,275 --> 00:14:23,185 Um, and there's a lot of literature on what reachable moments are. 148 00:14:23,650 --> 00:14:29,650 But it's really your opportunity to reach out to the patient and say, Hey, I'm here to treat your infection. 149 00:14:29,920 --> 00:14:31,180 I'm here to make you feel better. 150 00:14:31,240 --> 00:14:58,900 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. 151 00:14:59,290 --> 00:15:03,610 We can prescribe all of these medications to help our patients feel more comfortable. 152 00:15:03,850 --> 00:15:17,949 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. 153 00:15:18,250 --> 00:15:30,189 Sara Dong: 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. 154 00:15:30,370 --> 00:15:37,640 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. 155 00:15:38,339 --> 00:15:39,075 Raagini Jawa: Oh, of course. 156 00:15:39,495 --> 00:15:44,865 So ID docs love histories, and I love this. 157 00:15:45,075 --> 00:15:53,564 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. 158 00:15:53,955 --> 00:15:59,655 And so I like to ask nitty gritties, what drugs are my patients injecting or using? 159 00:15:59,775 --> 00:16:04,245 Cause it doesn't necessarily mean that my patients are going to be using an injection route of drugs. 160 00:16:04,245 --> 00:16:04,515 Right? 161 00:16:04,515 --> 00:16:06,525 They might be inhaling. 162 00:16:06,525 --> 00:16:07,665 They might be smoking. 163 00:16:07,665 --> 00:16:13,425 They might be taking oral medications or other routes of administration. 164 00:16:13,665 --> 00:16:15,824 And I like to ask what drugs they're using. 165 00:16:15,824 --> 00:16:19,335 So is it opioids only or is it opioids and stimulants? 166 00:16:19,335 --> 00:16:24,555 And if it's stimulants then which stimulants, like, is it cocaine, crack, methamphetamine? 167 00:16:25,635 --> 00:16:44,925 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. 168 00:16:45,075 --> 00:16:49,650 So for instance, things like methamphetamine, so stimulants are vasoconstricting. 169 00:16:49,650 --> 00:16:55,170 And so those patients often tend to have a lot of ischemic, uh, skin infections. 170 00:16:55,260 --> 00:17:06,899 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. 171 00:17:07,170 --> 00:17:08,639 So the questions keep going. 172 00:17:08,970 --> 00:17:14,909 Um, the questions you can ask are when was the last time they used, how are the patients injecting? 173 00:17:15,210 --> 00:17:18,750 Um, and how frequently are your patients injecting? 174 00:17:18,930 --> 00:17:20,280 And you might be surprised. 175 00:17:20,280 --> 00:17:22,500 Some patients will say I live at home. 176 00:17:22,740 --> 00:17:25,380 I inject in the bathroom maybe once a day. 177 00:17:25,710 --> 00:17:33,150 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. 178 00:17:33,390 --> 00:17:35,670 I'm injecting 10, 15 times a day. 179 00:17:36,150 --> 00:17:38,880 Um, and then the obvious next questions would be. 180 00:17:39,720 --> 00:17:46,140 Where are you getting your injection drug preparation equipment from, is it the local needle exchange? 181 00:17:46,140 --> 00:17:47,550 Is it the local pharmacy? 182 00:17:47,610 --> 00:17:56,160 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? 183 00:17:56,160 --> 00:18:10,649 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. 184 00:18:11,090 --> 00:18:15,360 The other questions I ask it'll be, you know, how are you cooking your drugs? 185 00:18:15,389 --> 00:18:19,649 That means are you using a flame to dissolve your drugs? 186 00:18:19,649 --> 00:18:22,500 And where are you getting your solvents from? 187 00:18:22,500 --> 00:18:23,760 Is it tap water? 188 00:18:23,850 --> 00:18:24,419 Is it. 189 00:18:25,155 --> 00:18:26,625 Uh, toilet water. 190 00:18:26,685 --> 00:18:27,885 Is it spit? 191 00:18:27,975 --> 00:18:29,085 Is it snow? 192 00:18:29,325 --> 00:18:30,675 Um, balls? 