Immunohistochemical evidence of Clostridium sp, Staphylococcus aureus, and group A Streptococcus in severe soft tissue infections related to injection drug use

OBJECTIVE:To identify and describe all cases of invasive group A streptococcal (GAS) infection occurring in British Columbia during a two-year period.DESIGN:Active, laboratory-based surveillance with supplemental case description.SETTING:Forty community and regional hospitals and the provincial laboratory participated, encompassing all health regions.POPULATION STUDIED:Entire provincial population from April 1, 1996 to March 31, 1998.MAIN RESULTS:Over the 24-month surveillance period, 182 eligible cases were identified, yielding a mean annual incidence rate of 2.3/100,000. Patients ranged in age from two to 91 years, with a mean of 39.1 years. Soft tissue infections accounted for 89 of 130 cases (68.5%) with a defined clinical syndrome, 20 of which were necrotizing fasciitis. Injection drug use was described in 55 patients, who, as a group, were younger, more likely to have soft tissue infections and less likely to die of infection than nondrug users. Other risk factors for infection included HIV infection (19 patients); skin damage (26 patients, damage independent of injection drug use); chronic illness (27 patients); and immunosuppresion (three patients). Death from GAS infection occurred in 15 of 131 (11.5%) cases with known outcome, yielding an annual case fatality rate of 1.9/million population. Among necrotizing faciitis cases, the mortality rate was 30%.CONCLUSIONS:Invasive GAS infections are rare in British Columbia and tend to involve persons with chronic illness or prior skin trauma, especially injection drug abuse, which accounted for nearly half of the cases.

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Type and Location of Injection Drug Use-Related Soft Tissue Infections Predict Hospitalization

Journal of Urban Health ◽

10.1093/jurban/jtg127 ◽

2003 ◽

Vol 80 (1) ◽

pp. 127-136 ◽

Cited By ~ 26

Author(s):

T. A. Takahashi

Keyword(s):

Soft Tissue ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug ◽

Soft Tissue Infections

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Hospital Utilization for Injection Drug Use-Related Soft Tissue Infections in Urban versus Rural Counties in California

Journal of Urban Health ◽

10.1007/s11524-005-9021-6 ◽

2006 ◽

Vol 83 (2) ◽

pp. 176-181 ◽

Cited By ~ 11

Author(s):

Keith G. Heinzerling ◽

David A. Etzioni ◽

Brian Hurley ◽

Paul Holtom ◽

Ricky N. Bluthenthal ◽

...

Keyword(s):

Soft Tissue ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug ◽

Hospital Utilization ◽

Soft Tissue Infections ◽

Rural Counties ◽

Urban Versus

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1558. Injection Drug Use-Related Skin and Soft Tissue Infections Serve as Sentinel Events for Healthcare Utilization in a Vulnerable Population

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1738 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S779-S779

Author(s):

Ryan D Knodle ◽

Catherine Bielick ◽

Shana Burrowes ◽

Tamar F Barlam

Keyword(s):

Soft Tissue ◽

Drug Use ◽

Healthcare Utilization ◽

Injection Drug Use ◽

Vulnerable Population ◽

Injection Drug ◽

Categorical Variables ◽

Rank Test ◽

Soft Tissue Infections ◽

Sentinel Events

Abstract Background Persons with injection drug use (IDU) can have frequent skin and soft tissue infections (SSTIs) and high healthcare utilization. We sought to examine whether IDU-related SSTIs are associated with an acceleration in disease course and increased healthcare utilization (a ‘sentinel event’) and may present an important opportunity for intervention. Methods We performed a retrospective chart review of patients with an emergency department (ED) visit or hospital admission due to an IDU-related SSTI between 10/1/2015 and 6/1/2019 to obtain information on demographics, microbiologic data, addiction service consultation, and treatment with medications for opioid use disorder (MOUD). We compared the number of healthcare encounters in the 12 months before and after the SSTI using the Wilcoxon signed rank test for data with non-normal distribution. We examined differences in the distribution of variables between patients who were admitted and those discharged from the ED using Chi Square and Fisher exact tests for categorical variables and t-tests and Wilcoxon tests for continuous variables. Results In all, 305 patients met inclusion criteria for an IDU-related SSTI. The patients were 66.5% male, had a median age of 41 years (range 23-70), 84% were experiencing homelessness and 87% had Medicaid. Most patients (55.7%) were admitted to the hospital and the remainder were discharged from the ED. There was a statistically significant change in healthcare utilization in the year prior to the SSTI compared to the year after (median change +16.7%, p < 0.0001). Compared to those who were admitted, it was rare for patients discharged from the ED to have microbiologic data sent (13% vs 87%, p < 0.0001), an addiction consult completed (4% vs 96%, p < 0.0001), or to be discharged on MOUD (8.0% vs 92%, p < 0.0001). Despite these differences, there were no significant predictors of high vs low utilization among all-comers based on demographic and clinical data. Conclusion IDU-related SSTIs serve as sentinel events with increased healthcare utilization after the episode. Addiction consultation and initiation of MOUD had no impact on the trajectory of healthcare utilization. Further work must be done to identify how best to improve outcomes for this vulnerable population. Disclosures All Authors: No reported disclosures

