Abstract
Background:
People who use drugs (PWUD) are at increased risk for severe infections and face many barriers when completing conventional, typically parenteral antimicrobial treatments. Despite evidence supporting various antibiotic options, such as oral antibiotic therapy, there has been limited uptake of these strategies by many clinicians.
Objectives:
Create a training for hospital-based clinicians detailing harm reduction and various antimicrobial treatment options for the care of PWUD with severe infections. Examine current hospital-based clinician practices regarding the care of PWUD. Compare pre- and post-training clinician knowledge and comfort around various antibiotic treatment options, harm reduction, and substance use stigma.
Design:
The study design was a pre- and post-intervention descriptive survey. The intervention was the training session. Surveys were completed by participants before and after the training. Surveys were completed by participants before and after the training and asked about participants’ practices and attitudes regarding PWUD and treatment options.
Methods:
The training was provided to hospital-based clinicians across eight different sites in four different states from November 2022 to November 2023. We examined knowledge, attitudes, and practices around treating injection drug use-associated infections, patients with substance use disorders, and comfort with antimicrobial treatment options using pre-and post-training surveys. We also used a modified version of a validated substance use stigma instrument to measure stigma pre- and post-training. For paired pre-post survey data, we used McNemar’s test to compare Likert scale responses.
Results:
Of 167 study participants, 126 (75%) completed the pretraining survey, and 42 (25%) provided paired pre-post survey responses. Among the 126 pre-survey respondents, 64 (51%) were trainees, 75 (60%) frequently treated patients with injection drug use-associated infections, and 61 (50%) reported consistently applying harm reduction strategies to these patients in the hospital. Post-training, participants with paired data were significantly more likely to agree with applying harm reduction principles to the care of PWUD (pre, 23 (55%); post, 39 (95); p < 0.001) and discussing safer drug use practices (pre, 16 (38%); post, 29 (69%); p = 0.004).
Conclusion:
Our study shows that an interactive training for hospital-based clinicians can significantly improve clinician knowledge and comfort with applying harm reduction strategies and with offering various antibiotic treatment options to PWUD with severe infections.
Keywords: anti-bacterial agents, education, harm reduction, substance-related disorders
Background
The United States continues to face a severe opioid use crisis. Recent estimates reveal that approximately 6–7 million adults in the U.S. live with opioid use disorder 1 and approximately 3.6 million of those inject drugs. 2 Although much of the public health focus has been on the rising mortality associated with opioid and stimulant overdoses, which has increased by a factor of 6 between 1999 and 2021, serious infections from both injection and non-injection drug use have also increased.3,4
People who use drugs (PWUD) who are admitted with infectious complications of injection drug use are often prescribed long durations of intravenous (IV) antibiotic therapy for conditions such as bacteremia, endocarditis, and osteomyelitis. PWUD often find themselves with restrictive options for outpatient treatment, leading to prolonged and expensive hospital stays that may bring about consequences such as social isolation, inadequate pain control, and stigma from clinicians. 5 This unintentionally contributes to a high rate of patient-directed discharges, with a recent study that found 24% of patients at a tertiary care hospital with invasive Staphylococcus aureus infections have patient-directed discharges. The same study found that PWUD who undergo self-discharge face nearly four times the risk of readmission, and of those who are not re-admitted, few complete prescribed medical therapy for serious infections. 6
Past research shows that clinicians are hesitant to provide outpatient treatment options for patients with a history of drug use due to clinicians’ perceptions of the inferiority of non-standard treatment options and concerns about adverse events with outpatient parenteral antimicrobial therapy (OPAT).7,8 Despite this, evidence suggests that OPAT is effective for certain patients and is only rarely associated with increased adverse events such as overdoses and self-administration of non-prescribed drugs.9–16 Directly treating opioid use disorder and providing safer use supplies has also been shown to significantly reduce the rate of such complications with OPAT.9,13,14,16