193 00:18:30,915 --> 00:18:44,445 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. 194 00:18:44,925 --> 00:18:51,375 And so the last few questions I like to ask is number of times they've reused or shared their injection equipment. 195 00:18:51,764 --> 00:18:53,595 Um, if they have engaged in. 196 00:18:54,175 --> 00:18:55,735 Uh, cotton shots. 197 00:18:56,035 --> 00:19:03,925 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. 198 00:19:05,235 --> 00:19:35,310 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. 199 00:19:35,640 --> 00:19:40,350 Um, because you know that that cotton is probably loaded with a little bit of drug products in it. 200 00:19:40,650 --> 00:19:47,250 In my mind, if a patient is engaging in cotton shots, that's like a real red flag that this patient is really struggling. 201 00:19:47,720 --> 00:19:48,890 We need to engage them. 202 00:19:48,890 --> 00:19:52,070 They're high risk of bacterial and fungal complications. 203 00:19:52,550 --> 00:19:56,840 Um, on the other stuff is like, uh, you know, we ask about past medical history. 204 00:19:56,840 --> 00:20:01,970 So injection past medical history is going to be, are they having prior skin and soft tissue infections? 205 00:20:01,970 --> 00:20:08,930 Have they had serious infection, infectious complications, like abscesses or endocarditis or osteomyelitis? 206 00:20:08,930 --> 00:20:12,500 Have they had a prior immunocompromised infection like HIV? 207 00:20:12,970 --> 00:20:15,449 Have they ever been on PrEP? 208 00:20:15,810 --> 00:20:18,330 And then how are they supporting their habit? 209 00:20:18,510 --> 00:20:20,939 Our patient is unstable housed. 210 00:20:21,000 --> 00:20:29,129 It seems like this person's really struggling, maintaining their, you know, usual, uh, ability to do their day to day. 211 00:20:29,459 --> 00:20:32,129 Um, how are they may, you know, supporting their habit? 212 00:20:32,129 --> 00:20:40,770 Is it through, um, selling drugs or peddling or is it through transactional sex or other risky behaviors? 213 00:20:40,860 --> 00:20:49,544 All of these questions should be in our background for talking to patients with injection drug use, um, and addiction. 214 00:20:49,544 --> 00:21:05,774 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. 215 00:21:06,260 --> 00:21:08,450 Your patient will very naturally open up. 216 00:21:08,480 --> 00:21:10,820 You might not even have to prompt these questions. 217 00:21:10,820 --> 00:21:20,930 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. 218 00:21:21,350 --> 00:21:26,150 Um, uh, it stinks guys, like there's so much stigma around patients with addiction. 219 00:21:27,180 --> 00:21:31,830 And while I'd love to think that the medical environment is immune to that stigma. 220 00:21:32,430 --> 00:21:44,580 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. 221 00:21:45,100 --> 00:21:48,580 That the hospital is a welcoming environment. 222 00:21:48,760 --> 00:21:49,060 Sara Dong: Yeah. 223 00:21:49,090 --> 00:21:49,690 Thanks so much. 224 00:21:49,690 --> 00:21:54,010 I really wanted to make sure we outlined those questions explicitly. 225 00:21:54,010 --> 00:21:55,510 And I totally agree with you. 226 00:21:55,510 --> 00:22:02,260 I think it makes a huge difference when you have these conversations with our patients, uh, to try to develop that trust. 227 00:22:02,290 --> 00:22:08,200 But also I think to make sure we're continuing to model that to others around you in the healthcare setting. 228 00:22:08,290 --> 00:22:28,080 Raagini Jawa: 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. 229 00:22:28,410 --> 00:22:30,030 And that has implications, right? 230 00:22:30,030 --> 00:22:35,685 Like if we feel compassionate to someone suffering, we also provide them better care. 231 00:22:36,225 --> 00:22:40,455 And I think that oftentimes, like these questions are not taught in medical school. 