PICC Your Battles: Considering the Appropriateness of Peripherally Inserted Central Catheter (PICC) Lines for Outpatient Parenteral Antimicrobial Therapy (OPAT) in Injection Drug Users (IDUs)
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Abstract
Injection drug users (IDUs) requiring outpatient parenteral antibiotic therapy (OPAT) for injection-related infections are regularly de- nied 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 or mortality. Successful transition of IDUs from inpatient treatment to OPAT requires appropriate patient selec- tion. Namely, housing status, mental health history, the presence of a support system, and a patient’s willingness to comply with treatment all play a significant role in OPAT success. Honest and straightforward conversations must be undertaken between patient and provider regarding the risks and benefits of a PICC line if injecting drugs. Close follow-up, a compassionate approach, provider education, and the expansion of respite programs all introduce novel spaces for ongoing harm reduction and good patient care. Finally, further research is needed to establish protocols, guidelines, screening criteria, transition of care, and to clarify best practices for OPAT in patients who inject drugs.
RÉSUMÉ
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 at- tentive 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.
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