In cases where OPAT is not feasible, other evidence-based antimicrobial treatment options are available and can be offered to PWUD. 17 In select groups of patients, growing evidence supports that oral antimicrobials can be as effective as IV antimicrobial options.7,13,18–21 Despite these data, few guidelines incorporate PO therapy into the treatment for endocarditis or osteomyelitis, and many hospital-based clinicians are reluctant to offer this option to patients. 15 In addition, long-acting injectable antibiotics such as dalbavancin administered at outpatient infusion centers are another potential treatment option for patients with gram-positive infections. 22 Notably, offering patients a range of antimicrobial treatment options has been shown to reduce stigma and improve patient engagement in their health care.7,13,18,23–25
To increase antimicrobial therapy completion in PWUD, clinicians can apply harm reduction approaches to care, including offering patients various antimicrobial treatment options tailored to their preferences. Harm reduction is a social justice movement started by PWUD that emphasizes autonomy and respect for PWUD and can be broadly defined as a set of practices to reduce the negative consequences of drug use while acknowledging that people may continue to use drugs. 26 Examples of harm reduction interventions have included needle exchange and vaccination clinics through syringe service programs, naloxone distribution, fentanyl and/or xylazine test strips, drug checking, and referrals to low-barrier addiction treatment. Reducing clinician stigma around substance use and harm reduction strategies is necessary to improve access to harm reduction interventions. 27 Harm reduction principles can also be applied to patients with infectious complications of drug use, honoring their autonomy and preferences in antimicrobial treatment decisions 28 and using shared decision making to develop a safe discharge plan for each patient.23,29
Medical education remains a cornerstone of updating clinicians on evidence-based medicine and frequently involves short lectures by fellow clinicians in healthcare settings such as weekly didactics, grand rounds, and morning rounds. Research suggests that medical education sessions can not only increase a participant’s fund of knowledge but also help reduce stigmatization for PWUD.8,30 Therefore, we developed a medical education intervention to primarily increase knowledge about harm reduction principles and various evidence-based antimicrobial treatment options for PWUD with severe infections.
The Harm Reduction Implementation Framework, developed to assist institutions in adopting harm reduction approaches, calls for a shared understanding of substance use and its complications, reducing stigma by promoting evidence-based harm reduction strategies, developing an organizational culture of harm reduction, and making harm reduction resources accessible. In this study, we used these Harm Reduction Implementation Framework tenets 31 aimed to: (1) develop and implement an interactive training to improve hospital-based clinician knowledge about harm reduction principles and various antimicrobial treatment options for PWUD with severe infections, (2) examine clinician practices regarding the care of PWUD, such as antimicrobial prescribing practices for PWUD with severe infections, and (3) compare pre- and post-training clinician knowledge and comfort around offering antimicrobial options and harm reduction principles, as well as pre- and post-training stigma scores. We hypothesized that knowledge, comfort, and stigma scores would improve post-training.
Methods
Study design
The study took the form of a descriptive survey with pretraining and post-training survey data. Led by an infectious disease fellow, through an iterative process among infectious disease clinicians at six academic medical centers across the United States, we created a 1-hour-long, interactive case-based training (see Supplemental Appendix A). We chose this format so that the training could be easily provided during typical didactic times without a significant time commitment from participants. All the clinicians were board certified in infectious disease, some also in addiction medicine, and all have significant experience working with PWUD with infectious complications. Current IDSA guidelines on the treatment of serious infections such as endocarditis and osteomyelitis were reviewed, along with recent literature published regarding alternatives to guideline-based therapies for the treatment of these infections. The training included topics such as stigmatization of substance use disorders, patient perspectives on being hospitalized for injection drug use-associated infections, and a brief literature review supporting evidence-based antimicrobial treatment options such as OPAT and de-escalation to oral antibiotic therapy. The training also included a review of harm reduction interventions such as naloxone prescribing, safer use techniques, and peripherally inserted catheter (PICC) safety. We embedded clinical cases that covered common issues such as discharging with OPAT, partial IV/partial PO treatment, long-acting injectable antimicrobials, and early patient-directed discharges.