232 00:22:40,815 --> 00:22:48,765 And so we can only model it through these podcasts and model it through champions, local champions who are taking care of these patients. 233 00:22:49,125 --> 00:22:52,665 Uh, but I really do hope that there is a culture change over the years. 234 00:22:53,640 --> 00:22:56,850 Well, our patients are coming in more and more with infectious complications. 235 00:22:56,880 --> 00:23:14,820 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. 236 00:23:15,300 --> 00:23:17,640 Nathan Nolan: So that was a really great explanation. 237 00:23:17,730 --> 00:23:26,565 And, uh, I appreciate you talking about also the use of, of short acting opioids in, uh, treating withdrawal. 238 00:23:26,595 --> 00:23:31,605 You know, oftentimes we have patients that come in that, uh, like you said, trying to meet a patient where they're at. 239 00:23:31,635 --> 00:23:42,375 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. 240 00:23:42,405 --> 00:23:45,555 So, uh, we'll move on with the case. 241 00:23:45,645 --> 00:23:48,465 Um, the patient has started on buprenorphine. 242 00:23:48,705 --> 00:23:50,675 This improves his symptoms of withdrawal. 243 00:23:51,145 --> 00:23:55,710 He is also provided with symptomatic relief, including loperamide and Clonidine. 244 00:23:56,310 --> 00:24:00,840 On hospital day two, his blood cultures turned positive for Gram positive cocci in chains. 245 00:24:01,380 --> 00:24:06,030 Uh, repeat blood cultures are obtained and the transthoracic echocardiogram is performed. 246 00:24:06,570 --> 00:24:12,000 This demonstrates a three centimeter vegetation on the tricuspid valve on hospital day three. 247 00:24:12,000 --> 00:24:14,760 The organism is identified as Streptococcus mitis. 248 00:24:15,615 --> 00:24:21,175 And so given this information, is there anything you would do different in regards to this patient's management? 249 00:24:21,195 --> 00:24:26,175 Raagini Jawa: So Nathan, I'm going to probe you and say, what do you mean by the patient's management? 250 00:24:26,175 --> 00:24:32,625 Do you mean the antibiotic management, the medication for opiate use disorder management or harm reduction management? 251 00:24:34,695 --> 00:24:43,514 Nathan Nolan: 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. 252 00:24:43,814 --> 00:24:44,475 Raagini Jawa: Totally. 253 00:24:44,475 --> 00:24:53,215 So for a Strep mitis species that is typically, uh, uh, very sensitive pathogen. 254 00:24:53,215 --> 00:24:58,315 I think that narrowing the antibiotics is probably most appropriate in this case. 255 00:24:58,315 --> 00:25:03,325 Typically Strep mitis is, is a if I don't remember if you said it's penicillin susceptible. 256 00:25:03,325 --> 00:25:11,485 So I would, I would narrow it down to the most susceptible type of agent, um, to simplify the patient's antibiotic regimen. 257 00:25:11,905 --> 00:25:21,285 In terms of the medications for opioid use disorder management seems like the patient was started on buprenorphine for, or opioid withdrawal. 258 00:25:21,585 --> 00:25:27,675 And I think that this would be an appropriate time to check in on the patient and see how are those symptoms going? 259 00:25:27,975 --> 00:25:36,495 Is the patient's withdrawal being managed appropriately on the current dose and or does that dose need to be titrated further? 260 00:25:36,705 --> 00:25:42,054 Typically buprenorphine is dosed either once or twice or thrice a day. 261 00:25:42,534 --> 00:25:49,195 Um, and the questions to ask your patient for any medication for opioid use disorder, there's actually three goals. 262 00:25:49,524 --> 00:26:00,925 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. 263 00:26:01,165 --> 00:26:04,755 The second goal is to prevent cravings. 264 00:26:05,295 --> 00:26:16,815 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. 265 00:26:17,085 --> 00:26:22,905 And so that's really the goals that you should be trying to achieve even in the hospital, stay. 266 00:26:23,620 --> 00:26:34,120 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. 