“The Six Moments:” A Novel Educational Tool to Promote Infection Prevention Practices in Patients Injecting Drugs

Background: The opioid epidemic has led to a dramatic increase in the rate of invasive bacterial infections, including a 4-fold increase in sepsis and a 12-fold increase in endocarditis. The increase has been demonstrated in both veteran and nonveteran populations (Fig. 1). Thus, an urgent need exists to develop novel tools to educate patients and providers regarding (1) at-risk moments among intravenous drug users and (2) methods for preventing transmission of bacterial and viral infections associated with injection drug use. Methods: We conducted a survey among medical trainees and staff and collected information about knowledge and attitudes about harm-reduction services. To address gaps in knowledge, we developed an educational tool for promoting better infection prevention practices among patients who inject drugs by adapting the WHO Five Moments of Hand Hygiene. Results: In total, 43 medical trainees and staff responded to the survey. All respondents regarded infections as a serious risk among patients who inject drugs, although there was variation in perception about which types of pathogens were the most likely to be acquired through this pathway (ie, bacterial vs viral). Among survey respondents, 15 of 39 (38%) reported that they have counseled patients who inject drugs about infection prevention, whereas 24 (58%) reported that they had never provided counseling. The reason for the lack of counseling was primarily a lack of knowledge and a lack of resources (10 of 24, 42%). One-quarter (6 of 24, 25%) reported that they did perceive infection prevention counseling to be part of their role. To solve this knowledge and resource gap, we developed an educational tool designed to promote understanding of the risk of bacterial, viral, and fungal infections and how to prevent them (Fig. 2, A and B). The “Six Moments” model highlights important high-risk moments and activities, such as skin cleaning, use of clean needles, and avoiding oral contamination of needles, as well as the corresponding pathogens that can be transmitted at each stage. Infection prevention strategies are them applied to demonstrate how these infections can be averted. The tool focuses on simple infection prevention interventions that can be taught to patients and providers not trained in infection control to limit transmission of infections associated with IV drug use and addresses the knowledge gap identified through the provider survey. Conclusions: This novel tool can be part of a comprehensive educational program that translates infection prevention principles and applies them to reduce infectious morbidity and mortality related to injection drug use.Funding: NoneDisclosures: None

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Six Moments of Infection Prevention in Injection Drug Use: An Educational Toolkit for Clinicians

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab631 ◽

2022 ◽

Author(s):

Leah Harvey ◽

Jacqueline Boudreau ◽

Samantha K Sliwinski ◽

Judith Strymish ◽

Allen L Gifford ◽

...

Keyword(s):

Drug Use ◽

Harm Reduction ◽

Injection Drug Use ◽

Infection Prevention ◽

Viral Infections ◽

Fungal Infections ◽

Implementation Strategies ◽

Injection Drug ◽

Effective Prevention ◽

Provider Knowledge

Abstract Background Injection drug use-associated bacterial and viral infections are increasing. Expanding access to harm reduction services, such as safe injection education, are effective prevention strategies. However, these strategies have had limited uptake. New tools are needed to improve provider capacity to facilitate dissemination of these evidence-based interventions. Methods The “Six Moments of Harm Reduction” provider educational tool was developed using a global, rather than pathogen-specific, infection prevention framework, highlighting the prevention of invasive bacterial and fungal infections in additional to viral pathogens. The tool’s effectiveness was tested using a short, paired pre/post survey that assessed provider knowledge and attitudes about harm reduction. Results N=75 respondents completed the paired surveys. At baseline, 17 respondents (22.6%) indicated that they had received no prior training in harm reduction and 28 (37.3%) reported discomfort counseling patients who inject drugs (PWID). 60 respondents (80.0%) reported they had never referred a patient to a syringe service program (SSP) and, of those, 73.3% cited lack of knowledge regarding locations of SSPs and 40.0% reported not knowing where to access information regarding SSPs. After the training, 66 (88.0%) reported that they felt more comfortable educating PWID (p<0.0001), 65 respondents (86.6%) reported they planned to use the “Six Moments” model in their own practice, and 100% said they would consider referring patients to a SSP in the future. Conclusions The “Six Moments” model emphasizes the importance of a global approach to infection prevention and harm reduction. This educational intervention can be used as part of a bundle of implementation strategies to reduce morbidity and mortality in PWID.