The target audiences for the training were primarily hospitalists, internal medicine and/or family medicine residents, and subspecialty fellows. Most of the training took place during didactic sessions such as morning reports or noon-time conferences for house staff, or elective learning sessions for attendings. Trainings were typically scheduled during lunch periods and/or business hours, with some sessions occurring in the early evening as well. The trainings were hosted in person or virtually by either infectious disease fellows, infectious disease attendings, or combinations of both infectious disease fellows and infectious disease physicians. Audience participation was encouraged as time allowed, with frequent open-ended questions and group discussions. The training was administered between November 2022 and November 2023. Continuing medical education credits were provided at several of the sites per their request, but CME was not contingent on completing either the pretraining or post-training surveys.
Informed consent was obtained: a written consent script was included at the beginning of each electronic survey. All participants were invited but not required to complete a pre- and post-training online survey, which included questions about current practices treating injection drug use-associated infections, attitudes about patients with substance use disorders, and comfort with different antimicrobial treatment options such as OPAT or PO therapy for infections like osteomyelitis and endocarditis. We used the validated OM-PATOS instrument 32 with slight modifications to language to measure stigma (see Supplemental Appendix B). Other survey questions assessed the level of agreement with various statements on a five-point Likert scale (strongly disagree, disagree, neither disagree/agree, agree, strongly agree). Participants also had the option of providing free-response perspectives on the training in the post-training survey. To decrease attrition on post-training surveys, reminder emails were sent to participants weekly for 3 weeks following each training. Pretraining surveys were emailed to participants prior to the sessions, and/or participants had an opportunity to take the pretraining survey at the beginning of each session using a QR code link to the pretest survey. Because uploaded email addresses were checked as personal health information in our HIPAA-compliant online database, only de-identified responses were available to the study team for analysis, and thus, the MaineHealth IRB deemed this study exempt. The reporting of this study conforms to the EQUATOR Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. 33
Statistical analysis
We summarized categorical survey data as n (%), both overall (pre-survey) and for the subgroup providing paired pre-post survey responses. For presentation and analysis purposes, we condensed five-point Likert responses into two categories: strongly disagree/disagree/neutral and strongly agree/agree. We compared paired pre-/post-survey responses using McNemar’s test. We used Bonferroni’s correction to account for multiple comparisons. All analyses were performed using SPSS statistical software version 30 (IBM SPSS Inc., Armonk, NY, USA).
Results
From November 2022 to November 2023, training sessions were delivered at eight study sites across the United States, as summarized in Table 1. One hundred sixty-seven participants consented to the study, among whom 126 (75%) completed the pretraining survey and 42 (25%) completed both the pre- and post-training surveys. The distributions of study sites, participant specialty, and participant experience were similar between the 126 participants who completed the pretraining survey and the 42 participants who provided paired pre-post survey responses.
Table 1.
Study participant characteristics.
| Variable | Frequency, n (%) | |
|---|---|---|
| Overall a | Paired pre/post data | |
| N | 126 | 42 |
| Study site | ||
| Alabama b | 26 (21) | 8 (19) |
| Maine c | 67 (53) | 22 (52) |
| New Hampshire d | 16 (13) | 7 (17) |
| Oregon e | 16 (13) | 4 (10) |
| Not provided | 1 (1) | 1 (2) |
| Specialty | ||
| Infectious disease | 31 (25) | 14 (33) |
| Internal medicine | 51 (40) | 15 (36) |
| Family medicine | 35 (28) | 11 (26) |
| Other | 9 (7) f | 2 (5) g |
| Experience level | ||
| N | 125 | 42 |
| Resident or fellow | 64 (51) | 17 (40) |
| Practicing 1–5 years | 28 (22) | 13 (31) |
| Practicing more than 5 years | 33 (26) | 12 (29) |
| Frequency of treating patients with injection drug use-associated infections | ||
| N | 125 | 42 |
| Frequently | 75 (60) | 28 (67) |
| Occasionally | 39 (31) | 12 (29) |
| Rarely | 8 (6) | 2 (5) |
| Never | 3 (3) | 0 (0) |
n = 167 individuals participated in training, of whom n = 126 completed the pretraining survey (response rate, 74.4%).