267 00:26:34,330 --> 00:26:39,850 If those are managed, you're a rock star, then see if there you're being able to do. 268 00:26:40,515 --> 00:26:44,535 You know, the goal number two or three, are there cravings managed? 269 00:26:44,715 --> 00:26:47,145 Because being in the hospital is no joke. 270 00:26:47,235 --> 00:26:48,075 It stinks. 271 00:26:48,345 --> 00:26:57,165 And especially for patients who are struggling with a substance use disorder and unstable housing, being in a closed hospital, there is nothing worse. 272 00:26:57,195 --> 00:26:58,185 It feels like jail. 273 00:26:58,425 --> 00:27:02,315 And so patients will often have cravings as they're feeling better. 274 00:27:02,315 --> 00:27:02,405 And. 275 00:27:02,990 --> 00:27:03,320 Right. 276 00:27:03,470 --> 00:27:06,620 Um, and they might want to go out and use and treat themselves. 277 00:27:06,860 --> 00:27:11,180 And so your role would be to check in to see if we need to do dose titration. 278 00:27:11,570 --> 00:27:22,880 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. 279 00:27:23,270 --> 00:27:32,715 Um, one of my favorite patients had Serratia marcescens, uh, isolated and her blood cultures who had a history of injection drug use. 280 00:27:32,955 --> 00:27:46,305 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. 281 00:27:46,545 --> 00:27:49,905 And so when I asked her, I was like, so how are you injecting? 282 00:27:49,905 --> 00:27:55,635 And she's like, Hey Doctor Jawa, you know, I, uh, inject tap water because I think that's the safest. 283 00:27:55,845 --> 00:27:58,155 And that's where this pathogen was introduced. 284 00:27:58,669 --> 00:28:05,240 And so similarly, this patient is coming in with Strep mitis, which is typically an oral flora. 285 00:28:05,570 --> 00:28:16,280 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. 286 00:28:16,520 --> 00:28:23,980 Talk to me again about how you're injecting and, and you might realize that the patient will say, Hey, you know what? 287 00:28:24,070 --> 00:28:31,990 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. 288 00:28:32,260 --> 00:28:51,780 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. 289 00:28:53,960 --> 00:28:58,220 So the pathogen is key in engaging your patient in a conversation. 290 00:28:58,220 --> 00:29:01,610 Once you've identified the pathogen, it like blows their world. 291 00:29:01,639 --> 00:29:07,820 I kid you not, like it really helps, um, patients identify like, oh, I have an infection. 292 00:29:08,179 --> 00:29:10,699 I think now I understand where it came from. 293 00:29:11,000 --> 00:29:18,740 And this also then leads to the next step of you partnering with the patient to identify realistic risk mitigation strategies. 294 00:29:18,770 --> 00:29:47,310 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. 295 00:29:47,760 --> 00:29:52,530 Again, it's, it's giving, um, tools for your patient to keep them safe. 296 00:29:53,409 --> 00:29:55,240 In HIV, we do this all the time. 297 00:29:55,480 --> 00:29:58,990 Um, and, and frankly, in anything, we do this all the time. 298 00:29:59,200 --> 00:30:03,220 Like for our diabetic patients, we teach our patients how to inject insulin. 299 00:30:03,370 --> 00:30:08,530 We also give them glucose tablets along with the insulin to keep themselves safe. 300 00:30:08,800 --> 00:30:18,129 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. 301 00:30:18,460 --> 00:30:20,290 And like, here are the tools. 302 00:30:21,630 --> 00:30:23,610 And that tool might be cleaning your skin. 303 00:30:23,790 --> 00:30:26,340 That tool might be finding the local needle exchange. 304 00:30:26,520 --> 00:30:35,040 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. 305 00:30:36,855 --> 00:30:45,015 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. 