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

Abstract

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.

Skin Popping for the Hand Surgeon

“…The prevalence of injection drug use in the United States has been estimated to be 0.24% to 0.59% of the noninstitutionalized population of the United States, which is an estimated 1 million people 11 . There are no current published statistics on the incidence of SP in the general population, likely due to the stigma of illicit drug use, the continued use of open wounds as “shooter's patches,” and the self-treatment of infections outside of the hospital setting using antibiotics and drainage 12,13 . Patients typically present to medical care because of the sequelae of SP, such as cellulitis, wound botulism, renal dysfunction, or large wounds.…”

“…Overall, these findings are mostly consistent with our study, which found that patients typically used injection sites on the dorsal hands and forearm followed by the upper arm without mention of using the antecubital fossa. There has not been a demonstrated correlation between the rate of infection and the location of injection within the upper extremity 13 …”

“…In addition, in the hand surgery population, up to 25% of patients present because of hand infection, with some studies showing that IV drug use can contribute to up to 20% of these cases 29 . Subcutaneous or intramuscular drug injection, particularly with black tar heroin, has been found to be an independent risk factor for bacterial SSTIs in several studies 13,16,19,30–32 . Skin and soft tissue infections occur more commonly secondary to SP than IV drug use because of the direct inoculation of bacteria into the patient's body 12,17 .…”

“…11 There are no current published statistics on the incidence of SP in the general population, likely due to the stigma of illicit drug use, the continued use of open wounds as "shooter's patches," and the self-treatment of infections outside of the hospital setting using antibiotics and drainage. 12,13 Patients typically present to medical care because of the sequelae of SP, such as cellulitis, wound botulism, renal dysfunction, or large wounds. The most commonly injected agent in the studies surveyed is heroin, which was used by an estimated 902,000 people in the United States in 2020.…”

“…There has not been a demonstrated correlation between the rate of infection and the location of injection within the upper extremity. 13 In the acute stage, patients present with both typical and atypical findings of upper extremity infections. Typical presentations include SSTIs and necrotizing soft tissue infections (NSTIs).…”