Bacterial and Fungal Infections in Persons Who Inject Drugs - Western New York, 2017

Cost evaluation of continuation of therapy with dalbavancin compared to standard-of-care antibiotics alone in hospitalized persons who inject drugs with severe gram-positive infections

PURPOSE

Persons who inject drugs (PWID) are at risk for severe gram-positive infections and may require prolonged hospitalization and intravenous (IV) antibiotic therapy. Dalbavancin (DBV) is a long-acting lipoglycopeptide that may reduce costs and provide effective treatment in this population.

METHODS

This was a retrospective review of PWID with severe gram-positive infections. Patients admitted from January 1, 2017, to November 1, 2019 (standard-of-care [SOC] group) and from November 15, 2019, to March 31, 2022 (DBV group) were included. The primary outcome was the total cost to the healthcare system. Secondary outcomes included hospital days saved and treatment failure.

RESULTS

A total of 87 patients were included (37 in the DBV group and 50 in the SOC group). Patients were a median of 34 years old and were predominantly Caucasian (82%). Staphylococcus aureus (82%) was the most common organism, and bacteremia (71%) was the most common type of infection. Compared to the SOC group, the DBV group would have had a median of 14 additional days of hospitalization if they had stayed to complete their therapy (P = 0.014). The median total cost to the healthcare system was significantly lower in the DBV group than in the SOC group ($31,698.00 vs $45,093.50; P = 0.035). The rate of treatment failure was similar between the groups (32.4% in the DBV group vs 36% in the SOC group; P = 0.729).

CONCLUSION

DBV is a cost-saving alternative to SOC IV antibiotics for severe gram-positive infections in PWID, with similar treatment outcomes. Larger prospective studies, including other patient populations, may demonstrate additional benefit.

Roles of Nucleolar Factor RCL1 in Itraconazole Resistance of Clinical Candida albicans Under Different Stress Conditions

Purpose

RNA terminal phosphate cyclase like 1 (RCL1) undergoes overexpression during the immune response of Candida albicans following drug treatment. This study aims to investigate the expression levels of RCL1 in C. albicans under various stress conditions.

Methods

Fifteen itraconazole (ITR)-resistant strains of clinical C. albicans, and one standard strain were employed for RCL1 sequencing, and mutations in RCL1 were analyzed. Subsequently, 14 out of the 15 ITR-resistant clinical strains and 14 clinical strains sensitive to ITR, fluconazole (FCA) as well as voriconazole (VRC) were cultured under diverse conditions. The expression of RCL1 ITR-resistant and sensitive C. albicans was then assessed using real-time quantitative PCR (RT-qPCR) assays.

Results

Compared to the standard strain, three missense mutations (C6A, G10A, and A11T) were identified in the RCL1 gene of ITR-resistant C. albicans through successful forward sequencing. Additionally, using successful reverse sequencing, one synonymous mutation (C1T) and four missense mutations (C1T, A3T, A7G, and T8G) were found in the RCL1 gene of ITR-resistant C. albicans. RCL1 expression was significantly higher in ITR-resistant C. albicans than in sensitive strains under standard conditions (37°C, 0.03% CO2, pH 4.0). Low temperature (25°C) increased RCL1 expression in sensitive C. albicans while decreasing it in ITR-resistant strains. Elevated CO2 concentrations (5% CO2) had a negligible effect on RCL1 expression in sensitive C. albicans, but effectively reduced RCL1 level in ITR-resistant strains. Furthermore, a medium with a pH of 7 decreased the expression of RCL1 in both resistant and sensitive C. albicans.

Conclusion

This study demonstrated that RCL1 mutations in ITR-resistant C. albicans, and variations in culture conditions significantly influence RCL1 expression in both ITR-resistant and sensitive C. albicans, thereby inducing alterations in the dimorphism of C. albicans.

Comparative study of oral microbiota in the experimental long-term opioid exposure, after its withdrawal and the use of complex drug correction

OBJECTIVE

Aim: To study changes of dental biofilm microbiota composition during experimental opioid exposure, after its withdrawal and when using of complex drug correction..

PATIENTS AND METHODS

Materials and Methods: Microbiological studies (48 rats) included microscopic and bacteriological methods, as well as determination of antibiotic susceptibility of microbial isolates. Ceftriaxone and pentoxifylline were used to correction the changes.

RESULTS

Results: The action of opioid for 10 weeks caused considerable changes in the microbiocenosis, which was illustrated by a significant increasing of the opportunistic pathogens quantitative indicators and the emergence of pathogenic microbiota. Changes in the microbiocenosis at 6 weeks of opioid exposure and after its withdrawal for 4 weeks were expressed in the appearance of pathogenic microbiota and the absence of significant differences in quantitative indicators of saprophytic and opportunistic microflora compared to similar indicators in animals with 10 weeks opioid exposure. This indicated a slow progression of dysbiotic changes and the inflammatory process in the oral cavity of rats.