University of Alabama Health System.
Maine hospitals included Northern Light Eastern Maine Medical Center, MaineHealth Maine Medical Center, Maine General Medical Center, Redington Fairview General Hospital, and LM Strategy, LLC, a professional education consultation service.
Dartmouth Hitchcock Medical Center.
Oregon Health & Sciences University.
n = 3, Neurology; n = 1 each of anesthesia, surgery/surgical subspecialty, hospital medicine, emergency medicine, obstetrics and gynecology, and not provided.
n = 1 each of surgery/surgical subspecialty, emergency medicine.
Figures 1 and 2 summarize current practices among n = 113 providers who completed the pretraining survey and reported that they frequently or occasionally treat patients with injection drug use-associated infections. As shown in Figure 1, 52 (46%) frequently or occasionally provide OPAT to PWUD who are stable on medications for their opioid use disorder, while 61 (54%) rarely/never provide this option. When asked how often they prescribe oral antibiotics with good bioavailability in lieu of parenteral therapy (Figure 2), 78 (69%) reported prescribing oral antibiotics frequently or occasionally, while 35 (31%) responded rarely/never.
Figure 1.
OPAT prescribing practices for PWUD with an associated infection who are stable on medication for opioid use disorder, among providers who frequently/occasionally treat such patients.
Data represent pretraining responses from n = 113 providers who either frequently or occasionally treat PWUD for their injection-associated infections.
OPAT, outpatient parenteral antimicrobial therapy; PWUD, people who use drugs.
Figure 2.
Prescription of oral antimicrobials with good bioavailability in lieu of parenteral therapy; practice among providers who frequently/occasionally treat such patients.
Data represent pretraining responses from n = 113 providers who either frequently or occasionally treat PWUD for their injection-associated infections.
Table 2 summarizes responses related to participants’ knowledge and comfort with harm reduction, both overall (pretraining) and among those providing paired surveys (pre- and post-training). Following training, those with paired data reported significant pre/post increases in their familiarity with harm reduction (34, 81% and 41, 98%; p = 0.04) and their comfort with applying harm reduction strategies (23, 55% and 39, 93%; p < 0.001). They were also more comfortable with discussing safer use with patients (16, 38% and 29, 69%; p = 0.004) and having conversations about discharge options (25, 60% and 38, 90%; p = 0.001). These findings must be interpreted in the context of potential overlap among the concepts queried.
Table 2.
Participant harm reduction knowledge and comfort pre- and post-training.
| Harm reduction statement | Frequency, n (%) | |||
|---|---|---|---|---|
| Overall | Paired pre/post responses | |||
| Time period relative to training | Pre | Pre | Post | p-valuea,b |
| N | 126 | 42 | 42 | |
| I am familiar with the concept of harm reduction. | ||||
| N | 125 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 20 (16) | 8 (19) | 1 (2) | 0.04* |
| Strongly agree/agree | 105 (84) | 34 (81) | 41 (98) | |
| I feel comfortable applying harm reduction strategies to the care of patients with infectious complications of substance use disorder c | ||||
| N | 124 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 49 (40) | 19 (45) | 3 (7) | <0.001* |
| Strongly agree/agree | 75 (60) | 23 (55) | 39 (93) | |
| I feel comfortable discussing safer use practices with patients who inject drugs. | ||||
| N | 125 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 65 (52) | 26 (62) | 13 (31) | 0.004* |
| Strongly agree/agree | 60 (48) | 16 (38) | 29 (69) | |
| I feel comfortable having conversations with patients who inject drugs about discharge treatment options d | ||||
| N | 124 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 49 (40) | 17 (40) | 4 (10) | 0.001* |
| Strongly agree/agree | 75 (60) | 25 (60) | 38 (90) | |
| Patients who inject drugs should have some say in their discharge decisions e | ||||
| n | 124 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 12 (10) | 4 (10) | 3 (7) | 1.00 |
| Strongly agree/agree | 112 (90) | 38 (90) | 39 (93) | |
McNemar’s test; analysis limited to those with paired pre/post data.