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Population-based trends in hospitalizations due to injection drug use-related serious bacterial infections, Oregon, 2008 to 2018

PLoS ONE ◽

10.1371/journal.pone.0242165 ◽

2020 ◽

Vol 15 (11) ◽

pp. e0242165

Author(s):

Jeffrey Capizzi ◽

Judith Leahy ◽

Haven Wheelock ◽

Jonathan Garcia ◽

Luke Strnad ◽

...

Keyword(s):

Substance Use ◽

Drug Use ◽

Bacterial Infection ◽

Injection Drug Use ◽

Bacterial Infections ◽

Fold Increase ◽

Population Based ◽

Injection Drug ◽

Discharge Data ◽

Serious Bacterial Infections

Background Injection drug use has far-reaching social, economic, and health consequences. Serious bacterial infections, including skin/soft tissue infections, osteomyelitis, bacteremia, and endocarditis, are particularly morbid and mortal consequences of injection drug use. Methods We conducted a population-based retrospective cohort analysis of hospitalizations among patients with a diagnosis code for substance use and a serious bacterial infection during the same hospital admission using Oregon Hospital Discharge Data. We examined trends in hospitalizations and costs of hospitalizations attributable to injection drug use-related serious bacterial infections from January 1, 2008 through December 31, 2018. Results From 2008 to 2018, Oregon hospital discharge data included 4,084,743 hospitalizations among 2,090,359 patients. During the study period, hospitalizations for injection drug use-related serious bacterial infection increased from 980 to 6,265 per year, or from 0.26% to 1.68% of all hospitalizations (P<0.001). The number of unique patients with an injection drug use-related serious bacterial infection increased from 839 to 5,055, or from 2.52% to 8.46% of all patients (P<0.001). While hospitalizations for all injection drug use-related serious bacterial infections increased over the study period, bacteremia/sepsis hospitalizations rose most rapidly with an 18-fold increase. Opioid use diagnoses accounted for the largest percentage of hospitalizations for injection drug use-related serious bacterial infections, but hospitalizations for amphetamine-type stimulant-related serious bacterial infections rose most rapidly with a 15-fold increase. People living with HIV and HCV experienced increases in hospitalizations for injection drug use-related serious bacterial infection during the study period. Overall, the total cost of hospitalizations for injection drug use-related serious bacterial infections increased from $16,305,129 in 2008 to $150,879,237 in 2018 (P<0.001). Conclusions In Oregon, hospitalizations for injection drug use-related serious bacterial infections increased dramatically and exacted a substantial cost on the health care system from 2008 to 2018. This increase in hospitalizations represents an opportunity to initiate substance use disorder treatment and harm reduction services to improve outcomes for people who inject drugs.

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1215. A Mixed Methods Study on Severe Bacterial Infections in People Who Inject Drugs

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.1407 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S697-S697

Author(s):

Alexander Hrycko ◽

Benjamin Eckhardt ◽

Pedro Mateu-Gelabert ◽

Courtney Ciervo

Keyword(s):