CONCLUSION

Conclusions: After 10 weeks of experiment with opioid administration for 6 weeks and the use of ceftriaxone and pentoxifylline on the background of 4-week opioid withdrawal, a significant reduction of quantitative indicators of opportunistic bacteria and elimination of pathogenic species of microorganisms was determined. The use of complex drug correction on the background of 10 weeks of opioid exposure led to a significant reduction in the quantitative indicators of opportunistic pathogens and contributed to the elimination of most pathogenic species of microbiota under the action of ceftriaxone.

Research on the biological mechanism and potential application of CEMIP

Cell migration-inducing protein (CEMIP), also known as KIAA1199 and hyaluronan-binding protein involved in hyaluronan depolymerization, is a new member of the hyaluronidase family that degrades hyaluronic acid (HA) and remodels the extracellular matrix. In recent years, some studies have reported that CEMIP can promote the proliferation, invasion, and adhesion of various tumor cells and can play an important role in bacterial infection and arthritis. This review focuses on the pathological mechanism of CEMIP in a variety of diseases and expounds the function of CEMIP from the aspects of inhibiting cell apoptosis, promoting HA degradation, inducing inflammatory responses and related phosphorylation, adjusting cellular microenvironment, and regulating tissue fibrosis. The diagnosis and treatment strategies targeting CEMIP are also summarized. The various functions of CEMIP show its great potential application value.

Iteration is not solving the opioid crisis, it's time for transformation

Opioid use disorder (OUD) produces exceedingly high rates of morbidity and mortality in the United States and throughout the world. Almost 90% of persons qualifying for treatment do not enter treatment and 72% of those who initiate treatment leave within 60 days. This Perspective posits that over the past decade our OUD treatment system has produced only small iterative gains in treatment access because, in part, it is founded in a series of top-down regulatory policies dating back more than 100 years. These policies prioritized restricting persons with OUD from having access to opioid agonists over empirical discovery of treatment best practice. It further suggests that for persons who are not already responding positively to our existing treatments, we may need to fundamentally transform care to enact true, meaningful change. Four potential considerations are outlined: expanding beyond long-acting opioids for treatment, embracing safe use as a viable therapeutic target, ending closed medication distribution systems, and partnering with our patients. The overarching aim of this discussion is to motivate broader thinking about new solutions for the patients for whom the existing strategies are not working and who may benefit from more transformative approaches. Though efforts to-date to expand existing treatment systems and find new ways to promote existing MOUDs have been important, these efforts have represented iterative changes. For us to meet our goal of substantially reducing opioid-related harms, it may be time to consider strategies that represent true transformation.

Rationale, design, and methodology of a randomized pilot trial of an integrated intervention combining computerized behavioral therapy and recovery coaching for people with opioid use disorder: The OVERCOME study

Background

Opioid use disorder (OUD) has led to a staggering death toll in terms of drug-related overdoses. Despite the demonstrated benefits and effectiveness of buprenorphine, retention is suboptimal, and patients typically present with high rates of ongoing polysubstance use during treatment. A pilot trial provided preliminary support for the efficacy of computer-based cognitive-behavioral therapy (CBT4CBT) as an add-on to buprenorphine in reducing substance use. Recovery coaching services provided by individuals with substance use experience and successful recovery have also shown to positively influence recovery outcomes for people with OUD by increasing buprenorphine initiation and reducing opioid use.

Methods

The OVERCOME study is a randomized clinical trial (RCT) aimed to tests an integrated intervention combining CBT4CBT and Recovery Coaching relative to treatment-as-usual (TAU) among individuals with OUD on buprenorphine. The primary outcome measure is the percentage of samples with any drug tested as positive at each research visit conducted during treatment (visits 1 to 8). Secondary outcomes include the percentage of samples with any drug tested as positive at 1- and 3- month follow-up and retention to buprenorphine at 3- month follow-up.

Results

We describe the rationale, design, and methodology of the OVERCOME Study.

Conclusion

This trial will provide evidence of the efficacy of an integrated intervention combining CBT4CBT and Recovery Coaching for reducing substance use and increasing buprenorphine adherence which has the potential to reduce mortality among people with OUD.

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.

Hospitalisation with injection-related infections: Validation of diagnostic codes to monitor admission trends at a tertiary care hospital in Melbourne, Australia

INTRODUCTION

Injection-related infections (IRI) cause morbidity and mortality in people who inject drugs. Hospital administrative datasets can be used to describe hospitalisation trends, but there are no validated algorithms to identify injecting drug use and IRIs. We aimed to validate International Classification of Diseases (ICD) codes to identify admissions with IRIs and use these codes to describe IRIs within our hospital.

METHODS

We developed a candidate set of ICD codes to identify current injecting drug use and IRI and extracted admissions satisfying both criteria. We then used manual chart review data from 1 January 2017 to 30 April 2019 to evaluate the performance of these codes and refine our algorithm by selecting codes with a high-positive predictive value (PPV). We used the refined algorithm to describe trends and outcomes of people who inject drugs with an IRI at Alfred Hospital, Melbourne from 2008 to 2020.

