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

Kathleen P. Hartnett, PhD; Kelly A. Jackson, MPH; Christina Felsen, MPH; Robert McDonald, MD; Ana Cecilia Bardossy, MD; Runa H. Gokhale, MD; Ian Kracalik, PhD; Todd Lucas, MD; Olivia McGovern, PhD; Chris A. Van Beneden, MD; Michael Mendoza, MD; Michele Bohm, MPH; John T. Brooks, MD; Alice K. Asher, PhD; Shelley S. Magill, MD, PhD; Anthony Fiore, MD; Debra Blog, MD; Elizabeth M. Dufort, MD; Isaac See, MD; Ghinwa Dumyati, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(26):583-586. 

In This Article

Discussion

On average, at least one person with a bacterial or fungal infection who also injects drugs visited one of the five assessed hospitals every day during the analysis period. This investigation highlights the importance of preventing opioid misuse, treating opioid use disorder, and emphasizing the risks of bacterial and fungal infections as well as bloodborne pathogens during care of persons who inject drugs. In this assessment, infections related to injection drug use most often occurred at the site of injection and were predominantly caused by common skin and mouth flora that are introduced during injection. Infections related to injection also included invasive infections, such as endocarditis. Many of the infections required prolonged hospital stays, with 24% of patients hospitalized for at least 30 days. Although nearly all patients injected opioids, many were not offered medication-assisted treatment for opioid use disorder. Those seen only in the ED were less likely to be offered medication-assisted treatment than inpatients.

This assessment was limited to western New York; however, bacterial and fungal infections might also occur frequently in other communities in the United States. Although the prevalence of injection drug use is unknown, the age-adjusted rate of overdose deaths involving any drug in Monroe County, New York, where four of the five hospitals were located, was 24.5 per 100,000 residents in 2016, compared with 19.8 drug overdose deaths per 100,000 residents for the United States as a whole.[6]

The findings in this report are subject to at least three limitations. First, the number of bacterial and fungal infections among persons who inject drugs was likely underestimated because the data did not include outpatient visits or infections in persons who did not seek health care. Second, medical records do not always specify the route of drug administration; records indicating that the patient used drugs but did not document injection were excluded, which also might underestimate the number of persons injecting. Finally, the method of identifying infections could bias the distribution of pathogens or infection types. S. aureus, Candida spp. and GAS infections were identified by both culture and diagnostic codes. Infections with other pathogens or without a pathogen identified were identified by diagnostic codes only, and therefore were more likely to be missed. However, evidence suggests that most infections were identified through diagnostic codes. Among S. aureus, Candida spp., and GAS infections identified by culture, 74% had codes for both an infection syndrome and substance use.

Routine care for patients who continue to inject should include advice on hand hygiene and not injecting into skin that has not been cleaned or to use any equipment contaminated by reuse, saliva, soil, or water.[4,5] Risk factors for bacterial and fungal infections found in other recent assessments include skin breakdown and limited access to clean running water and showers.[7] Where legal, syringe service programs can provide referrals to treatment for substance use disorder, clean equipment, and education about safer injection practices. Other services, such as prompt wound care, laundry, and showers could also help prevent serious bacterial and fungal infections.[8] Because some persons who misuse prescription opioids transition to injecting opioids, primary prevention strategies that can reduce the risk for opioid misuse and potential subsequent infection from unsafe injection practices include appropriate opioid prescribing practices and efforts to ensure access to nonopioid treatments for pain.[9] Medication-assisted treatment addresses the underlying opioid use disorder through decreased cravings and prevents infections by reducing injection drug use. Initiating medication-assisted treatment when persons who inject opioids are found to have a bacterial or fungal infection might also improve retention of these patients in treatment for both the infection and substance abuse.[10] Hospitalizations and ED visits for these infections are opportunities to link patients to treatment for opioid use disorder and prevent recurrent infections.

New York State Opioid Dashboard. https://www.health.ny.gov/statistics/opioid.

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