Infectious disease syndromes and their treatments in marginalized populations

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Dr. Milan Raval

October 17, 2023

U of A ID Fellows Academic Half Day

Who am I? Why am I giving this talk?

• Infectious Diseases & Addictions Medicine MD

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• Current social climate has led to significant:
• Substance use
• Homelessness
• Trauma
• Mental health challenges
• Difficulties accessing care

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• ∴ it is your responsibility to learn to care for this population

Objectives

1. Brief introduction of marginalized populations in Alberta
2. Framework to think about infections in this population
3. Nuances with specific syndromes
4. What can we do about it

What’s the lay of the land in Edmonton/Alberta

Homelessness in Edmonton

• Chronic homelessness 🡪 2700 people

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• Translational homelessness 🡪 8600 people

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• Indigenous peoples are significantly overrepresented in the homeless population

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• Multiple complex challenges with safety

Alberta has an unprecedented number of fatal opioid poisonings

Fentanyl and its analogs drive this process

Hospitalizations related to opioid use in Alberta (count per 100,000)

Edmonton EMS Utilization

Why are things so bad?

1. COVID-19 related effects
• Social isolation
• Increased burden of mental health challenges
• Increased substance use
• Greater unpredictability of the drug supply
• Greater challenges accessing care and treatment
• Challenges accessing shelter
• Increased violence
2. Predominance of Fentanyl and its analogs in street supply
3. Legacy of residential schools and colonialism

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Infectious syndromes related to suboptimal living conditions & substance use

Framework of how to think about infections in this patient population*

• Infections directly from substance use
• Skin and soft tissue infections
• Bloodstream infections/Endocarditis
• Septic arthritis/osteomyelitis
• HIV/HCV/HBV
• Infections related to associated with living circumstances
• COVID-19
• Shigella
• Bartonella
• Scabies
• Lice
• STIs
• TB
• HAV
• Infections related to low vaccine rates
• COVID-19
• Pneumococcal infections

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Injection related infections: Injection Practices

1. Drug preparation
1. Crush drug & place in a cooker
2. Add water
3. Dissolve with heat +/- acidic component
4. Draw up
2. Drug Injection
• Inject through cotton filter

Injection related infections: Injection Practices

1. Drug preparation
1. Crush drug and place in cooker
1. Black tar heroin 🡪 increased risk of Botulism
2. Add water
• Toilet bowl water 🡪 E coli, E cloacae, Pseudomonas
• Puddles 🡪 environmental GNBs, Mycobacteria
3. Dissolve with heat +/- acidic component
• Lemon juice 🡪 increased risk for Candidemia
4. Clean injection area with alcohol swabs
• If not increased risk of S. aureus and Beta hemolytic streptococci
5. Draw up
6. +/- lubricating needle
• Some patients may lick needles 🡪 oral organisms (ie VGS)
2. Drug Injection
• Inject through cotton filter
• Cottom ball fever

Sharing supplies can lead to transmission of HIV/HCV/HBV

Skin & Soft tissue infections

• 4-32% of PWID will develop a SSTI in the next 4 weeks
• **most common reason PWID interact with the health care system
• SSTIs can be a marker of severity of substance use disorder
• Often starts in antecubital fossa in non-dominant arm, or LE for more discrete. Groin or neck once veins become sclerotic

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HIV in patients with substance use disorders

• In general:
• cART is not contraindicated in patients with active use disorders
• Preferred regimen is a single tablet formulation, with a high barrier to resistance and minimal DDIs (ie Biktarvy, Triumeq, etc)
• LAI (ie injectable cabotegravir/rilpivirine) 🡪 not an established option for those with sub-optimal adherence
• LATITUDE Study will provide answers
• ID week presented observational studies from Clinic 86 in San Francisco show promise

HIV in patients with substance use disorders

• Illicit Stimulant Use
• ~5-15% of PLHIV
• Associated with poorer HIV outcomes 🡪 ↓viral suppression, ↓adherence to ART, ↑risk sexual behavior, ↑CV disease, ↑neurocognitive impairment
• Stimulant use can lead to HIV disease progression even in those with viral suppression who are taking cART (MOA unknown)
• Tx: THN kits, Non-pharmacological therapies (Access 24/7)
• Illicit Opioid Use
• OAT decreases the risk of HIV acquisition
• OAT increases likelihood of viral suppression and decreases all cause mortality by 50%

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HIV in patients with tobacco use disorder

• Tobacco
• Smoking leads to a nearly 2X increase in mortality amongst those with HIV
• Via increased risk of lung CA, CV disease, pulmonary disease, and non-AIDS related CA
• Varenacline* is the most effective anti-cessation tool
• Motivational interviewing