306 00:30:45,345 --> 00:30:55,575 Oftentimes patients may have non-optimal dental hygiene and, and, and you can have odontogenic infections that can lead to hematogenous infections. 307 00:30:55,785 --> 00:31:02,775 And so, you know, they might have a broken tooth or whatever that could have led to the, this bacteria going into their bloodstream. 308 00:31:03,315 --> 00:31:04,305 So, yeah. 309 00:31:05,685 --> 00:31:15,105 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. 310 00:31:15,535 --> 00:31:23,085 And I empower you to say, not only can I do that, but I can manage their MOUD, their medication for opiate use disorder. 311 00:31:23,235 --> 00:31:30,645 I can check on them for their cravings and I can partner them with how to reduce their risk, um, of injection drug use. 312 00:31:31,625 --> 00:31:32,155 Nathan Nolan: Excellent. 313 00:31:33,360 --> 00:31:33,630 All right. 314 00:31:33,630 --> 00:31:41,670 So that was a really, uh, great and robust discussion on harm reduction and how we might further tailor our care for this patient. 315 00:31:41,700 --> 00:31:42,480 Thank you for that. 316 00:31:43,200 --> 00:31:53,580 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. 317 00:31:54,180 --> 00:31:58,620 Susceptibility testing revealed that the Strep mitis was highly susceptible to penicillin. 318 00:31:59,385 --> 00:32:05,625 The PICC line was placed and he has started on ceftriaxone with a plan for a four week course of IV antibiotics. 319 00:32:06,135 --> 00:32:11,715 His medical teams, uh, deems that he is not a candidate for outpatient parental antibiotics. 320 00:32:13,020 --> 00:32:16,139 So, I guess in this moment, my question for you, Dr. 321 00:32:16,139 --> 00:32:30,150 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. 322 00:32:30,660 --> 00:32:35,280 Um, what other screenings or interventions would you do while they're in the hospital? 323 00:32:35,550 --> 00:32:40,290 For example, would you screen them for STI or, uh, bloodborne viruses? 324 00:32:41,520 --> 00:32:55,350 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. 325 00:32:55,740 --> 00:32:58,169 Um, What do you do in that circumstance? 326 00:32:58,169 --> 00:33:03,360 Do you preemptively make a plan for that patient in case they need to discharge a prematurely? 327 00:33:04,020 --> 00:33:05,639 Raagini Jawa: Um, excellent questions. 328 00:33:06,270 --> 00:33:08,550 So yes, you have a captive audience. 329 00:33:08,550 --> 00:33:09,870 When does this ever happen? 330 00:33:10,290 --> 00:33:14,489 And so yes, to all of the above, you can do anything and everything. 331 00:33:14,489 --> 00:33:23,580 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. 332 00:33:23,580 --> 00:33:23,850 Right? 333 00:33:23,850 --> 00:33:27,720 So these patients are often very stigmatized against the health systems. 334 00:33:27,720 --> 00:33:29,250 They don't even want to come to see you. 335 00:33:29,400 --> 00:33:33,270 They will come only when they are so sick that they probably can't function. 336 00:33:33,270 --> 00:33:36,180 And so you can provide the clinical intervention. 337 00:33:37,005 --> 00:33:51,315 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. 338 00:33:52,125 --> 00:34:02,805 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. 339 00:34:03,105 --> 00:34:07,665 And again, pre-exposure prophylaxis is a, uh, an indication for PrEP. 340 00:34:07,925 --> 00:34:10,114 So you can do all of those things. 341 00:34:10,114 --> 00:34:12,645 So what I like to do is I screened for the hepatitides. 342 00:34:12,645 --> 00:34:13,764 I screened for STIs. 343 00:34:14,315 --> 00:34:21,784 I vaccinate my patients for the Hep B hepatitis B, if they need boosters, also have, uh, vaccinate them for COVID. 344 00:34:21,784 --> 00:34:27,304 If they haven't already received that, discuss with them about pre-exposure and post-exposure prophylaxis. 345 00:34:27,514 --> 00:34:41,400 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. 