Patient-Directed Discharges Among Persons Who Use Drugs Hospitalized with Invasive S. aureus Infections: Opportunities for Improvement

Abstract Background Despite the high burden of Staphylococcus aureus infections among persons who use drugs, limited data exist comparing outcomes of patient-directed discharge (also known as “against medical advice”) vs. 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, and/or vertebral osteomyelitis at two San Francisco hospitals between 2013–2018. We compared odds of one-year readmission for infection persistence/recurrence and one-year mortality via multivariable logistic regression models adjusting for age, sex, Charlson comorbidity index and homelessness. Results Overall, 80/340 (24%) of hospitalizations for invasive S. aureus infections among persons who use drugs involved patient-directed discharge. Over half of patient-directed discharges 41/80 (51%) required readmission for persistent/recurrent S. aureus infection vs. 54/260 (21%) patients without patient-directed discharge (adjusted odds ratio 3.8 [95% CI 2.2-6.7]). One-year cumulative mortality was 15% after PDD vs. 11% after standard discharge (p=0.02); however, this difference was not significant after adjustment for mortality risk factors. More than half of deaths in the patient-directed discharge group (7/12, 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 to standard discharge. All-cause one-year mortality was similarly high in both groups, and drug overdose was a common cause of death in patient-directed discharge group.