Bacterial infections may be less likely to make the headlines than fatal overdoses and blood-borne viruses, but they are a source of considerable suffering among people who inject drugs. Natalie Davies looks at the latest figures from Public Health England, which indicate a treatment gap and a prevention gap.

Data analysed by Public Health England suggests that a large proportion of people who inject drugs develop injecting-related infections, and too many do not access treatment for those infections. This prevention and treatment gap causes considerable suffering among people who inject drugs, and also puts an enormous strain on hospitals and other secondary healthcare services, which sometimes have to take aggressive approaches such as surgery, when simpler interventions such as wound care and antibiotics would have sufficed if the infections had been spotted early enough.

“Public Health Wales followed 35 cases necessitating surgical intervention or admission to an intensive care unit or high dependency unit over the 18-month period.”

In Wales between November 2017 and April 2019, there was a cluster of severe infections among people who inject drugs. Public Health Wales followed 35 cases necessitating surgical intervention or admission to an intensive care unit or high dependency unit over the 18-month period. Over half of patients underwent surgery, including four cases of ‘full hip disarticulation’, where the entire leg from the hip down was removed. Evidently many things must have gone wrong along the way for this degree of harm to result from injecting drugs.

The cause of bacterial infections

Serious bacterial infections are caused by bacteria (from non-sterile injecting equipment, or the patient’s own skin) entering the body through a needle and infecting the skin, a heart valve, joint, bone or other organ. Studies published in 2014 and 2017 suggest that the lifetime prevalence of injecting-related infections may be as high as 70%. The most recent “Shooting Up” report from Public Health England revealed that, over the previous year, 38% of people who inject drugs reported symptoms of an infection (e.g. abscess, sore or open wound), and over half (59%) did not seek treatment or reported treating the infection themselves. These figures were derived from the Unlinked Anonymous Monitoring (UAM) Survey, which provides a snapshot of people who inject drugs in England, Wales and Northern Ireland who are in contact with specialist services. The figures may therefore be even higher if we include people who are not engaged with treatment and support.

An intervention trialled in the United States attempted to cultivate hygienic injecting practices, in a bid to prevent serious bacterial infections, by teaching the skills of hand washing, injection site skin cleaning, and needle cleaning. To some extent it was successful. The intervention was associated with a significant (43%) reduction in injecting-related emergency department visits compared with usual treatment. But, against the study’s primary outcome of reducing the total number of emergency department visits, the intervention was not associated with a benefit for patients. Analysing the findings, Drug and Alcohol Findings came to the conclusion that the intervention was probably effective, but also probably not going to make a big impact on the total number of emergency department visits or hospital admissions as there are other reasons why people who inject drugs may disproportionately use secondary healthcare.

Addressing homelessness and public injecting

In the above intervention, homelessness was common. Nearly two-thirds (62%) of participants had spent at least one night on the street or in a shelter in the previous 90 days. While the ability of all participants to create a hygienic injecting experience may have been given a boost by the provision of a clean injection kit in the intervention – which included two small bottles of water, a small bottle of bleach, a small bottle of hand sanitizer gel, four alcohol pads, a cap to use as a cooker, two micro-cotton balls to use as filters and an instruction sheet about how to clean a syringe – nothing in the intervention was designed to compensate for, or address, risks relating to the physical environment in which people lived and injected drugs.

According to Public Health England, serious bacterial infections are associated with a lack of access to safe and hygienic injecting environments and inability to maintain general hygiene – circumstances characteristic of people who are homeless and who inject in public places and open areas (e.g. alleyways, car parks, train stations, neglected property, toilets, doorsteps, and stairwells).

In some countries, the answer has been to open drug consumption rooms, which radically change the conditions in which people take drugs by providing supervised and hygienic spaces for injections, and in doing so arguably shoulder some of the burden of reducing drug-related harm.

Drug consumption rooms operating in real-world conditions have generated evidence of the potential of these facilities to reduce harm among people who inject drugs. This includes evidence that they can make drug use safer (e.g. increase access to health and social services, and help identify and respond to emergencies), and do so without the feared countervailing problems (e.g. encourage drug use, delay treatment entry or aggravate problems arising from local drug markets).

To date, most of the focus has been on measures such as injecting-related litter, blood borne viruses, and overdose deaths; comparatively little is known about their impact on preventing injecting-related bacterial infections. Perhaps over time research will accumulate about the impact of drug consumption rooms on some of the lesser-known harms of injecting drug use, such as bacterial infections, and on the extent to which frequent use of drug consumption rooms can improve the adoption of harm reduction behaviours outside of the facilities. This latter point is important as we know that when drug consumption rooms are not open 24 hours a day, or are too far from the place of drug purchase for example, injecting drug use will probably also take place in public places.

Another response is to address the housing needs of people who inject drugs. Injecting in public places, for example because you have nowhere else to go, is associated with rushing the procedure (e.g. for fear of being overlooked or being caught by the police), not cleaning skin before injecting, and a lack of clean water and surfaces for preparing drugs. Homelessness may also increase people’s vulnerability to bacterial infections in other ways, such as needing to use public showers and share bedding with other people.

Building ‘wound aware’ services

The route of transmission of serious bacterial infection tells us that, short of stopping injections of illicit drugs altogether, hygienic injecting is the key to preventing bacterial infections in this population. Facilitating timely treatment, on the other hand, is the key to stopping bacterial infections having life-changing and potentially deadly consequences.

Treatment in the primary healthcare system (e.g. GPs and community services) can prevent suffering and serious consequences, and can prevent the need for emergency care. However, the barriers to these basic services for people who inject drugs are numerous and well-documented.

In 2021, Public Health England published guidance titled “Wound Aware”, which urged drug services to help prevent hospital admissions and deaths by providing early and rapid access to treatment for infections. One of the ways that a service can show it is ‘wound aware’ is by identifying worsening injection sites. This hinges on all staff keeping an eye on their service users’ health and knowing who to tell or what to do if they spot a problem, keyworkers having regular check-ins with service users about their injecting experiences, and wound care specialists being part of staff training and induction programmes.

by Natalie Davies

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