Antimicrobial Stewardship Can Help Prevent Injection Drug Use–Related Infections
Escalating usage and more drug choices are putting more people at risk.
There are many core elements to successful antimicrobial stewardship, though 1 key element is prevention of infection occurrence or reoccurrence.1 When it comes to substance use disorders (SUDs), particularly those involving injection drug use (IDU), the risk of infection is significantly increased, which warrants intervention with preventative measures.2 The most successful prevention strategy is to stop IDU altogether. It may sound simple, but it may not be a realistic goal for some and, for others, may be very challenging and take time. With this in mind, how can preventative education be adapted to include those who continue to engage in IDU? The answer is harm reduction.
IDU has increased as the opioid crisis continues to ravage the United States.2 With the landscape of the opioid crisis changing from predominantly prescription opioids in the 1990s, to heroin in 2010, and now to fentanyl and other synthetic opioids since 2013,3 the route by which opioids are used has changed from oral or intranasal to predominantly IDU.4 Fentanyl has a faster onset and a shorter half-life than heroin, which has led to an increase in the amount of injections per day.5,6 An added layer of complexity is the emerging stimulant crisis, where there has been an uptick in those engaging in cocaine or methamphetamine IDU.7 This is particularly worrisome from an infection standpoint because stimulants, particularly cocaine, are more damaging to veins and local tissue surrounding injection sites.8
Furthermore, likely stemming from decades of stigma and misconceptions about drug use, there remains a paucity of syringe service programs. According to the Policy Surveillance Program, as of August 2019, there were still 7 states where local law does not allow syringe services programs.9 However, in states where local law does allow for such programs, there are significant restrictions preventing full expansion, such as requiring 1-to-1 exchanges or involvement of law enforcement, that deter some individuals.9 Similarly, federal law makes it illegal to operate a safe consumption site, so those are that in operation are clandestine, leading to lack of funding and program support.10
There has been an increase in bloodborne infections such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV), in addition to other complications such as skin and soft tissue infections (abscesses, cellulitis) and more serious infections including endocarditis, osteomyelitis, and sepsis/bacteremia.2 Although the diagnosis and treatment of these infections are well-documented in the literature, implementing harm reduction interventions in clinical practice settings is not as widely documented, but it is imperative given the lack of access elsewhere.
Harm reduction involves evidence-based public health strategies designed to reduce the negative consequences of drug use for the individual and surrounding community.11 It is important to note that although harm reduction does not promote drug use or ignore the associated dangers, it does accept that drug use is part of our world and that steps should be taken to minimize harmful effects rather than disregard them.11 There are various IDU-related harm reduction strategies that can be implemented to reduce infections, including safer injection supplies and technique, SUD treatment, and prophylactic medications. As such, antimicrobial stewardship programs (ASPs) are uniquely positioned to support these interventions.12-14
Identifying an individual’s injection practice and supplies is the first step to a fruitful harm reduction discussion, as this allows for targeted interventions. Common supplies that may increase risk of infection if not sterile include syringe, cooker, dissolver, acidifier, and filter. Sterile syringes should be used for each injection rather than reusing or sharing. Syringes lose their integrity after just 1 use, which continues to worsen with each reuse, and they may become microscopically jagged or bent, which can damage veins. Additionally, reintroduction of a syringe that harbors bacteria may result in skin or blood infections. Sharing syringes may expose the individual to transmittable diseases such as HCV and HIV. Cookers, which are used to hold the drug during the dissolving, acidifying (if applicable), and drawing-up process, should also be unique to the individual and sterile as viruses such as HCV can survive at room temperature for weeks. When dissolving substances, using sterile water or boiled water that has been cooled decreases bacterial infections. If an acidifier is used to dissolve substances, vitamin C is preferred over lemon juice or vinegar, as these may introduce bacterial sources and are direct irritants. Filters, sometimes referred to as cotton pellets, should never be reused because the damp environment facilitates bacterial growth. Lastly, hands should be washed before injecting, the injection site should be swabbed with alcohol prior to injection, and a dry swab should be placed over the injection site with light pressure to allow for platelet aggregation.