Significance was accepted at p < 0.01 after Bonferroni correction for multiple comparisons.
That is, discussing naloxone, preexposure prophylaxis, and antimicrobial options.
That is, parenteral therapy inpatient versus outpatient, transitioning to oral antimicrobials.
That is, be included in multidisciplinary discussions about discharge options.
Indicated statistical significance (p < 0.05).
Table 3 summarizes overall pretraining and paired pre-post responses to questions from the OM-PATOS stigma instrument that addressed participants’ opinions about PWUD. The data indicated that participants had low levels of stigma toward PWUD prior to the training, and this was unchanged post-training. We observed similar findings for questions from the OM-PATOS instrument that queried participants about their personal feelings toward PWUD (data not shown).
Table 3.
Participant responses to statements about stigma, pre- and post-training.
| Stigma Statement (opinions about people who use drugs) | Frequency, n (%) | |||
|---|---|---|---|---|
| Overall | Paired pre-/post-responses | |||
| Time period relative to training | Pre | Pre | Post | p-Valuea,b |
| N | 126 | 42 | 42 | |
| People who use drugs: | ||||
| Are to blame for their situation | ||||
| N | 125 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 120 (96) | 41 (98) | 40 (95) | 1.00 |
| Strongly agree/agree | 5 (4) | 1 (2) | 2 (5) | |
| Cost the system too much money | ||||
| N | 125 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 95 (76) | 29 (69) | 32 (76) | 0.45 |
| Strongly agree/agree | 30 (24) | 13 (31) | 10 (24) | |
| Can’t be trusted | ||||
| N | 124 | 41 | 42 | |
| Strongly disagree/disagree/neutral | 111 (90) | 39 (95) | 42 (100) | 0.50 |
| Strongly agree/agree | 13 (10) | 2 (5) | 0 (0) | |
| Who take drug therapies like methadone are replacing one addiction with another | ||||
| N | 124 | 41 | 42 | |
| Strongly disagree/disagree/neutral | 117 (94) | 40 (98) | 42 (100) | 1.00 |
| Strongly agree/agree | 7 (6) | 1 (2) | 0 (0) | |
| Only care about getting their next dose of drugs | ||||
| N | 125 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 122 (98) | 41 (98) | 42 (100) | 1.00 |
| Strongly agree/agree | 3 (2) | 1 (2) | 0 (0) | |
| Who [have recurrence of use] while trying to recover aren’t trying hard enough to get better | ||||
| N | 125 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 123 (98) | 41 (98) | 40 (95) | 1.00 |
| Strongly agree/agree | 2 (2) | 1 (2) | 2 (5) | |
| Engage in crime to support their addiction | ||||
| N | 124 | 42 | 42 | |
| Strongly disagree/disagree/neutral | 117 (94) | 40 (95) | 41 (98) | 1.00 |
| Strongly agree/agree | 7 (6) | 2 (5) | 1 (2) | |
McNemar’s test; analysis limited to those with paired pre/post data.
Significance was accepted at p < 0.007 after Bonferroni correction for multiple comparisons.
Among the 42 with paired pre-/post-survey responses, 35 (83%) reported that they agreed/strongly agreed with the statement “After completing the training, I feel more comfortable having harm reduction conversations with patients who inject drugs” and 37/41 (90%) agreed/strongly agreed with the statement “After completing the training, I feel more comfortable having discharge treatment option conversations with patients who inject drugs”. Forty (95%) reported that the training was helpful for their knowledge/practice on hospital discharge care of patients who inject drugs.