Mixed Methods ◽

Drug Use ◽

Injection Drug Use ◽

Bacterial Infections ◽

Mixed Methods Study ◽

Injection Drug ◽

Daily Injection ◽

Drug Injection ◽

Structured Interviews ◽

Causative Microorganism

Abstract Background Severe bacterial infections (SBI) associated with intravenous drug use have been increasing in frequency in the U.S. over the last decade. This mixed methods study aims to identify the risk factors associated with SBI in hospitalized individuals with recent injection drug use. Methods We conducted 34 quantitative and 15 qualitative interviews between August 2020 and June 2021 at Bellevue Hospital in New York City. Eligible participants were (1) >/= 18 year of age, (2) admitted with a SBI, and (3) reported injection drug use within the 90 days prior to admission. Quantitative and qualitative data was obtained using a quantitative survey and in-depth, semi structured interviews of participants respectively. Analysis was performed to examine trends and explore common themes potentially contributing factors to SBI. Results Of the 34 participants included, the median age was 37.5, 85% were male, 53% white, and 65% reported being homeless within the past 3 months. Endocarditis was the most common primary diagnosis (65%). Median length of hospital stay was 24 days and 35% required ICU level care during admission. A causative microorganism was identified in 85% of participants and 50% had Staphylococcus aureus as the sole organism. Discharges against medical advice occurred in 35%. Daily injection drug use in prior 30 days was 95% with a median of 10 injections per day. In the 30 days prior to admission, 50% reported an increase in injection frequency, 80% reported reusing needles and/or syringes, 75% reused cookers, 65% reused cottons. Analysis of qualitative interview data revealed high risk injection behaviors. Participants were not practicing and unaware of strategies to reduce their risk of drug injection-related SBI. Prior hospitalizations for SBI did not impact on this knowledge deficit on what constitutes bacterial infection risk and how to prevent it. Conclusion Study findings highlight the complexity of the injection drug use process and the potential social and physiological pathways leading to SBI. Multiple domains at the structural, network, and individual level that impact drug injection practices and provide context by which these factors predispose and lead to physiological tissue damage and the development of SBI among PWID. Disclosures Benjamin Eckhardt, MD, MS, Gilead Sciences (Grant/Research Support)

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1315. Mind the Gap: Medical Trainees Require Training in Hepatitis C, Drug Use and Mental Health to Help Address the Opioid Crisis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.1148 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S402-S402

Author(s):

Kimberly Corace ◽

Isabelle Ares ◽

Nicholas Schubert ◽

Jason Altenberg ◽

Melanie Willows ◽

...

Keyword(s):

Mental Health ◽

Mental Illness ◽

Hepatitis C ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug ◽

Opioid Epidemic ◽

Hcv Treatment ◽

Medical Trainees ◽

Opioid Crisis

Abstract Background Dramatic increases in acute hepatitis C (HCV) incidence is linked to the opioid epidemic and increased injection drug use. Over 50% of people with HCV also have a mental illness. IDSA/HIVMA calls for the integration of infectious diseases, addiction medicine, and mental health as key to addressing the opioid epidemic. Barriers identified include limited physician education and stigma. This study examined medical trainees’ gaps in training and attitudes toward HCV, drug use, and mental illness. Methods Medical students and residents (N = 98) at a large Canadian University completed questionnaires assessing stigma, attitudes, knowledge, and training related to HCV, drug use, and mental illness. Results Most participants were medical residents (71%). Within-subjects ANOVAs showed that trainees worked with more patients with mental illness (71%) than drug use (55%) or HCV (21%) (P’s < 0.001). Trainees reported less positive experiences with patients with drug use (34%) and HCV (36%) compared with those with mental illness (55%) (p’s < 0.05). They reported that injection drug use (68%), prescription opioids (66%), and heroin use (59%) were the most challenging substance use problems to treat (P < 0.001). They were less satisfied working with patients with drug use (40%) or HCV (40%) than mental illness (59%) (P’s < 0.01). Trainees reported they were more able to help patients with mental illness (83%) than HCV (65%) or drug use (73%) (P’s < 0.01). Only 34% saw HCV treatment as central to their professional role. Their training better prepared them to treat mental illness (58%) than drug use (41%) or HCV (19%) (P’s < 0.001). They were more interested in training in drug use (76%) and mental health (71%) than HCV (62%) (P’s < 0.01). Conclusion Medical trainees report being ill-equipped to treat patients with HCV and drug use (specifically opioids) and are less satisfied with this work. Many report attitudes that may be viewed by patients as stigmatizing. There is a large knowledge gap related to the effectiveness of HCV treatment. Addressing the opioid crisis requires a physician workforce that is prepared to integrate treatment for HCV, drug use, and mental illness. Infectious disease specialists can take a leadership role in building capacity to foster integration. Disclosures All authors: No reported disclosures.

