IV-to-Oral Antibiotic Courses May Reduce Invasive Infection Readmissions During Opioid Epidemic

People who use injection drugs which are criminalized in the United States can develop potentially serious infections due to the unregulated nature of both substances and their administration. Resulting hospitalizations can be costly for health care systems, as the infections often require weeks of hospitalization to treat adequately.

A new study published in Clinical Infectious Diseases by investigators from the Washington University School of Medicine, St. Louis, suggests that drug users who begun IV antibiotics for serious infections in the hospital and then finished their courses of treatment at home with antibiotic pills fared as well as patients who stayed in the hospital for their full treatment course.

The findings have led Washington University physicians at Barnes-Jewish Hospital to change the treatment recommendations for such patients, according to a university press release.

“Most people don’t want to stay in the hospital for weeks at a time to get IV antibiotics when they could be treated at home,” said lead author Laura Marks, MD, PhD, a clinical fellow in infectious diseases. “But until recently, infectious disease doctors had limited evidence on effective treatment options for patients who could not complete long courses of IV antibiotics. No one wants to offer an ineffective treatment for what could be a life-threatening infection, and so we required everyone to stay. Now we recognize that when someone does not want to stay in the hospital, we can work with the patient to find another way to provide antibiotics.”

Authors of the press release pointed out that despite understandable concern over the SARS-CoV-2 pandemic dominating media cycles, the US opioid epidemic also continues unabated. Over the last decade, rising numbers of people have shown up in emergency rooms across the nation with serious bacterial infections related to illicit drug use.

Many patients who use drugs face barriers to health care entry related to social class, and some leave the hospital against medical advice before they’ve finished even a conservative antibiotic treatment course.

Previous studies have shown that people with invasive infections for reasons unrelated to use of injectable drugs can be treated successfully with a few days of IV antibiotics in the hospital, followed by oral antibiotics at home. But hospitals have been cautious to apply the same protocol to similar patients with cases complicated by opioid use disorder.

“There was this idea that people who inject drugs do not care about their health and would not adhere to an oral antibiotic regimen on discharge. So letting patients leave the hospital partway through an IV antibiotic course was akin to abandoning all treatments,” said senior author Michael Durkin, MD, co-director of antimicrobial stewardship at Barnes-Jewish Hospital. “We didn’t believe that was true.”

Patients in the study who ended hospitalization without antibiotic prescriptions were more than 2 times as likely to be readmitted within 3 months than those who left earlier in treatment course with prescriptions, or those who completed treatment in the hospital.

The investigators found that for every 3 people treated with oral antibiotics, 1 less patient needed to be readmitted to the hospital. Between the 2 full-course groups, there was no significant difference in readmissions between those who stayed in the hospital for full courses of IV antibiotics and those who completed partial courses of IV antibiotics followed by oral antibiotics, the authors wrote.

“It doesn’t matter why patients have an infection,” Marks said. “We want to make sure that we provide antibiotics to patients in a setting they prefer. If they are not comfortable staying in the hospital throughout their treatment, we will work to get them back home as soon as it is safe, and they can finish their treatment on an oral alternative.”