RESULTS

Current injecting drug use was best predicted by opioid-related disorders (F11), 80% (95% confidence interval [CI] 74-85%), and other stimulant-related disorders (F15), 82% (95% CI 70-90%). All PPVs were ≥67% to identify specific IRIs, and ≥84% for identifying any IRI. Using these codes over 12 years, IRIs increased from 138 to 249 per 100 000 admissions, and skin and soft tissues infections (SSTI) were the most common (797/1751, 46%).

DISCUSSION AND CONCLUSION

Validated ICD-based algorithms can inform passive surveillance systems. Strategies to reduce hospitalisation with IRIs should be supported by early intervention and prevention, particularly for SSTIs which may represent delayed access to care.

Modeling the Dynamics of Heroin and Illicit Opioid Use Disorder, Treatment, and Recovery

Opioid use disorder (OUD) has become a serious leading health issue in the USA leading to addiction, disability, or death by overdose. Research has shown that OUD can lead to a chronic lifelong disorder with greater risk for relapse and accidental overdose deaths. While the prescription opioid epidemic is a relatively new phenomenon, illicit opioid use via heroin has been around for decades. Recently, additional illicit opioids such as fentanyl have become increasingly available and problematic. We propose a mathematical model that focuses on illicit OUD and includes a class for recovered users but allows for individuals to either remain in or relapse back to the illicit OUD class. Therefore, in our model, individuals may cycle in and out of three different classes: illicit OUD, treatment, and recovered. We additionally include a treatment function with saturation, as it has been shown there is limited accessibility to specialty treatment facilities. We used 2002–2019 SAMHSA and CDC data for the US population, scaled to a medium-sized city, to obtain parameter estimates for the specific case of heroin. We found that the overdose death rate has been increasing linearly since around 2011, likely due to the increased presence of fentanyl in the heroin supply. Extrapolation of this overdose death rate, together with the obtained parameter estimates, predict that by 2038 no endemic equilibrium will exist and the only stable equilibrium will correspond to the absence of heroin use disorder in the population. There is a range of parameter values that will give rise to a backward bifurcation above a critical saturation of treatment availability. We show this for a range of overdose death rate values, thus illustrating the critical role played by the availability of specialty treatment facilities. Sensitivity analysis consistently shows the significant role of people entering treatment on their own accord, which suggests the importance of removing two of the most prevalent SAMHSA-determined reasons that individuals do not enter treatment: financial constraints and the stigma of seeking treatment for heroin use disorder.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

DYNAMICS OF CHANGES IN THE MICROBIAL PICTURE OF THE ORAL CAVITY ON THE BACKGROUND OF CHRONIC OPIOID EXPOSURE IN THE EXPERIMENT

OBJECTIVE

The aim is to investigate changes in the microbiota of dental biofilm at the end of the eighth, tenth and twelfth weeks of experimental opioid exposure.

PATIENTS AND METHODS

Materials and methods: The study was performed on 36 white outbred adult male rats, which were injected with the opioid analgesic nalbuphine in increasing doses (0,212 - 0,3 mg / kg) during 8, 10 and 12 weeks. Qualitative and quantitative composition of microbiota of dental biofilm was studied using statistical analysis.

RESULTS

Results: After eight weeks of opioid exposure, changes in microbiocenosis of dental biofilm of rats were caused by a significant increase in saprophytic and opportunistic microbiota and an appearance of pathogenic species of indicator microbiota with potential periodontopathogenic action. At the end of the tenth week, a significant increase in the quantitative indicators of certain species of opportunistic microbiota and increase in the quantitative composition of pathogenic bacteria were determined. After twelve week of opioid exposure, a significant increase in the quantitative indicators of pathogenic microbiota of dental biofilm was detected.

CONCLUSION

Conclusions: Changes in the qualitative and quantitative composition of the microbiocenosis of the dental biofilm at the end of 8, 10 and 12 weeks of opioid exposure were established, they were manifested by a significant increase in the quantitative indicators of certain species of opportunistic microorganisms and a significant increase in pathogenic microbiota in the dynamics, which led to the progression of dysbiotic changes and purulent-inflammatory process in the oral cavity of rats.

A syndemic examination of injecting drug use, incarceration and multiple drug-related harms in French opioid users

PURPOSE

People who inject drugs (PWID) face multiple health problems, including infectious diseases and drug overdoses. Applying syndemic and risk environment frameworks, this paper aims to examine the co-occurrence and clustering of drug-related harms and their association with incarceration experience with or without in-prison drug injection.

DESIGN/METHODOLOGY/APPROACH

The authors used data from a cross-sectional survey conducted in 2015 among 557 active opioid injectors. Self-reported data were collected through face-to-face or online questionnaires. They distinguished three harm categories, namely, viral infections, bacterial infections and overdoses, and built an index variable by summing the number of harm categories experienced, yielding a score from 0 to 3. Association between incarceration experience and co-occurrence of harms was modelled using a multinomial logistic regression.

