How I manage severe bacterial infections in people who inject drugs

Andrew J Stewardson; Joshua S Davis; Adrian J Dunlop; Steven Y C Tong; Gail V Matthews

doi:10.1016/j.cmi.2024.01.022

How I manage severe bacterial infections in people who inject drugs

Clin Microbiol Infect. 2024 Feb 3:S1198-743X(24)00046-6. doi: 10.1016/j.cmi.2024.01.022. Online ahead of print.

Authors

Andrew J Stewardson¹, Joshua S Davis², Adrian J Dunlop³, Steven Y C Tong⁴, Gail V Matthews⁵

Affiliations

¹ Department of Infectious Diseases, The Alfred and Central Clinical School, Monash University, Melbourne, VIC, Australia. Electronic address: andrew.stewardson@monash.edu.
² School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; Infection Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia; Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
³ School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, NSW, Australia; Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia.
⁴ Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia.
⁵ The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; St Vincent's Hospital, Sydney, NSW, Australia.

PMID: 38316359
DOI: 10.1016/j.cmi.2024.01.022

Abstract

Background: Injecting drug use is a risk factor for severe bacterial infection, but there is limited high-quality evidence to guide clinicians providing care to people who inject drugs. Management can be complicated by mistrust, stigma, and competing patient priorities.

Objectives: To review the management of severe infections in people who inject drugs, using an illustrative clinical scenario of complicated Staphylococcus aureus bloodstream infection.

Sources: The discussion is based on recent literature searches of relevant topics. Very few randomized clinical trials have focussed specifically on the management of severe bacterial infections among people who inject drugs. Most recommendations are, therefore, based on observational studies, extrapolation from other patient groups, and the experience and opinions of the authors.

Content: We discuss evidence and options regarding the following management issues for severe bacterial infections among people who inject drugs: initial management of sepsis; indications for surgical management; assessment and management of substance dependence; approaches to antibiotic administration following clinical stability; opportunistic health promotion; and secondary prevention of bacterial infections. Throughout, we highlight the importance of harm reduction and strategies to optimize patient engagement in care through a patient-centred approach.

Implications: We advocate for a multi-disciplinary trauma-informed approach to the management of severe bacterial infection among people who inject drugs. We emphasize the need for pragmatic trials to inform management guidelines, including those that are co-designed with the community. In particular, research is needed to establish the comparative effectiveness, safety, and cost-effectiveness of inpatient intravenous antibiotics vs. early oral antibiotic switch, outpatient parenteral therapy, and long-acting lipoglycopeptide antibiotics in this scenario.

Keywords: Addiction medicine; Bloodstream infection; Harm reduction; People who inject drugs; Staphylococcus aureus.

Publication types

Review