PICC Your Battles: Considering the Appropriateness of Peripherally Inserted Central Catheter (PICC) Lines for Outpatient Parenteral Antimicrobial Therapy (OPAT) in Injection Drug Users (IDUs)

Abstract

Les utilisateurs de drogues injectables (UDIs) ayant besoin d'une antibiothérapie par voie parentérale ambulatoire (APA) pour des infections associées aux injections se voient fréquemment refuser l'accès à un cathéter central à insertion périphérique (PICC, de l'anglais) puisqu'on présume qu'ils l'utiliseront pour s'injecter des drogues illicites, et que le cathéter sera utilisé de manière non stérile ou peu hygiénique. Bien que les UDIs présentent des taux plus élevés d'endocardite infectieuse, d'abcès et de septicémie, il n'existe pas de preuves substantielles qui démontrent que les PICCs chez les UDIs entraînent des infections plus sévères, ou une hausse de surdoses, de morbidité ou de mortalité. La transition réussie des UDIs d'un traitement hospitalier vers une APA exige une sélection attentive des patients. Notamment, la situation de logement, les antécédents de santé mentale, la présence d'un système de soutien et la volonté du patient de suivre le traitement contribuent tous au succès de l'APA. Des conversations honnêtes et directes doivent avoir lieu entre le patient et le fournisseur de soins quant aux risques et aux avantages d'un PICC et de l'utilisation de drogues injectables. Un suivi étroit, une approche compatissante, la formation appropriée des fournisseurs de soins, et l'expansion des programmes de répit constituent tous de nouvelles façons de réduire les méfaits et d'améliorer les soins aux patients. Finalement, plus de recherche est nécessaire afin de mettre en place des protocoles, des lignes directrices, des critères de dépistage et des transitions de soins, et pour clarifier les pratiques exemplaires quant à l'APA chez les patients qui utilisent des drogues injectables. BT lay with her head cocked in the only comfortable position, her thin legs protruding below flimsy hospital sheets. I was on a rotation in Infectious Diseases based at several Toronto-area hospitals and she was not my first intravenous (IV) drug-using patient. She was, however, the first patient I had seen who was unable to move her head more than several millimeters in either direction since a paraspinal abscess precariously abutted her spinal cord.BT could be argumentative-she had yelled at several nurses and often refused to have her vital signs taken. She also told me she was scared-she recognized that finding herself in this position was likely secondary to her IV drug use. Despite delivering attentive care, some of the nurses rolled their eyes when talking about Injection drug users (IDUs) requiring outpatient parenteral antibiotic therapy (OPAT) for injection-related infections are regularly denied the use of peripherally inserted central catheter (PICC) lines based on the assumption that they will use the port to inject illicit drugs, and that it will be used in a non-sterile/unclean fashion. While IDUs have higher rates of infective endocarditis, abscesses and septicemia, there is no substantial body of evidence that PICC lines in IDUs result in more serious infections, increased overdoses or increased morbidity o...

“I have such a hard time hitting myself, I thought it’d be easier”: perspectives of hospitalized patients on injecting drugs into vascular access devices

“…Additionally, there are currently no evidence-based pharmaceutical treatments for those with stimulant use disorders [48] and many acute care facilities still do not provide patients with opioid use disorders evidence-based medication treatment or harm reduction interventions [49]. Clinicians therefore should be educated and encouraged to engage patients with previous or active injection drug use in non-stigmatizing and factual conversations about reducing harms associated with drug use, including the potential risks of injecting into VADs [15,50]. Research to quantify VAD injecting risks is urgently needed to facilitate such factual discussions.…”

“…In cases where education and available supports have not deterred VAD injecting, staff might consider supervising patients injecting into their VADs from within their hospital room (in jurisdictions where this is permissible) [64], or demonstrating how to more safely and sterilely inject into VADs, requesting patients avoid certain VADs, and establishing a non-punitive system for patients to report to hospital staff after use [15,57]. However, more research is needed to evaluate the effectiveness of these harm reduction strategies for reducing health harms of VAD injecting for hospitalized PWID.…”

“…Conversely, people who inject drugs (PWID) often remain hospitalized for the duration of their treatment due to concerns that unstable housing or ongoing drug use may inhibit treatment adherence and that patients will inject drugs and/or diverted medications into these devices [9][10][11]. However, there is a lack of empirical evidence on the prevalence and health risks associated with injecting drugs into VADs among either outpatient or hospitalized PWID [12][13][14][15]. Nevertheless, clinical guidance in many jurisdictions advises inpatient hospitalization and close monitoring as the primary strategy to prevent VAD complications for this patient population [9][10][11].…”