PICC Your Poison: Resident Beliefs and Attitudes Regarding Discharge Parenteral Antibiotics for Patients Who Inject Drugs

Abstract

Background: Serious injection-related infections (SIRIs) in people who inject drugs often lead to prolonged hospitalizations or premature discharges. This may be in part due to provider reluctance to place peripherally inserted central catheters (PICCs) for outpatient parenteral antibiotic therapy in this population. Because internal medicine (IM) residents are often frontline providers in academic centers, understanding their perspectives on SIRI care is important to improve outcomes.

Methods: We surveyed IM residents in a large urban multicenter hospital system about SIRI care with a novel case-based survey that elicited preferences, comfort, experience, and stigma. The survey was developed using expert review, cognitive interviewing, and pilot testing. Results are reported with descriptive statistics and linear regression.

Results: Of 116 respondents (response rate 34%), most (73%) were uncomfortable discharging a patient with active substance use home with a PICC, but comfortable (87%) with discharge to postacute facilities. Many (∼40%) endorsed high levels of concern for PICC misuse or secondary line infections, but larger numbers cited concerns about home environment (50%) or loss to follow-up (68%). While overall rates were low, higher stigma was associated with more concerns around PICC use (r = -0.3, P = .002). A majority (58%) believed hospital policies against PICC use in SIRI may act as a barrier to discharge, and 74% felt initiation of medications for opioid use disorder (MOUD) would increase their comfort discharging with a PICC.

Conclusions: Most IM residents endorsed high levels of concern about PICC use for SIRI, related to patient outcomes and perceived institutional barriers, but identified MOUD as a mitigating factor.

Keywords: injection-related infections; medical residency; outpatient infusion therapy; stigma; substance use.

Figure 1.

Level of concern for peripherally inserted central catheter (PICC) outcomes. Percentage of respondents who endorsed their level of concern for six possible negative outcomes related to PICC use for a hypothetical patient with serious injection-related infection. Questions were formulated as “How concerned are you about this patient…?”

Figure 2.

Peripherally inserted central catheter (PICC)–related concerns and Medical Condition Regard Scale scores. Graph of respondents’ level of PICC-related concerns (sum total of Likert responses), with higher values indicating more concern, versus normalized stigma score using the Medical Condition Regard Scale (MCRS), with higher values indicating more positive regard (ie, less stigmatizing opinions). Line is linear regression fit; gray area is 95% confidence interval.

Figure 3.

Anticipated discharge barriers. Percentage of respondents who agreed that a suggested barrier was likely to occur in the process of discharging a patient with serious injection-related infection. Respondents were able to select multiple options or none. Abbreviations: ID, infectious diseases; PICC, peripherally inserted central catheter; SAR/SNF, subacute rehabilitation/skilled nursing facility; SIRI, serious injection-related infection; SUD, substance use disorder; VNS, visiting nurse service.