• Ayesha Appa, Meredith Adamo, Stephenie Le, Jennifer Davis, Lisa Winston, Sarah B Doernberg, Henry Chambers, Marlene Martin, Nancy K Hills, Phillip Coffin, and Vivek Jain.
• Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco. Electronic address: Ayesha.appa@ucsf.edu.
• Am. J. Med. 2022 Jan 1; 135 (1): 919691-96.

BackgroundDespite 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.MethodsWe 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.ResultsOverall, 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.ConclusionsAmong 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.Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

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