患者导向的出院决策在因侵袭性金黄色葡萄球菌感染住院的药物使用患者中：改进的机会。
Patient-Directed Discharges Among Persons Who Use Drugs Hospitalized with Invasive Staphylococcus aureus Infections: Opportunities for Improvement.
机构信息
Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco.
Department of Medicine, University of California San Francisco, San Francisco.
出版信息
Am J Med. 2022 Jan;135(1):91-96. doi: 10.1016/j.amjmed.2021.08.007. Epub 2021 Sep 9.
BACKGROUND
Despite the high burden of Staphylococcus aureus infections among persons who use drugs, limited data exist comparing outcomes of patient-directed discharge (known as discharge against medical advice) compared with standard discharge among persons who use drugs hospitalized with S. aureus infection.
METHODS
We conducted a retrospective study of hospitalizations among adults with S. aureus bacteremia, endocarditis, epidural abscess, or vertebral osteomyelitis at 2 San Francisco hospitals between 2013 and 2018. We compared odds of 1-year readmission for infection persistence or recurrence and 1-year mortality via multivariable logistic regression models adjusting for age, sex, Charlson comorbidity index, and homelessness.
RESULTS
Overall, 80 of 340 (24%) of hospitalizations for invasive S. aureus infections among persons who use drugs involved patient-directed discharge. More than half of patient-directed discharges 41 of 80 (51%) required readmission for persistent or recurrent S. aureus infection compared with 54 of 260 (21%) patients without patient-directed discharge (adjusted odds ratio 3.8, 95% confidence interval [CI] 2.2-6.7). One-year cumulative mortality was 15% after patient-directed discharge compared with 11% after standard discharge (P = .02); however, this difference was not significant after adjustment for mortality risk factors. More than half of deaths in the patient-directed discharge group (7 of 12, 58%) were due to drug overdose; none was due to S. aureus infection.
CONCLUSIONS
Among persons who use drugs hospitalized with invasive S. aureus infection, odds of hospital readmission for infection were almost 4-fold higher following patient-directed discharge compared with standard discharge. All-cause 1-year mortality was similarly high in both groups, and drug overdose was a common cause of death in patient-directed discharge group.
背景
尽管在使用毒品的人群中，金黄色葡萄球菌感染的负担很高，但在因金黄色葡萄球菌感染住院的使用毒品者中，与标准出院相比，患者自行出院（称为医嘱出院）的结果比较数据有限。
方法
我们对 2013 年至 2018 年期间在旧金山的 2 家医院住院的金黄色葡萄球菌菌血症、心内膜炎、硬膜外脓肿或脊椎骨髓炎的成年人进行了回顾性研究。我们通过多变量逻辑回归模型比较了 1 年内因感染持续或复发和 1 年内死亡率的可能性，调整了年龄、性别、Charlson 合并症指数和无家可归情况。
结果
总体而言，在 340 例因侵袭性金黄色葡萄球菌感染住院的使用毒品者中，有 80 例（24%）涉及医嘱出院。与没有医嘱出院的 260 例患者相比，医嘱出院的 80 例中有 41 例（51%）需要因持续或复发的金黄色葡萄球菌感染而再次入院，而 41 例（51%）需要因持续或复发的金黄色葡萄球菌感染而再次入院（调整后的比值比为 3.8，95%置信区间为 2.2-6.7）。医嘱出院后 1 年累积死亡率为 15%，而标准出院后为 11%（P=0.02）；然而，在调整了死亡率危险因素后，这一差异并不显著。在医嘱出院组中，超过一半的死亡（7 例中的 12 例，58%）是由于药物过量；没有因金黄色葡萄球菌感染而死亡。
结论
在因侵袭性金黄色葡萄球菌感染住院的使用毒品者中，与标准出院相比，医嘱出院后因感染再次住院的可能性几乎高出 4 倍。两组的全因 1 年死亡率均较高，且医嘱出院组中药物过量是常见的死亡原因。
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