Harm reduction for the treatment of patients with severe injection-related infections: description of the Jackson SIRI Team

Hospitalizations for severe injection-related infections (SIRI), such as endocarditis, osteomyelitis, and skin and soft tissue infections (SSTI) are increasingly common. People who inject drugs (PWID) experiencing SIRIs often receive inadequate substance use disorder (SUD) treatment and lack of access to harm reduction services. This translates into lengthy hospitalizations with high rates of patient-directed discharge, readmissions, and post-hospitalization mortality. The purpose of this study was to describe the development of an integrated “SIRI Team” and its initial barriers and facilitators to success. The Jackson SIRI Team was developed to improve both hospital and patient-level outcomes for individuals hospitalized with SIRIs at Jackson Memorial Hospital, a 1550-bed public hospital in Miami, Florida, United States. The SIRI Team provides integrated infectious disease and SUD treatment across the healthcare system starting from the inpatient setting and continuing for 90-days post-hospital discharge. The team uses a harm reduction approach, provides care coordination, focuses on access to medications for opioid use disorder (MOUD), and utilizes a variety of infection and addiction treatment modalities to suit each individual patient. Over the initial 8-months of the SIRI Team, 21 patients were treated with 20 surviving until discharge. Infections included osteomyelitis, endocarditis, bacteraemia/fungemia, SSTIs, and septic arthritis. All patients had OUD and 95% used stimulants. All patients were discharged on MOUD and 95% completed their prescribed antibiotic course. At 90-days post-discharge, 25% had been readmitted and 70% reported taking MOUD. A model of integrated infectious disease and SUD care for the treatment of SIRIs has the potential to improve infection and addiction outcomes. Providing attentive, patient-centered care, using a harm reduction approach can facilitate engagement of this marginalized population with the healthcare system.KEY MESSAGESIntegrated infectious disease and addiction treatment is a novel approach to treating severe injection-related infections.Harm reduction should be applied to treating patients with severe injection-related infections with a goal of facilitating antibiotic completion, remission from substance use disorder, and reducing hospital readmissions. Integrated infectious disease and addiction treatment is a novel approach to treating severe injection-related infections. Harm reduction should be applied to treating patients with severe injection-related infections with a goal of facilitating antibiotic completion, remission from substance use disorder, and reducing hospital readmissions.

重症注射相关感染（Severe injection-related infections, SIRI），如心内膜炎、骨髓炎及皮肤软组织感染（skin and soft tissue infections, SSTI）的住院病例正日益增多。注射毒品使用者（people who inject drugs, PWID）罹患SIRI后，常无法获得充分的物质使用障碍（substance use disorder, SUD）治疗，且难以获取减害服务。这会导致住院周期延长，同时伴随高比例的患者自主出院、再入院及出院后死亡情况。

本研究旨在描述整合型“SIRI团队”的构建过程，及其运行初期的成功障碍与促进因素。美国佛罗里达州迈阿密的杰克逊纪念医院（Jackson Memorial Hospital）是一家拥有1550张床位的公立综合医院，该院设立了SIRI团队，旨在改善因SIRI住院的患者的医院层面与个体层面预后。该团队将跨医疗体系提供整合型感染性疾病诊疗与SUD治疗服务，覆盖从住院阶段至出院后90天的全周期。团队采用减害治疗理念，提供医疗协调服务，重点保障阿片类使用障碍（opioid use disorder, OUD）治疗药物（medications for opioid use disorder, MOUD）的可及性，并结合多种感染与成瘾治疗手段以适配每位患者的个体化需求。

在SIRI团队运行的最初8个月内，共收治21例患者，其中20例存活至出院。感染类型涵盖骨髓炎、心内膜炎、菌血症/真菌血症、SSTI及化脓性关节炎。所有患者均存在OUD，其中95%同时使用兴奋剂。所有患者出院时均接受了MOUD治疗，95%完成了处方抗生素疗程。出院后90天时，25%的患者出现再入院，70%的患者坚持服用MOUD。

针对SIRI的整合型感染性疾病与SUD诊疗模式，有望改善感染与成瘾相关预后。采用减害理念提供专注且以患者为中心的诊疗服务，可助力这一边缘人群与医疗体系建立联结。

KEY MESSAGES
1. 整合型感染性疾病与成瘾治疗是治疗重症注射相关感染的创新方案。
2. 应采用减害理念治疗SIRI患者，以实现促进抗生素疗程完成、物质使用障碍缓解及降低医院再入院率的目标。
3. 整合型感染性疾病与成瘾治疗是治疗重症注射相关感染的创新方案。
4. 应采用减害理念治疗SIRI患者，以实现促进抗生素疗程完成、物质使用障碍缓解及降低医院再入院率的目标。