SUD treatment, particularly for medications for opioid use disorder (MOUD) such as methadone, buprenorphine, and extended-release naltrexone, has been associated with lower risk of transmitting HCV and HIV and improved viral suppression for those with active infection.15-21 Methadone, a full agonist opioid taken orally, can be started quickly during hospitalization, but it must be dispensed from a licensed opioid treatment program upon discharge.22 Buprenorphine, a partial agonist opioid, can be started quickly via microdosing or after onset of opioid withdrawal symptoms via traditional induction. It must be prescribed by a licensed provider upon discharge, with potential to change to extended-release injection in as soon as 7 days, or fewer in certain circumstances.22,23 Extended-release naltrexone typically cannot be started until an individual has been without opioid exposure for 7 to 10 days.22 Lastly, preexposure prophylaxis and postexposure prophylaxis should be offered to at-risk individuals, including those engaging in IDU, particularly if they share IDU supplies with a partner who has HIV.24
Discussing infection-prevention measures presents an opportunistic moment to discuss other safety measures, such as overdose prevention. In addition to reducing risk of IDU-related infection, MOUD has been associated with significantly reduced risk of opioid craving, use, and overdose.25-29 Overdose recognition and response training, alongside provision of naloxone, are essential to rapidly reverse an opioid overdose.30 Naloxone should not be limited to those with OUD, as there has been an increase in accidental opioid overdoses due to substances laced with fentanyl.7 Lastly, other measures to reduce overdose risk include maintaining the same supply source, using a small test amount of the substance first (particularly after a period of abstinence) to gauge effects, and avoiding high-risk combinations that further increase risk of respiratory depression, such as opioids and benzodiazepines.31
For a more comprehensive overview of other IDU-related harm reduction strategies, National Harm Reduction Coalition offers a publicly available safety manual detailing many safer injection techniques and supplies and is written for those who engage in IDU.11 The College of Psychiatric and Neurologic Pharmacists offers a harm reduction toolkit specifically written for pharmacists.32
ASPs are often involved in treatment of various IDU-related infections, which allows ASPs to identify individuals who may benefit from harm reduction with the prospect of delivering this education at bedside or during the office visit. Harm reduction aimed at preventing IDU-related infections should include, at a minimum, SUD treatment options, education regarding safer injection supplies and technique, and prophylaxis medication options. Ideally, these encounters also should cover other harm reduction measures such as overdose prevention strategies and provision of naloxone.
Alyssa M. Peckham, PharmD, BCPP, is board certified in psychiatry and works as an advanced practice pharmacist in a low-threshold, harm reduction SUDs clinic at Massachusetts General Hospital in Boston. Peckham has given more than 25 national presentations related to SUDs, has published more than 30 peer-reviewed SUD manuscripts, and was awarded an Excellence in Innovation Award from Upsher-Smith Laboratories in 2017 and the Pillars of Excellence: Advancing Innovation & Progress Award from Massachusetts General Hospital in 2021 for her SUDs-related work.
Michael G. Chan, PharmD, BCCCP, CACP, is board certified in critical care pharmacy and works as a clinical pharmacist in the neurocritical care unit at Brigham and Women’s Hospital in Boston, Massachusetts. Two of Chan’s clinical interests are neurological complications of SUDs and overdose, and IDU-related infections. Most recently, he was part of a research team that was awarded the Star Research Achievement Award from the Society of Critical Care Medicine.
- ASHP statement on the pharmacist's role in antimicrobial stewardship and infection prevention and control. Am J Health Syst Pharm. 2010;67(7):575-577. doi:10.2146/sp100001
- Centers for Disease Control and Prevention. Persons who inject drugs (PWIDs). July 19, 2018. Accessed February 25, 2021. https://www.cdc.gov/pwid/index.html
- Centers for Disease Control and Prevention. Understanding the epidemic. March 19, 2020. Accessed February 25, 2021. https://www.cdc.gov/drugoverdose/epidemic/index.html
- Levitt A, Mermin J, Jones CM, See I, Butler JC. Infectious diseases and injection drug use: public health burden and Rresponse. J Infect Dis. 2020;222(suppl 5):S213-S217. doi:10.1093/infdis/jiaa432
- Latimer J, Ling S, Flaherty I, Jauncey M, Salmon AM. Risk of fentanyl overdose among clients of the Sydney Medically Supervised Injecting Centre. Int J Drug Policy. 2016;37:111-114. doi:10.1016/j.drugpo.2016.08.004
- Lambdin BH, Bluthenthal RN, Zibbell JE, Wenger L, Simpson K, Kral AH. Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs. Int J Drug Policy. 2019;74:299-304. doi:10.1016/j.drugpo.2019.10.004
- O’Donnell J, Gladden RM, Mattson CL, Hunter CT, Davis NL. Vital signs: characteristics of drug overdose deaths involving opioids and stimulants - 24 states and the District of Columbia, January-June 2019. MMWR Morb Mortal Wkly Rep. 2020;69(35):1189-1197. doi:10.15585/mmwr.mm6935a1