FINDINGS

Of the 557 participants, 30% reported lifetime experience of drug-related viral infection, 46% bacterial infection and 22% drug overdose. Multinomial logistic models showed that those who injected drugs during incarceration were more likely to report two (aOR = 2.35, 95% CI: 1.03-5.36) and three (aOR = 9.72, 95% CI: 3.23-29.22) harm categories than those who had never been incarcerated. They were also more likely to report three harm categories than formerly incarcerated respondents who did not inject drugs in prison (aOR = 5.14, 95% CI: 1.71-15.48).

ORIGINALITY/VALUE

This study provides insights of the syndemic nature of drug-related harms and highlights that drug injection during incarceration is associated with co-occurring harms. Public health interventions and policy changes are needed to limit the deleterious impact of prison on PWID.

Staphylococcus aureus injection drug use-associated bloodstream infections are propagated by community outbreaks of diverse lineages

Background

The ongoing injection drug use (IDU) crisis in the United States has been complicated by an emerging epidemic of Staphylococcus aureus IDU-associated bloodstream infections (IDU-BSI).

Methods

We performed a case-control study comparing S. aureus IDU-BSI and non-IDU BSI cases identified in a large US Midwestern academic medical center between Jan 1, 2016 and Dec 21, 2019. We obtained the whole-genome sequences of 154 S. aureus IDU-BSI and 91 S. aureus non-IDU BSI cases, which were matched with clinical data. We performed phylogenetic and comparative genomic analyses to investigate clonal expansion of lineages and molecular features characteristic of IDU-BSI isolates.

Results

Here we show that patients with IDU-BSI experience longer durations of bacteremia and have lower medical therapy completion rates. In phylogenetic analyses, 45/154 and 1/91 contemporaneous IDU-BSI and non-IDU BSI staphylococcal isolates, respectively, group into multiple, unique clonal clusters, revealing that pathogen community transmission distinctively spurs IDU-BSI. Lastly, multiple S. aureus lineages deficient in canonical virulence genes are overrepresented among IDU-BSI, which may contribute to the distinguishable clinical presentation of IDU-BSI cases.

Conclusions

We identify clonal expansion of multiple S. aureus lineages among IDU-BSI isolates, but not non-IDU BSI isolates, in a community with limited access to needle exchange facilities. In the setting of expanding numbers of staphylococcal IDU-BSI cases consideration should be given to treating IDU-associated invasive staphylococcal infections as a communicable disease.

A Systematic Review and Meta-Analysis of Studies Evaluating the Effect of Medication Treatment for Opioid Use Disorder on Infectious Disease Outcomes

The opioid epidemic has fueled infectious disease epidemics. We determined the impact of medications for opioid use disorder (MOUD) on treatment outcomes of opioid use disorder (OUD)-associated infectious diseases: antiretroviral therapy (ART) adherence, human immunodeficiency virus (HIV) viral suppression, hepatitis C virus (HCV) sustained virologic response, HCV reinfection, new hepatitis B virus infections, and infectious endocarditis-related outcomes. Manuscripts reporting on these infectious disease outcomes in adults with OUD receiving MOUD compared with those with OUD "not" receiving MOUD were included. Initial search yielded 8169 papers; 9 were included in the final review. The meta-analysis revealed that MOUD was associated with greater ART adherence (odds ratio [OR] = 1.55; 95% confidence interval [CI] = 1.12-2.15) and HIV viral suppression (OR = 2.19; 95% CI = 1.88-2.56). One study suggested a positive association between MOUD and HCV sustained virologic response. There is significant support for integrating MOUD with HIV treatment to improve viral suppression among persons with HIV (PWH) and OUD. Treatment of OUD among PWH should be a priority to combat the opioid and HIV epidemics.

Bacterial infections in people who inject psychoactive substances: An observational study in a French university hospital

AIM OF THE STUDY

To describe bacterial infections in injection drug users (IDUs) hospitalized at Montpellier University Hospital, France, and to identify factors that might influence the development of local or systemic infections.

METHODS

This cross-sectional observational monocentric study prospectively included bacterial infections in IDUs hospitalized at Montpellier University Hospital between 2012 and 2018. Types of infection (local or systemic) were described and compared to identify specific features (injection practices).

RESULTS

The study included 144 bacterial infections (56% of local infections and 44% of systemic infections) concerning 117 IDUs. The most common infection types were abscesses (50%), skin and soft tissue infections (33%), bacteremia/sepsis (20%), endocarditis (17%), and bone and joint infections (16%). Patients were mainly men (n=94; 80%), and the median age was 40 years [IQR_25-75: 34-47]. Four deaths related to systemic infection were reported. The most frequent injected substances were cocaine, opioid maintenance treatments (OMT), and opioids. According to the multivariate analysis, factors associated with the occurrence of systemic infections were number of injection (OR 2.59 [1.07-6.27]; P=0.034) and injection of at least one opioid (OR 3.52 [1.28-9.72]; P=0.015).

CONCLUSION

Different types of bacterial infections, local or systemic, are observed in IDUs. Skin infections are quite common, but other infection types also are reported, with sometimes serious consequences. It is already known that injection practices are contributing factors in infection development, but the type of injected psychoactive substance(s) also may have an influence.