346 00:34:41,670 --> 00:34:54,915 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? 347 00:34:55,155 --> 00:34:57,105 So do they have a primary care doctor? 348 00:34:57,345 --> 00:35:02,955 Do they have any social worker who can help them with like, uh, paperwork or housing? 349 00:35:02,985 --> 00:35:12,075 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? 350 00:35:12,555 --> 00:35:17,720 Um, In terms of the ID questions is can we come up with a preemptive plan? 351 00:35:17,990 --> 00:35:22,910 Well, I challenge us to say, can we come up with a preemptive ID and an addiction plan? 352 00:35:23,090 --> 00:35:46,595 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. 353 00:35:46,595 --> 00:36:02,105 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. 354 00:36:02,464 --> 00:36:12,104 And then in terms of the ID plan, well, this patient has a really sensitive pathogen Strep mitis, which is penicillin susceptible. 355 00:36:12,345 --> 00:36:34,225 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. 356 00:36:34,495 --> 00:36:48,505 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. 357 00:36:49,605 --> 00:37:02,985 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. 358 00:37:02,985 --> 00:37:11,685 Nathan Nolan: Alright, so our patients now, uh, about two weeks into treatment, um, he's doing well on his, uh, dosing of buprenorphine. 359 00:37:11,685 --> 00:37:13,634 He's not having any withdrawal symptoms. 360 00:37:13,965 --> 00:37:15,105 He feels pretty well. 361 00:37:15,105 --> 00:37:20,895 In fact, he's, uh, getting a little bit stir crazy, doing laps around the hospital ward. 362 00:37:21,285 --> 00:37:27,375 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. 363 00:37:28,035 --> 00:37:41,415 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. 364 00:37:42,180 --> 00:37:57,540 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? 365 00:37:57,720 --> 00:37:59,460 If they don't feel that they can stay in the home. 366 00:38:01,635 --> 00:38:12,945 Raagini Jawa: 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. 367 00:38:13,305 --> 00:38:58,045 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. 368 00:38:58,045 --> 00:39:06,175 If the patient misuses the PICC line and gets a PICC line associated infection or some other adverse, uh, clinical symptom. 369 00:39:06,910 --> 00:39:25,990 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. 370 00:39:26,140 --> 00:39:43,045 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. 371 00:39:43,405 --> 00:39:54,255 Um, it's because of a lot of systemic, um, variability and some stigma and some lack of infrastructural support that exists for patients. 372 00:39:54,285 --> 00:40:03,255 So while some institutions have figured out avenues to support patients who use drugs with PICC lines in their homes, others have not. 373 00:40:03,255 --> 00:40:08,295 So am I surprised that the initial team deemed this patient not eligible? 374 00:40:08,705 --> 00:40:12,735 No but do I, would I challenge them? 375 00:40:12,765 --> 00:40:13,485 Absolutely. 376 00:40:14,145 --> 00:40:35,985 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. 377 00:40:36,075 --> 00:40:36,495 Right? 378 00:40:36,525 --> 00:40:39,495 Like it is a shared decision making venture. 379 00:40:39,735 --> 00:40:42,435 We can't be, uh, paternalistic about the. 380 00:40:42,920 --> 00:40:48,110 That, oh, this patient has an addiction and I can't discharge them on a PICC line because I could get sued. 381 00:40:48,470 --> 00:40:52,550 No, the patient has a cat or whatever that they need to take care of. 382 00:40:52,550 --> 00:41:02,390 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. 383 00:41:02,690 --> 00:41:12,800 Um, and, and we can't insert our morals or our own stigma into the clinical decisions that we make for this patient population. 