- Phillips KT, Stein MD. Risk practices associated with bacterial infections among injection drug users in Denver, Colorado. Am J Drug Alcohol Abuse. 2010;36(2):92-97. doi:10.3109/00952991003592311
- The Policy Surveillance Program. Syringe service program laws. August 1, 2019. Accessed February 25, 2021. http://lawatlas.org/datasets/syringe-services-programs-laws
- The United States Department of Justice. Appellate court agrees with government that supervised injection sites are illegal under federal law; reverses district court ruling. January 13, 2021. Accessed February 25, 2021. https://www.justice.gov/opa/pr/appellate-court-agrees-government-supervised-injection-sites-are-illegal-under-federal-law
- National Harm Reduction Coalition. Getting off right: a safety manual for injection drug users. Updated August 31, 2020. Accessed February 25, 2021. https://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/
- Serota DP, Barocas JA, Springer SA. Infectious complications of addiction: a call for a new subspecialty within infectious diseases. Clin Infect Dis. 2020;70(5):968-972. doi:10.1093/cid/ciz804
- The National Academies of Science, Engineering, Medicine. Examination of the integration of opioid and infectious disease prevention efforts. Accessed February 25, 2021. https://www.nationalacademies.org/our-work/examination-of-the-integration-of-opioid-and-infectious-disease-prevention-efforts-in-select-programs
- Peckham AM, Young EH. Opportunities to offer harm reduction to people who inject drugs during infectious disease encounters: narrative review. Open Forum Infect Dis. Published online October 20, 2020. doi:10.1093/ofid/ofaa503
- Sullivan LE, Moore BA, Chawarski MC, et al. Buprenorphine/naloxone treatment in primary care is associated with decreased human immunodeficiency virus risk behaviors. J Subst Abuse Treat. 2008;35(1):87-92. doi:10.1016/j.jsat.2007.08.004
- MacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. BMJ. 2012;345:e5945. doi:10.1136/bmj.e5945
- Springer SA, Qiu J, Saber-Tehrani AS, Altice FL. Retention on buprenorphine is associated with high levels of maximal viral suppression among HIV-infected opioid dependent released prisoners. PLoS One. 2012;7(5):e38335. doi:10.1371/journal.pone.0038335
- Edelman EJ, Chantarat T, Caffrey S, et al. The impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected, opioid-dependent patients. Drug Alcohol Depend. 2014;139:79-85. doi:10.1016/j.drugalcdep.2014.03.006
- Metzger DS, Donnell D, Celentano DD, et al; HPTN 058 Protocol Team. Expanding substance use treatment options for HIV prevention with buprenorphine-naloxone: HIV Prevention Trials Network 058. J Acquir Immune Defic Syndr. 2015;68(5):554-561. doi:10.1097/QAI.0000000000000510
- Springer SA, Di Paola A, Azar MM, et al. Extended-release naltrexone improves viral suppression among incarcerated persons living with HIV with opioid use disorders transitioning to the community: results of a double-blind, placebo-controlled randomized trial. J Acquir Immune Defic Syndr. 2018;78(1):43-53. doi:10.1097/QAI.0000000000001634
- Springer SA, Di Paola A, Barbour R, Azar MM, Altice FL. Extended-release naltrexone improves viral suppression among incarcerated persons living with HIV and alcohol use disorders transitioning to the community: results from a double-blind, placebo-controlled trial. J Acquir Immune Defic Syndr. 2018;79(1):92-100. doi:10.1097/QAI.0000000000001759
- The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 focused update. J Addict Med. 2020;14(suppl 1):1-91. doi:10.1097/ADM.0000000000000633
- Peckham AM, Kehoe LG, Gray JR, Wakeman SE. Real-world outcomes with extended-release buprenorphine (XR-BUP) in a low threshold bridge clinic: a retrospective case series. J Subst Abuse Treat. 2021;126:108316. doi:10.1016/j.jsat.2021.108316
- Centers for Disease Control and Prevention. Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). September 10, 2020. Accessed February 25, 2021. https://www.cdc.gov/hiv/clinicians/prevention/prep-and-pep.html
- Lee JD, Friedmann PD, Kinlock TW, et al. Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. N Engl J Med. 2016;374(13):1232-1242. doi:10.1056/NEJMoa1505409
- Tanum L, Solli KK, Latif ZEH, et al. Effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: a randomized clinical noninferiority trial. JAMA Psychiatry. 2017;74(12):1197-1205. doi:10.1001/jamapsychiatry.2017.3206
- Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med. 2018;169(3):137-145. doi:10.7326/M17-3107
- Lee JD, Nunes EV Jr, Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. Lancet. 2018;391(10118):309-318. doi:10.1016/S0140-6736(17)32812-X
- Wakeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622. doi:10.1001/jamanetworkopen.2019.20622
- Carroll JJ, Green TC, Noonan RK. Evidence-based strategies for preventing opioid overdose: what’s working in the United States. Centers for Disease Control and Prevention. Accessed February 25, 2021. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
- World Health Organization. Opioid overdose. August 28, 2020. Accessed February 25, 2021. https://www.who.int/news-room/fact-sheets/detail/opioid-overdose
- Stock C, Geier M, Nowicki K. Harm reduction strategies for people who inject drugs: considerations for pharmacists. College of Psychiatric and Neurologic Pharmacists. Accessed February 25, 2021. https://cpnp.org/guideline/harmreduction