Post-training, we received 19 free-text responses providing further feedback about the participants’ experiences. Overall, participants felt the lecture was very informative and evidence-based, though multiple participants commented that the material was too broad for a limited 1-h lecture and that the surveys were burdensome due to length. One participant expressed concern about the legal implications of discharging PWUD on non-guideline-based therapies. This topic would be beneficial to include in future trainings. Several participants expressed interest in attending future similar trainings and having the opportunity to participate in simulated counseling sessions or hands-on training in safer use techniques.
Discussion
We developed and implemented an interactive training to improve hospital-based clinician knowledge about antimicrobial treatment options and incorporating harm reduction principles into discharge planning for patients with injection drug use-associated infections. Our study adds to the literature by demonstrating that a brief, novel, low-barrier training can potentially increase clinicians knowledge and comfort around providing harm reduction strategies and antimicrobial treatment options.
Our training addresses several components of the Harm Reduction Implementation Framework; specifically, creating shared understanding and promoting a culture of harm reduction. Compared to pretraining responses, participants who completed the post-training survey reported significantly more comfort with the application of harm reduction strategies for PWUD, discussing safer use practices, and having conversations with PWUD about discharge treatment options.
As previously noted, the Harm Reduction Implementation Framework was developed to help reduce stigma. While our study found that the training had no significant effect on participants’ agreement with the various stigma scale statements, this result is likely explained by participants’ low stigma scores at baseline. Notably, a systematic review of several international studies of mainly pedagogical interventions aimed at reducing stigma did find that lecture-based, indirect contact-based interventions, such as our training, could be most effective for reducing stigma among clinicians. 34 A similar recent study by Sulzer et al. found that using interactive, contact-based education was effective for reducing stigma among clinicians, though in that study, the educational training was 8 h and spread over three sessions. 8 Perhaps in a study sample with higher baseline stigma scores, we may have detected a significant difference in stigma scales pre- versus post-training.
Another aspect of the Harm Reduction Implementation Framework involves making harm reduction resources equitable and accessible. Shorter harm reduction trainings like ours have the benefit of potentially being more generalizable and accessible, given the ease of application. For example, teleconferencing software has become commonplace, and in this study, we were able to successfully facilitate online discussions for several of our trainings. In addition, we were able to offer the training in person without needing to alter the curriculum or require advanced registration. Because the training was administered during grand rounds or other weekly didactic offerings, which clinicians typically attend, we were able to reach a wide audience.
Hawk et al. identified six principles of harm reduction in healthcare settings for people who use drugs: humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination. 35 We believe that our training encompasses several of these principles by encouraging learners to view PWUD as humans with autonomy who should be given pragmatic options regarding their care that is responsive to their individual situations. For example, we focused a segment of the lecture on a qualitative assessment of the PWUD healthcare experience, which we believe shows learners that harmful health behaviors are not always illogical, and sometimes provide some benefits to the individual. We emphasized that PWUD should be provided evidence-based options regarding their treatments, and be allowed to make decisions that may not be “guideline based” but that are appropriate for the individual as they see it.
Our study does have several limitations. First, despite being multi-site and spread across several healthcare systems in the United States, our survey sample size was relatively small. We did not perform an a priori sample size calculation as the parameters needed to inform this were not available, and our findings need to be interpreted in the context of an exploratory study. Although 167 participants attended the training, only 25% of participants completed both the pre- and post-training surveys. Thus, our findings for pre-post comparisons may have limited internal validity due to selection bias. Also, most of our participants reported some level of agreement with harm reduction principles at baseline.
Second, because of our small sample size, we were not able to properly examine whether there were differences in responses based on study site. More research should be done to evaluate whether a training session like ours is better suited to different geopolitical contexts. For example, the majority of our participants were from Maine, which has more progressive laws regarding syringe service programs and other services for people who use drugs.