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Maternal Bacteremia Caused by Staphylococcus Aureus With a Focus on Infective Endocarditis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa239 ◽

2020 ◽

Vol 7 (8) ◽

Author(s):

Morgan K Morelli ◽

Michael P Veve ◽

Mahmoud A Shorman

Keyword(s):

Staphylococcus Aureus ◽

Infective Endocarditis ◽

Drug Use ◽

Hospital Mortality ◽

Injection Drug Use ◽

Pregnant Patient ◽

Infectious Complications ◽

Injection Drug ◽

Secondary Outcome ◽

Targeted Interventions

Abstract Background Sepsis is an important cause of morbidity and mortality in the pregnant patient. Injection drug use in pregnant populations has led to increased cases of bacteremia and infective endocarditis (IE) due to Staphylococcus aureus. We describe all cases of S. aureus bacteremia and IE among admitted pregnant patients at our hospital over a 6-year period. Methods This was a retrospective review of pregnant patients hospitalized with S. aureus bacteremia between April 2013 and November 2019. Maternal in-hospital mortality and fetal in-hospital mortality were the primary outcomes measured; the secondary outcome was the rate of 6-month maternal readmission. Results Twenty-seven patients were included; 15 (56%) had IE. The median (interquartile range [IQR]) age was 29 (25–33) years; 22 (82%) patients had methicillin-resistant S. aureus. Infection onset occurred at a median (IQR) of 29 (23–34) weeks’ gestation. Twenty-three (85%) mothers reported active injection drug use, and 21 (78%) were hepatitis C seropositive. Fifteen (56%) mothers required intensive care unit (ICU) care. Twenty-two (81%) patients delivered 23 babies; of the remaining 5 mothers, 3 (11%) were lost to follow-up and 2 (7%) terminated pregnancy. Sixteen (73%) babies required neonatal ICU care, and 4/25 (16%) infants/fetuses died during hospitalization. One (4%) mother died during hospitalization, and 7/26 (27%) mothers were readmitted to the hospital within 6 months for infectious complications. Conclusions Injection drug use is a modifiable risk factor for S. aureus bacteremia in pregnancy. Fetal outcomes were poor, and mothers were frequently readmitted secondary to infection. Future targeted interventions are needed to curtail injection drug use in this population.

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Septic Arthritis and the Opioid Epidemic: 1465 Cases of Culture-Positive Native Joint Septic Arthritis From 1990–2018

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa089 ◽

2020 ◽

Vol 7 (3) ◽

Author(s):

John J Ross ◽

Kevin L Ard ◽

Narath Carlile

Keyword(s):