Streptococcus pyogenes Infective Endocarditis-Association With Injection Drug Use: Case Series and Review of the Literature

BACKGROUND

Streptococcus pyogenes, or Group A Streptococcus (GAS), is not considered a typical cause of infective endocarditis (IE), but has anecdotally been observed in unexpectedly high rates in people who inject drugs (PWID) at our institution.

METHODS

All cases of possible or definite GAS IE per Modified Duke Criteria in adults at an academic hospital between 11/15/2015 and 11/15/2020 were identified. Medical records were reviewed for demographics, comorbidities, treatment, and outcomes related to GAS IE. The literature on cases of GAS IE was reviewed.

RESULTS

Eighteen cases of probable (11) or definite (7) GAS IE were identified; the mean age was 38 years, and the population was predominantly female (56%) and Caucasian (67%), which is inconsistent with local population demographics. Sixteen cases were in people who inject drugs (PWID; 89%); 14 were also homeless, 6 also had HIV (33%), and 2 were also pregnant. Antibiotic regimens were variable due to polymicrobial bacteremia (39%). One patient underwent surgical valve replacement. Four patients (22%) died due to complications of infection. The literature review revealed 42 adult cases of GAS IE, only 17 of which were in PWID (24%).

CONCLUSIONS

The 16 cases of possible and definite GAS IE in PWID over a 5-year period in a single institution reported nearly doubles the number of cases in PWID from all previous reports. This suggests a potential increase in GAS IE particularly in PWID and PWH, which warrants further epidemiologic investigation.

Group A streptococcal bacteraemia at a tertiary hospital in Melbourne: concern of an under-reported risk group in Australia

BACKGROUND

Invasive group A streptococcal (iGAS) infections are increasing worldwide with at-risk groups being children, pregnant women and the elderly. In 2017, there was a rise in iGAS cases in Victoria, prompting a Chief Health Officer advisory.

AIMS

To describe the characteristics of patients with GAS bacteraemia admitted to a tertiary hospital. To compare at-risk groups in our population with those identified in the Victorian Government health alert.

METHODS

Retrospective review of patients with GAS bacteraemia admitted between June 2014 and December 2017 at a tertiary hospital in Melbourne, Victoria.

RESULTS

Forty-three cases of GAS bacteraemia occurred. Average age was 52 years (range 15-88 years) with 63% male. Average length of stay was 14 days (range 0-72 days) and all-cause mortality occurred in two (5%) cases. Twelve (28%) patients presented with shock, 11 (26%) required intensive care unit admission and 13 (30%) surgical intervention. A history of intravenous drug use was documented in 18 (42%) cases and was commonly complicated by bone or joint involvement or thrombosis. Typing of GAS samples identified 22 different emm-types.

CONCLUSION

GAS bacteraemia resulted in significant morbidity and prolonged hospitalisation. In contrast to the at-risk groups identified in the Victorian Government health advisory, the commonest risk group in this series were people who inject drugs and most commonly middle-aged men. Invasive GAS should be considered if a person who injects drugs presents with acute severe sepsis.

Bacterial Infections Associated With Substance Use Disorders, Large Cohort of United States Hospitals, 2012-2017

BACKGROUND

Rises in the incidence of bacterial infections, such as infective endocarditis (IE), have been reported in conjunction with the opioid crisis. However, recent trends for IE and other serious infections among persons with substance use disorders (SUDs) are unknown.

METHODS

Using the Premier Healthcare Database, we identified hospitalizations from 2012 through 2017 among adults with primary discharge diagnoses of bacterial infections and secondary SUD diagnoses, using International Classification of Diseases, Clinical Modification Ninth and Tenth Revision codes. We calculated annual rates of infections with SUD diagnoses and evaluated temporal trends. Blood and cardiac tissue specimens were identified from IE hospitalizations to describe the microbiology distribution and temporal trends among hospitalizations with and without SUDs.

RESULTS

Among 72 481 weighted IE admissions recorded, SUD diagnoses increased from 19.9% in 2012 to 39.4% in 2017 (P < .0001). Hospitalizations with SUDs increased from 1.1 to 2.1 per 100 000 persons for IE, 1.4 to 2.4 per 100 000 persons for osteomyelitis, 0.5 to 0.9 per 100 000 persons for central nervous system abscesses, and 24.4 to 32.9 per 100 000 persons for skin and soft tissue infections. For adults aged 18-44 years, IE-SUD hospitalizations more than doubled, from 1.6 in 2012 to 3.6 in 2017 per 100 000 persons. Among all IE-SUD hospitalizations, 50.3% had a Staphylococcus aureus infection, compared with 19.4% of IE hospitalizations without SUDs.

CONCLUSIONS

Rates of hospitalization for serious infections among persons with SUDs are increasing, driven primarily by younger age groups. The differences in the microbiology of IE hospitalizations suggest that SUDs are changing the epidemiology of these infections.

