Table 1.

Case Examples of People Who Use Drugs, With Diagnostic and Management Recommendations

Case No.	Case Summary	Key Diagnostic Lessons	Key Infection Management Lessons	Key Substance Use Disorder Management Lessons
1	35-year-old woman with OUD on methadone hospitalized for Staphylococcus mitis bacteremia related to dental infection; presentation delayed by 1 wk (and complicated by prehospital antibiotics she got from a friend) due to fear of being labeled as “drug-seeking”	Recognize that people with SUD may present with advanced and/or partially treated infection because of stigma, trauma previously experienced in medical settings	Use shared decision making to partner with your patient and choose the best antimicrobial option, including setting and route	For patients with OUD on methadone, consider the potential need to attend a methadone clinic daily upon discharge
			Do not create a scenario in which patients must choose either MOUD or antibiotics (eg, once-daily antibiotic push doses or continuous infusion pumps for patients needing to attend methadone clinic may be optimal)
2	44-year-old man with OUD and methamphetamine use and chronic back pain experiencing homelessness in rural Maine after release from jail, hospitalized with MSSA mitral valve endocarditis and continued back pain on day 8 of positive blood cultures	Take reports of pain seriously and examine for potential sources of continued infection such as epidural abscess	Assess for drug interactions with methadone; avoid MOUD discontinuation; consider alternatives to scheduled, in-person follow-up visits (eg, telehealth, drop-in model) if more patient-centered	Buprenorphine and methadone confer mortality benefit in OUD; contingency management could be considered if resources available
3	35-year-old transgender woman experiencing homelessness with opioid and stimulant use disorders, hospitalized with Serratia bacteremia; source of infection from injecting with nonsterile water and reused needles given no access to SSPs in her primarily Black neighborhood; wants to leave hospital before antibiotic plan finalized	Pathogens may come from not only needles/syringes but also drugs or adulterants, materials used to prepare drugs for consumption, and/or skin; consider providing sexually transmitted infection screening and relevant vaccinations early in hospital stay	For patients leaving hospital early, discharge with highly bioavailable oral antibiotics in hand and the option to make follow-up outpatient appointments prior to leaving	Discuss safer use practices to prevent secondary infection and ensure patient has access to harm reduction services/equipment; prescribe naloxone and discuss universal overdose precautions (eg, use small “test” doses, avoid using alone when possible, stagger drug use with others, use drug-checking services, if available)
			Recognize and address health inequities (eg, ensure providing equitable access to harm reduction services as well as infectious disease/SUD treatment options) and partner with the community to provide low-barrier care
4	25-year-old man experiencing homelessness with opioid and stimulant use disorders, and MSSA prosthetic valve endocarditis, receiving intravenous cefazolin through PICC at respite care center; treated with methadone and mirtazapine for stimulant use disorder; experienced triggering event and used PICC line to inject methamphetamine once	Nonjudgmental conversation about injection drug use to explore the differential of ongoing injection drug use (eg, undertreated withdrawal and/or pain, cravings, stress, trauma)	Use a structured conversation guide to review risks and benefits of PICC vs other antimicrobial routes (oral, long-acting injection)	Work with addiction medicine/psychiatry providers and modify substance use treatment plan if needed; implement and advocate for harm reduction services (eg, safe consumption sites)

Abbreviations: MOUD, medication for opioid use disorder; MSSA, methicillin-susceptible Staphylococcus aureus; OUD, opioid use disorder; PICC, peripherally inserted central catheter; SSPs, syringe services programs; SUD, substance use disorder.