Abstract
The opioid crisis and complications related to injection drug use are a public health emergency. The combination of addiction and injection drug use is a devastating double-edged sword: it predisposes patients to severe life-threatening infections like endocarditis, and epidural abscess, as well as to disorganized behaviour and impaired decision-making that interferes with the completion of prolonged courses of required antibiotic therapy. Poverty and stigma add further fuel to the fire. The Community Transitional Care Team (CTCT) is a revolutionary community-based short-term residence where people who inject drugs can stay to complete their course of antibiotics. We present the case of a young woman struggling with addiction, tremendous social barriers to health, and life threating Staphylococcus aureus infection that highlights the benefits of strong, community-based, and individualized models of patient care.
Key words: addiction, bacteremia, injection drug use, Staphylococcus aureus
Abstract
La crise des opioïdes et les complications liées à la consommation de drogues injectables représentent une urgence de santé publique. L’association de la dépendance et de la consommation de drogues injectables est une épée à double tranchant dévastatrice. En effet, elle prédispose les patients à de graves infections au potentiel mortel comme l’endocardite et l’abcès épidural, de même qu’à une désorganisation du comportement et à une altération des décisions qui compromettent les antibiothérapies prolongées. La pauvreté et l’opprobre jettent de l’huile sur le feu. L’équipe communautaire de soins transitoires est une résidence communautaire de courte durée révolutionnaire où les personnes qui s’injectent des drogues peuvent habiter pour terminer leur antibiothérapie. Les auteurs présentent le cas d’une jeune femme aux prises avec la dépendance, d’énormes obstacles sociaux en matière de santé et une infection à Staphylococcus aureus au potentiel mortel qui fait ressortir les avantages de modèles communautaires et personnalisés robustes pour les soins aux patients.
Mots-clés : dépendance, bactériémie, consommation de drogues injectables, Staphylococcus aureus
Case Presentation
A 20-year-old woman was brought by ambulance to the emergency department at Vancouver General Hospital following a drug overdose. She was found unconscious in the community, resuscitated at the scene with naloxone, and taken to hospital for further management.
She faced tremendous social and medical barriers to health. She had no home or fixed address. She slept outside or temporarily in shelters or with other people in downtown Vancouver.
She reported daily use of injectable fentanyl and methamphetamine. Both her parents had alcohol use disorder. She began drinking alcohol heavily and smoking crystal methamphetamine in her teens. She started using injectable drugs after losing the custody of her child as she felt that she had nothing else to live for. She had several prior admissions to rehabilitation facilities and had previously used methadone and buprenorphine/naloxone (Suboxone).
As well as depression and attention deficit hyperactivity disorder (ADHD), she had been diagnosed with fetal alcohol syndrome and received financial support from the government for her disability. She had prior self-harming behaviour manifest by lateral scars from cuts across her forearms.
In the emergency department, she appeared thin and dishevelled. She was drowsy and difficult to rouse and to engage in conversation. Her temperature was 37.9oC, heart rate 125 beats per minute, blood pressure 90/50 mmHg, respiratory rate 16 breaths per minute, and O2 saturation 99% on room air. She had normal heart sounds, no audible murmurs, clear lung fields, no focal neurological deficits, and no skin abscess, active joints or vertebral percussion tenderness.
Her initial investigations documented a white blood cell count of 12,300/mm3 and creatinine of 39 µmol/L. Her HIV, HCV, and syphilis serology were negative. Her chest X-ray documented right lower lobe patchy opacities. She was started on empiric vancomycin and ceftriaxone and admitted to hospital.
Ten hours later, her blood cultures flagged positive for gram-positive cocci in clusters, later identified as methicillin-sensitive Staphylococcus aureus (MSSA).
Her antibiotics were changed to IV cloxacillin. Her blood cultures were positive at 48 hours but negative at 72 hours. Transthoracic echocardiogram documented normal valves, no vegetations were seen; however, there was global hypokinesis with a left ventricular ejection fraction (EF) of only 38%.
She was seen by a physician specialized in drug addiction and received intermittent treatment with Suboxone and levomepromazine (Nozinan) in hospital. However, after completing only 12 days of antibiotics, encouraged by her boyfriend, she left hospital against medical advice. She was told that she had a life-threatening infection, that she needed to complete 4 more weeks of IV antibiotics, and to return to hospital as soon as possible to restart antibiotics.
Are there community supports to assist in the care of individuals like this young woman in the community where you work? What alternative plan could be offered?