Not Just Endocarditis: Hospitalizations for Selected Invasive Infections Among Persons With Opioid and Stimulant Use Diagnoses-North Carolina, 2010-2018

BACKGROUND

While increases in overdoses, viral hepatitis, and endocarditis associated with drug use have been well-documented in North Carolina, the full scope of invasive drug-related infections (IDRIs) has not. We characterized trends in IDRIs among hospitalized patients in North Carolina.

METHODS

We compared invasive infections that were related or not related to drug use among hospitalized patients aged 18-55 years based on retrospective review of administrative records from 2010-2018. Hospitalizations for endocarditis, central nervous system/spine infections, osteomyelitis, and septic arthritis were labeled as IDRIs if discharge codes included opioid and/or amphetamine misuse. Trends, rates, and distributions were calculated.

RESULTS

Among 44 851 hospitalizations for the specified infections, 2830 (6.3%) were IDRIs. The proportion of infections attributable to drug use increased from 1.5% (2010) to 13.1% (2018), and the rate grew from 1.2 to 15.1 per 100 000. Compared with those who had non-drug-related infections, patients with IDRIs were younger (median age, 35 vs 46 years), more likely to be non-Hispanic white (81% vs 56%), and had longer hospitalizations (median, 8 vs 6 days). 43% of hospitalizations for IDRIs involved infective endocarditis.

CONCLUSIONS

The rate of IDRIs in North Carolina increased substantially during 2010-2018, indicating an urgent need for enhanced infection prevention, harm reduction, and addiction services aimed at community and inpatient settings.

National Public Health Burden Estimates of Endocarditis and Skin and Soft-Tissue Infections Related to Injection Drug Use: A Review

BACKGROUND

Despite concerns about the burden of the bacterial and fungal infection syndromes related to injection drug use (IDU), robust estimates of the public health burden of these conditions are lacking. The current article reviews and compares data sources and national burden estimates for infective endocarditis (IE) and skin and soft-tissue infections related to IDU in the United States.

METHODS

A literature review was conducted for estimates of skin and soft-tissue infection and endocarditis disease burden with related IDU or substance use disorder terms since 2011. A range of the burden is presented, based on different methods of obtaining national projections from available data sources or published data.

RESULTS

Estimates using available data suggest the number of hospital admissions for IE related to IDU ranged from 2900 admissions in 2013 to more than 20 000 in 2017. The only source of data available to estimate the annual number of hospitalizations and emergency department visits for skin and soft-tissue infections related to IDU yielded a crude estimate of 98 000 such visits. Including people who are not hospitalized, a crude calculation suggests that 155 000-540 000 skin infections related to IDU occur annually.

DISCUSSION

These estimates carry significant limitations. However, regardless of the source or method, the burden of disease appears substantial, with estimates of thousands of episodes of IE among persons with IDU and at least 100 000 persons who inject drugs (PWID) with skin and soft-tissue infections annually in the United States. Given the importance of these types of infections, more robust and reliable estimates are needed to better quantitate the occurrence and understand the impact of interventions.

A two-component intervention to improve hand hygiene practices and promote alcohol-based hand rub use among people who inject drugs: a mixed-methods evaluation

Background

Inconsistent hand hygiene puts people who inject drugs (PWID) at high risk of infectious diseases, in particular skin and soft tissue infections. In healthcare settings, handwashing with alcohol-based hand rubs (ABRH) is recommended before aseptic procedures including intravenous injections. We aimed to evaluate the acceptability, safety and preliminary efficacy of an intervention combining ABHR provision and educational training for PWID.

Methods

A mixed-methods design was used including a pre-post quantitative study and a qualitative study. Participants were active PWID recruited in 4 harm reduction programmes of France and followed up for 6 weeks. After baseline assessment, participants received a face-to-face educational intervention. ABHR was then provided throughout the study period. Quantitative data were collected through questionnaires at baseline, and weeks 2 (W2) and 6 (W6) post-intervention. Qualitative data were collected through focus groups with participants who completed the 6-week study.

Results

Among the 59 participants included, 48 (81%) and 43 (73%) attended W2 and W6 visits, respectively. ABHR acceptability was high and adoption rates were 50% (W2) and 61% (W6). Only a minority of participants reported adverse skin reactions (ranging from 2 to 6%). Preliminary efficacy of the intervention was shown through increased hand hygiene frequency (multivariable linear mixed model: coef. W2 = 0.58, p = 0.002; coef. W6 = 0.61, p = 0.002) and fewer self-reported injecting-related infections (multivariable logistic mixed model: AOR W6 = 0.23, p = 0.021). Two focus groups were conducted with 10 participants and showed that young PWID and those living in unstable housing benefited most from the intervention.

Conclusions

ABHR for hand hygiene prior to injection are acceptable to and safe for PWID, particularly those living in unstable housing. The intervention’s educational component was crucial to ensure adoption of safe practices. We also provide preliminary evidence of the intervention’s efficacy through increased hand hygiene frequency and a reduced risk of infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05895-1.

