The Clinical and Financial Burden of Spinal Infections in People who Inject Drugs

The Intersection of Substance Use Disorders and Infectious Diseases in the Emergency Department

Substance use disorders (SUDs) intersect clinically with many infectious diseases, leading to significant morbidity and mortality if either condition is inadequately treated. In this article, we will describe commonly seen SUDs in the emergency department (ED) as well as their associated infectious diseases, discuss social drivers of patient outcomes, and introduce novel ED-based interventions for co-occurring conditions. Clinicians should come away from this article with prescriptions for both antimicrobial medications and pharmacotherapy for SUDs, as well as an appreciation for social barriers, to care for these patients.

The burden of skin and soft tissue, bone and joint infections in an Australian cohort of people who inject drugs

INTRODUCTION

There are currently limited data regarding the clinical and economic significance of skin and soft tissue infections (SSTI) and bone and joint infections in Australian people who inject drugs (PWID).

METHODS

Retrospective cohort study in adult PWID admitted to Monash Health, a large heath care network with six hospitals in Victoria, Australia. Inpatients were identified using administrative datasets and International Classification of Disease (ICD-10) coding for specific infection-related conditions. Cost analysis was based on mean ward, intensive care and hospital-in-the-home (HITH) lengths of stay. Spinal infections and endocarditis were excluded as part of previous studies.

RESULTS

A total of 185 PWID (61 female, 124 male, median age 37) meeting the study criteria were admitted to Monash Health between January 2010 and January 2021. Admitting diagnoses included 78 skin abscesses, 80 cellulitis, 17 septic arthritis, 4 osteomyelitis, 3 thrombophlebitis and 1 each of necrotising fasciitis, vasculitis and myositis. Pain (87.5%) and swelling (75.1%) were the most common presenting complaints. Opioids (67.4%) and methamphetamine (37.5%) were the most common primary drugs injected. Almost half (46.5%) of patients had concurrent active hepatitis C (HCV) infection on admission. Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV) were uncommon. The most significant causative organism was methicillin-susceptible Staphylococcus aureus (24.9%). In 40.0% (74/185) no organism was identified. Patients required a median acute hospital stay of 5 days (2-51 days). There were 15 patients admitted to the intensive care unit (ICU) with median duration 2 days. PICC line insertion for antibiotics was required in 16.8% of patients, while 51.4% required surgical intervention. Median duration of both oral and IV antibiotic therapy was 11 days. Almost half (48.6%) of patients were enrolled in an opioid maintenance program on discharge. Average estimated expenditure was AUD $16, 528 per admission.

CONCLUSION

Skin and soft tissue and joint infections are a major cause of morbidity for PWID. Admission to hospital provides opportunistic involvement of addiction specialty services.

Epidemiology of acute infections in people who inject drugs in Australia

ISSUES

People who inject drugs are at risk of acute infections, such as skin and soft tissue infections, infective endocarditis, bone and joint infections and bloodstream infections. There has been an increase in these infections in people who inject drugs internationally over the past 10 years. However, the local data regarding acute infections in Australia has not been well described.

APPROACH

We review the epidemiology of acute infections and associated morbidity and mortality amongst people who inject drugs in Australia. We summarise risk factors for these infections, including the concurrent social and psychological determinants of health.

KEY FINDINGS

The proportion of people who report having injected drugs in the prior 12 months in Australia has decreased over the past 18 years. However, there has been an increase in the burden of acute infections in this population. This increase is driven largely by skin and soft tissue infections. People who inject drugs often have multiple conflicting priorities that can delay engagement in care.

IMPLICATIONS

Acute infections in people who inject drugs are associated with significant morbidity and mortality. Acute infections contribute to significant bed days, surgical requirements and health-care costs in Australia. The increase in these infections is likely due to a complex interplay of microbiological, individual, social and environmental factors.

CONCLUSION

Acute infections in people who inject drugs in Australia represent a significant burden to both patients and health-care systems. Flexible health-care models, such as low-threshold wound clinics, would help directly target, and address early interventions, for these infections.

Trends and characteristics of primary pyogenic spine infections among people who do and do not inject drugs: Northeast New York State, 2007 to 2018

Background:

Pyogenic spine infections (PSIs) are challenging to diagnose and treat. People who inject drugs (PWID) are at increased risk and contribute to rising PSI incidence.

Objective:

To analyze trends and characterize PSI in persons who do and do not inject drugs in northeast New York State (NYS), a predominantly rural region.

Methods:

A retrospective study of PSI patients at a regional tertiary care hospital from 2007 to 2018 was conducted. PSI incidence, population demographics, microbiology, surgical interventions, length of stay (LOS), and costs were compared between injection substance use disorder (ISUD) and non-ISUD cohorts.

Results:

Two hundred and seventy patients (59 ISUD and 211 non-ISUD) were included in this study. PSI incidence due to ISUD increased 1175% during the study time periods. The median age of the ISUD and non-ISUD cohorts was 39 and 65, respectively. Staphylococcus aureus was the most common causative organism, although a variety of bacterial and fungal pathogens were identified. Nearly half of the patients in each cohort required surgical intervention. Median acute care LOS was 12 days and comparable between cohorts. However, the ISUD cohort was frequently discharged against medical advice, or transferred back to acute care hospitals to complete antibiotic courses. Median inpatient hospital costs were approximately $25,000 and were comparable between cohorts. These costs do not reflect inpatient costs once the patient was transferred back to the referring hospital, nor costs for outpatient care. Medicaid and Medicare were the most common primary insurance payers for the ISUD and non-ISUD cohorts, respectively.

Conclusions:

Incidence of PSI has increased significantly coincident with the opioid epidemic and has had significant impact on a large, rural region of NYS. PSIs consume large amounts of healthcare resources. This study can inform hospitals and public health agencies regarding the need for substance abuse harm reduction strategies.

Opium Addiction: Practical Issues in ICU

How to cite this article: Das AK, Sharma A, Kothari N, Goyal S. Opium Addiction: Practical Issues in ICU. Indian J Crit Care Med 2021;25(9):1082–1083.