Also, due to sample size, we did not examine whether or not who delivered the training (e.g., ID fellow vs ID attending vs a combination of ID fellow/ID attending) yielded different results. In future studies, it would be interesting to examine peer-to-peer dynamics and differences in results based on the trainer. Many participants were interested in learning about the legal implications of discharging PWUD on non-guideline–based therapies, which we feel would be a valuable addition to future trainings. Future research should include (1) identifying which harm reduction principles participants are most comfortable with (e.g., syringe service program referrals, and naloxone), (2) a broader audience, particularly with more surgical, anesthesia, and obstetrics and gynecology participants, and from a broader geographical area, and (3) shorter surveys to potentially improve survey response rates.
Conclusion
Harm reduction principles can be applied to antimicrobial treatment for patients with injection drug use-associated infections. In this study, however, we found that there is discomfort among clinicians in discussing and implementing these antimicrobial options among people who use drugs. Our study demonstrates that a brief interactive training in harm reduction strategies can improve clinician knowledge, familiarity, and comfortability with harm reduction principles, particularly when applying them to antimicrobial treatment decisions.
Supplemental Material
Supplemental material, sj-docx-3-tai-10.1177_20499361251375334 for A descriptive survey evaluating the implementation and outcomes of a training session highlighting concepts in antimicrobial management and harm reduction for hospital-based clinicians treating persons who use drugs by Michael P. Madaio, Wendy Y. Craig, Amy Eckland, Nichole Moore, Rattanaporn Mahatanan, Colleen M. Kershaw, William Bradford, Ellen Eaton, Alison B. Rapoport, Monica K. Sikka, Hirofumi Yoshida and Kinna Thakarar in Therapeutic Advances in Infectious Disease
Supplemental material, sj-pdf-1-tai-10.1177_20499361251375334 for A descriptive survey evaluating the implementation and outcomes of a training session highlighting concepts in antimicrobial management and harm reduction for hospital-based clinicians treating persons who use drugs by Michael P. Madaio, Wendy Y. Craig, Amy Eckland, Nichole Moore, Rattanaporn Mahatanan, Colleen M. Kershaw, William Bradford, Ellen Eaton, Alison B. Rapoport, Monica K. Sikka, Hirofumi Yoshida and Kinna Thakarar in Therapeutic Advances in Infectious Disease
Supplemental material, sj-pdf-2-tai-10.1177_20499361251375334 for A descriptive survey evaluating the implementation and outcomes of a training session highlighting concepts in antimicrobial management and harm reduction for hospital-based clinicians treating persons who use drugs by Michael P. Madaio, Wendy Y. Craig, Amy Eckland, Nichole Moore, Rattanaporn Mahatanan, Colleen M. Kershaw, William Bradford, Ellen Eaton, Alison B. Rapoport, Monica K. Sikka, Hirofumi Yoshida and Kinna Thakarar in Therapeutic Advances in Infectious Disease
Acknowledgments
The authors would like to thank the study participants, as well as Dr. Daniel Solomon, and Deanna Williams for their time and expertise.
Footnotes
ORCID iDs: Monica K. Sikka 
https://orcid.org/0000-0001-8192-8019
Kinna Thakarar
https://orcid.org/0000-0003-4689-0240
Supplemental material: Supplemental material for this article is available online.
Contributor Information
Michael P. Madaio, MaineHealth Mid Coast Hospital, Division of Infectious Disease, 121 Medical Center Drive, Suite 2550, Brunswick, ME 04011-2652, USA
Wendy Y. Craig, MaineHealth Institute for Research, Scarborough, ME, USA Tufts University School of Medicine, Boston, MA, USA.
Amy Eckland, Tufts University School of Medicine, Boston, MA, USA.
Nichole Moore, Tufts University School of Medicine, Boston, MA, USA.
Rattanaporn Mahatanan, Dartmouth Hitchcock Medical Center, Section of Infectious Disease and International Health, Lebanon, NH, USA.
Colleen M. Kershaw, Dartmouth Hitchcock Medical Center, Section of Infectious Disease and International Health, Lebanon, NH, USA Dartmouth College Geisel School of Medicine, Hanover, NH, USA.
