What to do with a patient who wants to leave AMA after abscess incision and drainage with a history of IV (Intravenous) drug use?

Management of IV Drug User Wanting to Leave AMA After Forearm Abscess Drainage

The immediate priority is to assess for infective endocarditis before allowing discharge, as IV drug users with skin/soft tissue infections have significant risk of this life-threatening complication that requires weeks of inpatient IV antibiotics. 1

Critical Assessment Before Discharge

Rule Out Infective Endocarditis

• Obtain blood cultures immediately (at least 2 sets from separate sites) before the patient leaves, as bacteremia is common in IV drug users with abscesses and can indicate endocarditis 1
• Assess for clinical signs of endocarditis: new heart murmur, fever, embolic phenomena (splinter hemorrhages, Janeway lesions, Osler nodes), or any cardiac symptoms 1
• If any suspicion exists, obtain urgent echocardiography (transthoracic initially, transesophageal if high suspicion) before discharge 1
• The period of greatest risk for systemic emboli is within the first 1-2 weeks, making early detection critical 1

Assess Decision-Making Capacity

• Evaluate whether the patient has capacity to refuse care by assessing: understanding of their condition, appreciation of consequences, ability to reason about treatment options, and ability to communicate a choice 2
• Document this capacity assessment thoroughly in the medical record 2

If Endocarditis is Ruled Out

Wound Management

• Ensure adequate drainage was achieved during the I&D procedure, as inadequate drainage is associated with high recurrence rates 3
• Antibiotics are NOT routinely indicated after adequate surgical drainage of simple abscesses 3, 4
• Consider antibiotics only if: surrounding cellulitis present, systemic signs of infection, immunocompromised state, or diabetes 3

Special Considerations for IV Drug Users

• Outpatient parenteral antibiotic therapy (OPAT) for IV drug users is problematic due to compliance difficulties and high risk of misuse of IV access 1
• Foreign bodies (broken needles) should be ruled out by radiography if not already done 1
• Screen for viral infections (HIV, HCV, HBV) as these are common in this population 1

Substance Use Disorder Management

• Provide referral to drug cessation program before discharge, as this is a critical intervention 1
• Offer harm reduction counseling and resources 1

Documentation for AMA Discharge

Essential Elements

• Document capacity assessment showing patient understands: diagnosis, recommended treatment, risks of leaving, and potential complications including death 2
• Explain specific risks: abscess recurrence (up to 44% without adequate treatment), progression to necrotizing fasciitis, sepsis, endocarditis, and death 1, 3
• Document that patient was offered alternatives and refused 2
• Have patient sign AMA form acknowledging these risks 2
• This documentation provides legal protection by proving the provider's duty ended with discharge and patient assumed risk 2

Discharge Instructions (If Proceeding with AMA)

Warning Signs Requiring Immediate Return

• Fever, chills, or rigors (suggesting bacteremia/endocarditis) 1
• Worsening redness, swelling, or pain at wound site 4
• Red streaking from wound (lymphangitis) 4
• Shortness of breath or chest pain (possible endocarditis complications) 1
• New neurological symptoms (embolic phenomena) 1

Wound Care

• Warm soaks to affected area 5
• Keep wound clean and dry between soaks 4
• Remove packing in 24-48 hours if placed 4

Follow-Up

• Arrange urgent follow-up within 24-48 hours for wound check 4
• Provide written instructions with emergency contact information 2

Common Pitfalls to Avoid

• Never allow discharge without blood cultures if any systemic symptoms present, as missing endocarditis can be fatal 1
• Do not rely solely on antibiotics without adequate surgical drainage - this is insufficient treatment 6
• Avoid assuming simple abscess when patient may have deeper infection or endocarditis 1
• Do not skip capacity assessment - this is both ethically required and provides legal protection 2, 7
• Failing to address substance use disorder misses opportunity for life-saving intervention 1