Infectious Complications of Addiction: A Call for a New Subspecialty Within Infectious Diseases

Infectious diseases (ID) physicians are increasingly responsible for the management of infectious consequences of substance use disorders (SUD). While we are often consulted for diagnosis and treatment of the infectious disease, it is clear that successful management of these infections requires a holistic approach, including acknowledgement and treatment of the underlying SUD. As we have learned through years of treating human immunodeficiency virus and hepatitis C virus infections, ID physicians have unique expertise in addressing both the infection and the complex biopsychosocial factors that underpin the infection. Many ID physicians have incorporated the management of addiction as part of their scope of practice, and here we seek to give a name and define the role of these ID/addiction dual specialists. We define the potential role of ID/addiction physicians in clinical care, health administration, and research, as well as provide recommendations to bolster the supply and reach of this burgeoning subspecialty.

Predictors of skin and soft tissue infections among sample of rural residents who inject drugs

Introduction

Skin and soft tissue infections (SSTIs) are among the leading causes of morbidity and mortality for people who inject drugs (PWID). Studies demonstrate that certain injection practices correlate with SSTI incidence among PWID. The opioid epidemic in the USA has particularly affected rural communities, where access to prevention and treatment presents unique challenges. This study aims to estimate unsafe injection practices among rural-dwelling PWID; assess treatments utilized for injection related SSTIs; and gather data to help reduce the overall risk of injection-related SSTIs.

Methods

Thirteen questions specific to SSTIs and injection practices were added to a larger study assessing unmet health care needs among PWID and were administered at six syringe exchange programs in rural Wisconsin between May and July 2019. SSTI history prevalence was estimated based on infections reported within one-year prior of response and was compared to self-reported demographics and injection practices.

Results

Eighty responses were collected and analyzed. Respondents were white (77.5%), males (60%), between the ages 30 and 39 (42.5%), and have a high school diploma or GED (38.75%). The majority of respondents (77.5%) reported no history of SSTI within the year prior to survey response. Females were over three times more likely to report SSTI history (OR = 3.07, p = 0.038) compared to males. Water sources for drug dilution (p = 0.093) and frequency of injecting on first attempt (p = 0.037), but not proper skin cleaning method (p = 0.378), were significantly associated with a history of SSTI. Injecting into skin (p = 0.038) or muscle (p = 0.001) was significantly associated with a history of SSTI. Injection into veins was not significantly associated with SSTI (p = 0.333).

Conclusion

Higher-risk injection practices were common among participants reporting a history of SSTIs in this rural sample. Studies exploring socio-demographic factors influencing risky injection practices and general barriers to safer injection practices to prevent SSTIs are warranted. Dissemination of education materials targeting SSTI prevention and intervention among PWID not in treatment is warranted.

New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use

Hospitalists are increasingly responsible for the management of infectious consequences of opioid use disorder (OUD), including increasing rates of hospitalization for injection drug use (IDU)-associated infective endocarditis, osteomyelitis, and soft tissue infections. Management of IDU-associated infections poses unique challenges: symptoms of the underlying addiction can interfere with care plans, patients often have difficult psychosocial circumstances in addition to their addiction, and they are often stigmatized by the healthcare system. Although there are few randomized trial data to support one particular approach to management, the literature suggests that successful treatment of IDU-associated infections requires appropriate antimicrobial and surgical interventions in addition to acknowledgment and treatment of the underlying OUD. In this narrative review, the best available evidence is used to answer several of the most commonly encountered questions in the management of IDU-associated infections. These data are used to develop a framework for hospitalists to approach the care of patients with IDU-associated infections.

Long-term infective endocarditis mortality associated with injection opioid use in the United States: a modeling study

BACKGROUND

The expansion of the U.S. opioid epidemic has led to significant increases in infections such as infective endocarditis (IE), which is tied to injection behaviors. We aimed to estimate the population-level IE mortality among people who inject opioids and compare the risk of IE death against the risks of death from other causes.

METHODS

We developed a microsimulation model of the natural history of injection opioid use. We defined injection behavior profile by both injection frequency and injection techniques. We accounted for competing risks of death and populated the model with primary and published data. We modeled cohorts of 1 million individuals with different injection behavior profiles until age 60. We combined model-generated estimates with published data to project the total expected IE deaths in the U.S. by 2030.

RESULTS

The probability of death from IE by age 60 years for 20-, 30-, and 40-year-old men with high frequency use with higher infection risk techniques compared to lower risk techniques for IE was 53.8% versus 3.7%, 51.4% versus 3.1%, and 44.5% versus 2.2%, respectively. The predicted population-level attributable fraction of 10-year mortality for IE among all risk groups was 20%. We estimated that approximately 257,800 people are expected to die from IE by 2030.

CONCLUSIONS

The expected burden of IE among people who inject opioids in the U.S. is large. Adopting a harm reduction approach, including expansion of syringe service programs, to address injection behaviors could have a major impact on decreasing the mortality associated with the opioid epidemic.