384 00:41:12,800 --> 00:41:18,390 So I think that your, what w what kind of plan should we make? 385 00:41:18,420 --> 00:41:25,830 Well it should really be dictated by the patient and their clinical ID and addiction optimization. 386 00:41:26,100 --> 00:41:27,200 And my colleague, Dr. 387 00:41:27,200 --> 00:41:30,960 Ayesha Appa, who's also an infectious disease and addiction medicine provider. 388 00:41:31,319 --> 00:41:51,565 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. 389 00:41:52,410 --> 00:42:00,450 Uh, for people who use drugs, I manage numerous patients with IV antibiotics and I don't see any contra-indication to discharge. 390 00:42:00,780 --> 00:42:06,240 Um, and this is not just because Doctor Jawa said, so this is actually evidence-based. 391 00:42:06,570 --> 00:42:07,290 Um, Dr. 392 00:42:07,290 --> 00:42:18,830 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. 393 00:42:18,830 --> 00:42:23,640 So if they took their PO antibiotics, don't you think that also take their IV antibiotics? 394 00:42:23,640 --> 00:42:24,930 Like no one wins. 395 00:42:25,379 --> 00:42:30,839 If, if you don't take your medication and, and so that's really getting to the point that. 396 00:42:32,370 --> 00:42:37,799 It's not that patients at substance use disorder are a nonadherent. 397 00:42:38,250 --> 00:42:40,200 They also want to get better. 398 00:42:40,410 --> 00:42:45,029 And so, uh, they might just need a little bit more multidisciplinary, outpatient support. 399 00:42:45,060 --> 00:42:47,669 And then in terms of the literature that's shown. 400 00:42:48,675 --> 00:42:52,635 PICC line complications among people who use drugs while that's been mixed. 401 00:42:52,665 --> 00:42:56,205 And the data is like a lot of retrospective studies. 402 00:42:56,205 --> 00:43:13,035 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. 403 00:43:13,435 --> 00:43:17,045 What all of these, you know, studies really show us is that. 404 00:43:17,865 --> 00:43:20,654 While there's a lot of variability in PICC line eligibility. 405 00:43:21,194 --> 00:43:24,525 Oftentimes it's dictated by what the institutional norm is. 406 00:43:24,975 --> 00:43:28,964 And sometimes the institutional norm is no that we will not. 407 00:43:29,535 --> 00:43:42,000 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. 408 00:43:42,390 --> 00:43:45,660 Um, because there really isn't any negative outcome. 409 00:43:45,720 --> 00:43:54,270 It does require a fair amount of case management VNA buy-in, um, an outpatient sort of support for this patient population. 410 00:43:54,509 --> 00:43:55,290 But your clinic. 411 00:43:56,355 --> 00:44:04,155 Uh, decisions for this patient's outpatient management should not be dictated by anything except for, is this person optimized from their addiction? 412 00:44:04,155 --> 00:44:04,725 Yes or no. 413 00:44:05,085 --> 00:44:07,155 Is this person optimized for their infection? 414 00:44:07,155 --> 00:44:07,905 Yes or no. 415 00:44:08,205 --> 00:44:13,095 And then do they have like a stable way to get their IV antibiotics? 416 00:44:13,515 --> 00:44:15,495 Um, and that's it. 417 00:44:15,855 --> 00:44:28,705 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. 418 00:44:28,945 --> 00:44:39,745 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. 419 00:44:40,255 --> 00:44:47,090 They would not inject in their PICC and they say that they recognize the complications of injecting their PICCs are quite large. 420 00:44:47,509 --> 00:44:52,549 Um, they have other ways of injecting if they really needed to inject and if a patient wants to use, they will. 421 00:44:52,850 --> 00:44:56,840 Um, and I certainly have had a fair amount of patients who have triggers. 422 00:44:56,840 --> 00:45:14,450 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. 423 00:45:14,940 --> 00:45:17,460 Um, that being said, I don't think that. 424 00:45:18,825 --> 00:45:22,575 IV antibiotics is necessarily the best route for everyone. 