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Both localized and systemic bacterial infections are predicted by injection drug use: A prospective follow-up study in Swedish criminal justice clients

PLoS ONE ◽

10.1371/journal.pone.0196944 ◽

2018 ◽

Vol 13 (5) ◽

pp. e0196944 ◽

Cited By ~ 10

Author(s):

Disa Dahlman ◽

Jonas Berge ◽

Per Björkman ◽

Anna C. Nilsson ◽

Anders Håkansson

Keyword(s):

Criminal Justice ◽

Drug Use ◽

Injection Drug Use ◽

Bacterial Infections ◽

Injection Drug ◽

Follow Up Study

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High prevalence of injection drug use and blood-borne viral infections among patients in an urban emergency department

PLoS ONE ◽

10.1371/journal.pone.0233927 ◽

2020 ◽

Vol 15 (6) ◽

pp. e0233927

Author(s):

Erik S. Anderson ◽

Carly Russell ◽

Kellie Basham ◽

Martha Montgomery ◽

Helen Lozier ◽

...

Keyword(s):

Emergency Department ◽

Drug Use ◽

Injection Drug Use ◽

Viral Infections ◽

Injection Drug ◽

High Prevalence ◽

Urban Emergency Department

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972. Infection and Overdose Prevention for Persons with Injection Drug Use-Related Infections: Evaluation of an Inpatient Quality Improvement Program

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1158 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S515-S515

Author(s):

Carly C Speight ◽

Bobbi J Stoner ◽

George A Guthrie ◽

Turkeisha S Brown ◽

Claire E Farel ◽

...

Keyword(s):

Quality Improvement ◽

Drug Use ◽

Injection Drug Use ◽

Infection Prevention ◽

Injection Drug ◽

Improvement Program ◽

Overdose Prevention ◽

Prevention Services ◽

Common Diagnosis ◽

Comparison Data

Abstract Background Hospitalizations for injection drug use-related infections (IDU-I) are increasing in North Carolina and nationally. Many IDU-I, such as endocarditis, bone, joint, and spine infections, require long antimicrobial courses and extended inpatient stays. These hospitalizations are opportunities to engage patients in overdose and infection prevention. Methods A quality improvement (QI) program was piloted for inpatients with IDU-I. Eligible patients admitted to the inpatient pulmonary or infectious disease teams from 11/2019 to 01/2020 were referred to the QI team if they reported or were suspected to have injected drugs over the past year, or felt to benefit from drug-related infection prevention and overdose services. A checklist of recommendations to the care teams included: (1) screening for HIV, Hepatitis B (HBV) and C (HCV), (2) immunization for Hepatitis A (HAV), HBV, and tetanus, (3) prescription of naloxone at discharge, and (4) information on a syringe services program in or near their county. After review of the medical record, the QI team made recommendations on the appropriate taks from the checklist. The number of QI checklist tasks performed on the two inpatient teams during a 9-week pilot period (the above period excepting a two-week break) was reviewed. Baseline comparison data was not incorporated, owing to the challenges in retrospective identification of IDU-I. Results 20 patients were included in the intervention. The median age was 32 years (IQR 27-38) and 70% were female. The most common diagnosis was endocarditis (40%) and the median length of stay was 11 days (IQR 5-42). HIV and HCV tests were each conducted in 95% of patients (Table). Screenings for HAV and HBV immunity were done in 90% of patients. HAV, HBV, and Tdap immunizations were given to 20%, 35%, and 50%, respectively. Naloxone was provided to 60% of patients at discharge and half of patients were referred to syringe programs. HCV was detected in 8 patients and HBV in 2 patients. No patients were diagnosed with HIV. Percentage of infection and overdose prevention services provided to eligible IDU-I patients during hospitalization. Conclusion In a setting without comprehensive addiction consultation, a simple intervention provided guideline-concordant infection and overdose prevention services for persons hospitalized for IDU-I. Disclosures All Authors: No reported disclosures

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