Infective Endocarditis in Persons Who Use Drugs: Epidemiology, Current Management, and Emerging Treatments

Infective endocarditis associated with injection drug use (IDU-IE) is markedly increasing in the United States and Canada. Long-term outcomes are dismal and stem from insufficient substance use disorder treatment. In this review, we summarize the principles of antimicrobial and surgical management for infective endocarditis associated with injection drug use. We discuss approaches to opioid use disorder care and harm reduction in the inpatient setting and review opportunities to address preventable infections among persons injecting drugs. We highlight barriers to implementing optimal treatment and consider novel approaches that may reshape infective endocarditis associated with injection drug use treatment in coming years.

Assessing Solid Organ Donors and Monitoring Transplant Recipients for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infection - U.S. Public Health Service Guideline, 2020

The recommendations in this report supersede the U.S Public Health Service (PHS) guideline recommendations for reducing transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through organ transplantation (Seem DL, Lee I, Umscheid CA, Kuehnert MJ. PHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep 2013;128:247-343), hereafter referred to as the 2013 PHS guideline. PHS evaluated and revised the 2013 PHS guideline because of several advances in solid organ transplantation, including universal implementation of nucleic acid testing of solid organ donors for HIV, HBV, and HCV; improved understanding of risk factors for undetected organ donor infection with these viruses; and the availability of highly effective treatments for infection with these viruses. PHS solicited feedback from its relevant agencies, subject-matter experts, additional stakeholders, and the public to develop revised guideline recommendations for identification of risk factors for these infections among solid organ donors, implementation of laboratory screening of solid organ donors, and monitoring of solid organ transplant recipients. Recommendations that have changed since the 2013 PHS guideline include updated criteria for identifying donors at risk for undetected donor HIV, HBV, or HCV infection; the removal of any specific term to characterize donors with HIV, HBV, or HCV infection risk factors; universal organ donor HIV, HBV, and HCV nucleic acid testing; and universal posttransplant monitoring of transplant recipients for HIV, HBV, and HCV infections. The recommendations are to be used by organ procurement organization and transplant programs and are intended to apply only to solid organ donors and recipients and not to donors or recipients of other medical products of human origin (e.g., blood products, tissues, corneas, and breast milk). The recommendations pertain to transplantation of solid organs procured from donors without laboratory evidence of HIV, HBV, or HCV infection. Additional considerations when transplanting solid organs procured from donors with laboratory evidence of HCV infection are included but are not required to be incorporated into Organ Procurement and Transplantation Network policy. Transplant centers that transplant organs from HCV-positive donors should develop protocols for obtaining informed consent, testing and treating recipients for HCV, ensuring reimbursement, and reporting new infections to public health authorities.

When is an abscess more than an abscess? Syringe services programs and the harm reduction safety-net: a case report

Background

Syringe services programs (SSPs) are able to offer wrap-around services for people who inject drugs (PWID) and improve health outcomes.

Case presentation

A 47-year-old man screened positive for a skin and soft tissue infection (SSTI) at an SSP and was referred to a weekly on-site student-run wound care clinic. He was evaluated by first- and third-year medical students, and volunteer attending physicians determined that the infection was too severe to be managed on site. Students escorted the patient to the emergency department, where he was diagnosed with a methicillin-resistant Staphylococcus aureus arm abscess as well as acute HIV infection.

Conclusion

Student-run wound care clinics at SSPs, in conjunction with ongoing harm reduction measures, screenings, and treatment services, provide a safety-net of care for PWID and help mitigate the harms of injection drug use.

Recurrent Endocarditis in Persons Who Inject Drugs

Background

Infective endocarditis (IE) is increasing among persons who inject drugs (PWID) and has high morbidity and mortality. Recurrent IE in PWID is not well described.

Methods

This was a retrospective cohort study conducted between February 2007 and March 2016. It included adult inpatients (≥18) at any of 3 tertiary care centers in London, Ontario, with definite IE based on the Modified Duke's Criteria. The objectives were to characterize recurrent IE in PWID, identify risk factors for recurrent IE, identify the frequency of fungal endocarditis, and establish whether fungal infection was associated with higher mortality.

Results

Three hundred ninety patients had endocarditis, with 212/390 in PWID. Sixty-eight of 212 (32%) PWID had a second episode, with 28/212 (12%) having additional recurrences. Second-episode IE was more common in PWID (11/178 [6.2%] vs 68/212 [32.1%]; P < .001). Peripherally inserted central catheter (PICC) line abuse was associated with increased risk of recurrent endocarditis (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.01–3.87; P = .04). In PWID, fungal IE was more common in second episodes than first episodes (1/212 [0.5%] vs 5/68 [7.4%]; P = .004). Additionally, fungal infections were associated with mortality in second-episode IE in PWID with an adjusted OR of 16.49 (95% CI, 1.12–243.17; P = .041). Despite recurrent infection, likely due to continued drug use, there was a low rate of referral to addiction treatment (14/68 [20.6%]).

Conclusions

PWID have a high risk of recurrent endocarditis, particularly in patients who abuse PICC lines. Fungal endocarditis is more common in second-episode endocarditis and is associated with increased mortality. Consideration of empiric antifungal therapy in PWID with IE history and suspected IE should be considered.