Staphylococcus Aureus ◽

Drug Use ◽

Synovial Fluid ◽

Septic Arthritis ◽

Injection Drug Use ◽

Injection Drug ◽

Facet Joints ◽

Cell Counts ◽

Culture Positive ◽

Fluid Cell

Abstract Background The clinical spectrum of septic arthritis in the era of the opioid crisis is ill-defined. Methods This is a retrospective chart review of 1465 cases of culture-positive native joint septic arthritis at Boston teaching hospitals between 1990 and 2018. Results Between 1990–2008 and 2009–2018, the proportion of septic arthritis cases involving people who inject drugs (PWID) rose from 10.3% to 20% (P < .0000005). Overall, methicillin-sensitive Staphylococcus aureus (MSSA) caused 41.5% of cases, and methicillin-resistant Staphylococcus aureus (MRSA) caused 17.9%. Gram-negative rods caused only 6.2% of cases. Predictors of MRSA septic arthritis included injection drug use (P < .001), bacteremia (P < .001), health care exposure (P < .001), and advancing age (P = .01). Infections with MSSA were more common in PWID (56.3% vs 38.8%; P < .00001), as were infections with MRSA (24% vs 16.8%; P = .01) and Serratia sp. (4% vs 0.4%; P = .002). Septic arthritis in the setting of injection drug use was significantly more likely to involve the sacroiliac, acromioclavicular, and facet joints; 36.8% of patients had initial synovial fluid cell counts of <50 000 cells/mm3. Conclusions Injection drug use has become the most common risk factor for septic arthritis in our patient population. Septic arthritis in PWID is more often caused by MRSA, MSSA, and Serratia sp., and is more prone to involve the sacroiliac, acromioclavicular, sternoclavicular, and facet joints. Synovial fluid cell counts of <50 000 cells/mm3 are common in culture-positive septic arthritis.

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

Communications Medicine ◽

10.1038/s43856-021-00053-9 ◽

2021 ◽

Vol 1 (1) ◽

Author(s):

Laura R. Marks ◽

Juan J. Calix ◽

John A. Wildenthal ◽

Meghan A. Wallace ◽

Sanjam S. Sawhney ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Drug Use ◽

Injection Drug Use ◽

Academic Medical Center ◽

Bloodstream Infections ◽

Clonal Expansion ◽

The United States ◽

Injection Drug ◽

Comparative Genomic ◽

Molecular Features

Abstract 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.

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Disparity in Quality of Infectious Disease vs Addiction Care Among Patients With Injection Drug Use–Associated Staphylococcus aureus Bacteremia

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz289 ◽

2019 ◽

Vol 6 (7) ◽

Cited By ~ 14

Author(s):

David Phillip Serota ◽

Emily D Niehaus ◽

Marcos C Schechter ◽

Jesse T Jacob ◽

Jeb Jones ◽

...

Keyword(s):

Infectious Disease ◽

Staphylococcus Aureus ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug ◽

Evidence Based ◽

High Quality ◽

Staphylococcus Aureus Bacteremia ◽

Addiction Care

Abstract Evidence-based interventions for Staphylococcus aureus bacteremia (SAB) are well known, but it is unclear how they are implemented among patients with injection drug use–associated (IDU) SAB. Of 46 patients with IDU-SAB identified, all received high-quality SAB management; however, few received appropriate recognition or treatment of their underlying substance use disorder.

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Correlation Between Immunoglobulin Dose Administered and Plasma Neutralization of Streptococcal Superantigens in Patients With Necrotizing Soft Tissue Infections

Clinical Infectious Diseases ◽

10.1093/cid/ciaa022 ◽

2020 ◽

Vol 71 (7) ◽

pp. 1772-1775 ◽

Cited By ~ 8

Author(s):

Helena Bergsten ◽

Martin Bruun Madsen ◽

Francois Bergey ◽

Ole Hyldegaard ◽

Steinar Skrede ◽

...

Keyword(s):

Cell Proliferation ◽

Clinical Trials ◽

T Cell ◽

Soft Tissue ◽

Negative Correlation ◽

Group A Streptococcus ◽

T Cell Proliferation ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections ◽

Group A

Abstract Analyses of plasma collected pre- and postadministration of intravenous immunoglobulin (IVIG) from patients with group A Streptococcus necrotizing soft tissue infections demonstrated a negative correlation between IVIG dose and toxin-triggered T-cell proliferation (r = −.67, P < .0001). One 25-g IVIG dose was sufficient to yield plasma-neutralizing activity against streptococcal superantigens. Clinical Trials Registration. NCT 01790698 and NCT02111161.

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

Journal of Hospital Medicine ◽

10.12788/jhm.3342 ◽

2019 ◽

Vol 15 (10) ◽

pp. 606-612

Author(s):

David P Serota ◽

Theresa Vettese

Keyword(s):

Drug Use ◽

Injection Drug Use ◽

Opioid Use Disorder ◽

Trial Data ◽

Injection Drug ◽

Soft Tissue Infections ◽

Opioid Use ◽

Surgical Interventions ◽

Care Plans ◽

Severe Infections

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.

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