William Bradford, Division of Infectious Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
Ellen Eaton, Division of Infectious Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
Alison B. Rapoport, Cambridge Health Alliance, Medical Specialties, Somerville, MA, USA
Monica K. Sikka, Division of Infectious Diseases, Oregon Health & Science University, Portland, OR, USA
Hirofumi Yoshida, Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA.
Kinna Thakarar, MaineHealth Maine Medical Center Portland, Division of Infectious Disease, 41 Donald B Dean Drive, Suite B, South Portland, ME 04106, USA; Tufts University School of Medicine, Boston, MA, USA.
Declarations
Ethics approval and consent to participate: The MaineHealth Institutional Review Board reviewed this study and deemed the project exempt (ID #1843362). Informed consent was obtained: participants received an electronic, written consent script, and all data were stored on a HIPAA-compliant online database. Only de-identified responses were available for analysis.
Consent for publication: Not applicable.
Author contributions: Michael P. Madaio: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Software; Visualization; Writing – original draft; Writing – review & editing.
Wendy Y. Craig: Formal analysis; Investigation; Methodology; Supervision; Validation; Writing – review & editing.
Amy Eckland: Conceptualization; Data curation; Visualization; Writing – review & editing.
Nichole Moore: Conceptualization; Data curation; Writing – review & editing.
Rattanaporn Mahatanan: Conceptualization; Data curation; Writing – review & editing.
Colleen M. Kershaw: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Supervision; Writing – review & editing.
William Bradford: Conceptualization; Data curation; Investigation; Project administration; Writing – review & editing.
Ellen Eaton: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Supervision; Writing – review & editing.
Alison B. Rapoport: Conceptualization; Investigation; Writing – review & editing.
Monica K. Sikka: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – review & editing.
Hirofumi Yoshida: Conceptualization; Data curation; Investigation; Methodology; Writing – review & editing.
Kinna Thakarar: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Supervision; Writing – original draft; Writing – review & editing.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the Northern New England Clinical and Translational Research grant U54GM115516. William Bradford is supported by grant T32HS013852 from the Agency for Healthcare Research and Quality.
The authors declare that there is no conflict of interest.
Availability of data and materials: De-identified data can be made available on request to the corresponding author.
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Supplementary Materials
Supplemental material, sj-docx-3-tai-10.1177_20499361251375334 for A descriptive survey evaluating the implementation and outcomes of a training session highlighting concepts in antimicrobial management and harm reduction for hospital-based clinicians treating persons who use drugs by Michael P. Madaio, Wendy Y. Craig, Amy Eckland, Nichole Moore, Rattanaporn Mahatanan, Colleen M. Kershaw, William Bradford, Ellen Eaton, Alison B. Rapoport, Monica K. Sikka, Hirofumi Yoshida and Kinna Thakarar in Therapeutic Advances in Infectious Disease
Supplemental material, sj-pdf-1-tai-10.1177_20499361251375334 for A descriptive survey evaluating the implementation and outcomes of a training session highlighting concepts in antimicrobial management and harm reduction for hospital-based clinicians treating persons who use drugs by Michael P. Madaio, Wendy Y. Craig, Amy Eckland, Nichole Moore, Rattanaporn Mahatanan, Colleen M. Kershaw, William Bradford, Ellen Eaton, Alison B. Rapoport, Monica K. Sikka, Hirofumi Yoshida and Kinna Thakarar in Therapeutic Advances in Infectious Disease
Supplemental material, sj-pdf-2-tai-10.1177_20499361251375334 for A descriptive survey evaluating the implementation and outcomes of a training session highlighting concepts in antimicrobial management and harm reduction for hospital-based clinicians treating persons who use drugs by Michael P. Madaio, Wendy Y. Craig, Amy Eckland, Nichole Moore, Rattanaporn Mahatanan, Colleen M. Kershaw, William Bradford, Ellen Eaton, Alison B. Rapoport, Monica K. Sikka, Hirofumi Yoshida and Kinna Thakarar in Therapeutic Advances in Infectious Disease