After being discharged from hospital without an alternative management plan in the community, she came in and out of hospital an additional 4 times over the next few weeks (see Box 1).
Box 1: Course of hospitalization prior to admission to CTCT.
| Day 0: | Admitted to hospital, blood cultures positive for MSSA, started IV antibiotics |
| Day 12: | Discharged from hospital without any antibiotics |
| Day 14: | Returned to hospital with fever, blood cultures positive for MSSA |
| Day 15: | Discharged from hospital without any antibiotics |
| Day 17: | Returned to hospital, blood cultures positive for MSSA |
| Day 20: | Discharged from hospital without any antibiotics |
| Day 23: | Returned to hospital, blood cultures positive for MSSA |
| Day 24: | Discharged from hospital without any antibiotics |
| Day 27: |
Returned to hospital, blood cultures positive for MSSA
|
| Day 41: | Discharged from hospital following a verbal altercation between her boyfriend and nursing staff at the hospital |
During her last hospital stay, 1 month after her initial presentation to hospital with bacteremia, she was referred to the Community Transitional Care Team (CTCT) to complete her antibiotic therapy at the CTCT facility. The CTCT facility was full at the time, but after being notified of her discharge against medical advice, CTCT staff arranged a physician outreach visit to the shelter where she was staying. Guided by antibiotic susceptibility test results, she was given tablets of rifampin and moxifloxacin to take and supported with daily visits by an outreach worker. A few days later a bed became available and she was admitted to CTCT where she successfully completed an additional 4 weeks of antibiotics. One year later, she was still struggling with addiction and enormous socioeconomic challenges but had not had a relapse of her bacterial infection.
Discussion
The treatment of endocarditis and other life-threatening bacterial infections among persons who use illicit injectable drugs (PWID) can be very challenging (1). The current standard of care calls for prolonged courses of IV antibiotic therapy. However, many PWID are unable to complete therapy in hospital, are marginally housed, and may not be offered outpatient IV therapy in the community (1).
The CTCT facility is a community-based residence designed to support PWID complete prolonged courses of antibiotic therapy, decrease barriers to health services, and facilitate the transition from hospital to community.
The facility is located in the heart of the Downtown Eastside Vancouver neighbourhood and staff are well connected with the surrounding clinical and community supports, particularly the supervised injection and overdose prevention sites (Figure 1) (2). The facility can accommodate nine residents at a time. There are private rooms with a kitchenette and bathroom and all amenities and meals included.
Figure 1:
The Community Transitional Care Team (CTCT) is located on the second floor of the Pennsylvania Hotel in the heart of the Downtown Eastside Vancouver neighbourhood
There is a strong emphasis on multidisciplinary care to address complex medical, addiction, housing, socioeconomic issues (3). There is 24-hour on site nursing and daily visits during the week by a physician with expertise in treatment of drug addiction, mental health and substance dependence counselling.
There is no requirement to be abstinent. Patients can use their own drugs in their room, including injectable opiates and cigarettes. Patients with a peripherally inserted central catheter (PICC) are asked to sign an agreement to not use the PICC for injection drug use and green chlorhexidine impregnated caps are used to help monitor and reduce additional use of the line. The approach to patients who tamper with their PICC is individualized, non-punitive and often entails a switch to an oral antibiotic regimen judged to be equally effective.
Preliminary findings of a retrospective review that has not yet been published has documented a marked increase in treatment completion rates among patients who were transferred to CTCT compared with patients who remained in hospital because of lack of available rooms at CTCT.
The recent Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis (POET) trial has made waves, and there is increasing evidence for the role of oral antibiotics in the treatment of endocarditis (4). Oral antibiotics may present an alternative to intravenous antibiotics and central lines, however, resources for strong community supports need to be provided.
This young woman’s case and the challenges to provide care for her may resonate with other doctors and clinicians looking after patients who are addicted to illicit injectable drugs. In the end, although she continues to struggle with addiction, the outcome of treatment for her severe bacterial infection was positive, and highlights the benefits of strong, community-based, and individualized models of patient care.
Funding Statement
Publication of this article was funded by the Association of Medical Microbiology and Infectious Disease (AMMI) Canada.
Competing Interests:
The authors have nothing to disclose.
Ethics Approval:
N/A
Informed Consent:
N/A
Registry and the Registration No. of the Study/Trial:
N/A
Animal Studies:
N/A
Funding:
Publication of this article was funded by the Association of Medical Microbiology and Infectious Disease (AMMI) Canada.
Peer Review:
This article has been peer reviewed.
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