425 00:45:23,175 --> 00:45:34,815 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 426 00:45:35,390 --> 00:45:38,060 outpatient antibiotics for people who inject drugs. 427 00:45:38,390 --> 00:45:44,810 It includes that the patient is willing to engage in close, follow up, that they, the patient has safe and stable housing. 428 00:45:44,840 --> 00:45:48,290 Even if this patient that we have in this case is not stable housed. 429 00:45:48,590 --> 00:45:54,200 Maybe they have a family member who's really engaged in their recovery that can house them that as a responsible adult. 430 00:45:54,230 --> 00:45:55,610 And then we'll continue to help. 431 00:45:56,194 --> 00:45:59,075 Administer the antibiotics and get them to appointments, et cetera. 432 00:45:59,464 --> 00:46:03,694 And I think that that should be included in the conversations that you have with your patients. 433 00:46:04,055 --> 00:46:10,895 I think that there's a lot of gray zones and, um, I encourage you all to have conversations with your patients. 434 00:46:11,314 --> 00:46:15,484 And Nathan, the other question you asked is, well, have antibiotics. 435 00:46:16,134 --> 00:46:21,625 In this day and age, our IV antibiotics really needed after two weeks. 436 00:46:21,924 --> 00:46:33,715 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. 437 00:46:33,985 --> 00:46:38,575 And, and this patient is lucky because they don't have a methicillin-resistant staph or is. 438 00:46:40,020 --> 00:46:44,399 Um, but you know, the POET trial didn't really include a lot of patients with substance use disorders. 439 00:46:44,759 --> 00:46:49,950 That being said the outcomes for, from the more sensitive pathogens was probably fine. 440 00:46:50,339 --> 00:46:56,220 Um, so I really think it's dependent on what your ID consultants in your institution are comfortable doing. 441 00:46:56,680 --> 00:47:03,569 There are other trials about long-acting lipo, um, glycopeptides and whatnot that can help. 442 00:47:04,049 --> 00:47:13,290 Um, facilitate patients being able to go home earlier, uh, that, uh, yeah, uh, I think the world is our oyster. 443 00:47:13,500 --> 00:47:29,009 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. 444 00:47:29,609 --> 00:47:47,580 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. 445 00:47:48,030 --> 00:48:03,285 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. 446 00:48:03,555 --> 00:48:05,475 It is a cost-effective strategy. 447 00:48:05,475 --> 00:48:16,694 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. 448 00:48:17,160 --> 00:48:20,130 This might be a waste of our money. 449 00:48:20,400 --> 00:48:25,680 Well there's data that suggests that it might actually be a cost saving venture for the hospital system. 450 00:48:26,100 --> 00:48:29,550 And ha heck, it'll be a real, real benefit for our patients. 451 00:48:30,030 --> 00:48:33,900 Patients who inject drugs are just like every other patient that we take care of. 452 00:48:33,930 --> 00:48:43,860 They should be getting the same standard of care and should not be discriminated against, um, forgetting serious bacterial and fungal infections. 453 00:48:45,525 --> 00:48:46,125 Sara Dong: Hi, everyone. 454 00:48:46,155 --> 00:48:53,655 Thanks again for listening to Febrile, we will put links to tons of resources about the topics that we covered in today's episode. 455 00:48:53,985 --> 00:49:00,675 Do not forget to check out the website, febrilepodcast.com, where you will find the Consult Notes, which are written complements to the show. 456 00:49:01,540 --> 00:49:04,779 Our library of ID infographics and a link to our merch store. 457 00:49:05,350 --> 00:49:09,370 Please reach out if you have any suggestions for future shows or want to be more involved with febrile. 458 00:49:09,640 --> 00:49:10,509 Thanks for listening. 459 00:49:10,540 --> 00:49:12,069 Stay safe, and I'll see you next time.