HIV PrEP in PWID

• Can be indicated in PWID (people who inject drugs) if:
• 1) Sharing injectable paraphernalia in the last 6 mos w/ other PWID, MSM, PLHIV w/ detectable VL, person from a highly endemic country
• 35X increased risk of HIV acquisition in PWID
• PrEP can decrease risk of HIV transmission by ?50%
• Limited data, efficacy is linked to adherence

HCV

• Epidemiology
• ~70% of new cases of HCV are related to substance use
• ~40% of PWID will develop HCV within the first few years of injecting
• Diagnosis/Screening
• Screening at least q12mos for patients who use drugs
• Treatment
• Active substance use is NOT a contraindication to therapy
• DAAs favored (Epclusa/Maviret) 🡪 theoretical increased risk of opioid poisoning with Maviret + must be taken with food (these pts have food insecurity)
• SVR12 ~90%+ in this population
• Counselling on preventing reinfection
• Not sharing injection supplies
• Not sharing inhalational supplies

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Bacterial infections in patients with unstable housing or poor living conditions: Shigellosis

• Microbiology
• GNB
• 10-100 microorganisms to transmit infection
• 4 groups:
• A 🡪 Shigella dysenteriae
• B 🡪 Shigella flexneri
• C 🡪 Shigella boydii
• D 🡪 Shigella sonnei
• Diagnostics
• NAT of feces or rectal swab
• Syndrome
• Disease of small and large intestine causing diarrhea (+/- blood/mucus), cramping, abdominal pain
• Can cause bacteremia

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Bacterial infections in patients with unstable housing or poor living conditions: Shigellosis

• Decreases duration of illness + fecal excretion (∴ transmission)
• Inpatient
• CTX 1-2 g IV daily x 5d
• + outpatient
• Outpatient
• Ciprofloxacin 500 mg PO BID x 3 days
• Azithromycin 1g PO x1 (high risk of loss in follow-up)
• Cefixime 200mg PO BID x 5 days

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Emerging Syndromes: Xylazine related wounds

• Xylazine 🡪 veterinary medication (partial alpha 2 adrenergic receptor agonist)
• Peripheral vasoconstriction
• Central sympathetic antagonist
• Recently added to illicit synthetic opioids (to prolong high)
• local vasoconstriction and decreased skin perfusion (+HoTN, bradycardia, ↓ resp rate)
• ↑ 6X risk of skin infection/ulceration
• Treatment:
• Dx: urine drug testing to confirm xylazine is possible
• Wound care: debridement + Adaptic/Gauze/Adhesive
• Antimicrobial therapy

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Emerging infections: Bartonella quintana

• Microbiology
• Louse borne GNB
• Transmitted to humans via human body louse (Pediculus humanus corporis) 🡪 defecates feces laden w/ B. quintana
• Diagnosis
• BCx w/ prolonged incubation (14d)
• Serology (IFA>1:256 w/ acute infection, 1:800 or greater for chronic/IE) – variable sens
• 16s on tissue (IE valve)
• Clinical Syndrome
• Acute self-limiting febrile illness
• Chronic bacteremia w/ culture negative endocarditis
• Visceral or cutaneous bacillary angiomatosis

Fevers q4-5d (hence name)

Non-ID Interventions

Opioid use disorder (OUD)

• Opioid agonist therapy (OAT) including Suboxone (buprenorphine/naloxone) and methadone decrease all cause mortality by 50% in patients who have OUD

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• OAT cessation leads to a 6X increase in all cause mortality in the next 4 weeks

Who to call for help w/ patients w/ Opioid Use Disorder?

• Royal Alexandra Hospital: Addiction Recovery Community Health (ARCH) Team
• Inpatient MD (patients admitted on the wards)
• Emergency MD (patients in the ED or who will not be admitted)
• Any other site (Opioid Use Disorder Telephone Consult Services) via RAAPID Tel: 780-735-0811
• Open 8AM – 8PM every single day of the year
• When all fails 🡪 Call Dr. Raval (780-919-7990)

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Naloxone Kits

• Give to ALL inpatients/outpatients w/
• Opioid Use Disorder
• Stimulant Use Disorder
• Intermittent use of street obtained drugs
• Provide Because:
• Hospitalized patients have a 4X↑ risk of OD in the first 2 days following discharge
• Elevated risk of poisoning events as an inpatient
• 5-10% of the illicit drug supply is contaminated with fentanyl

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Injection Practices Safer Use:�”6 moments of injection hygiene”

1. Setting: calm, well lit, not alone
2. Wash your hands
3. Sterile water + cooker +/- single pack vitamin C when dissolving substance
4. Clean skin
5. Single use cotton ball filter
6. Use sterile injection supplies, dispose of it in sterile fashion after finished

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Contingency Planning

• Patient directed discharges are not infrequent amongst this population
• Some antimicrobials better than no antimicrobials
• Day 1 plan:
• What pharmacy will they attend if, worst case scenario, they leave
• Place were Rx for antimicrobials/other therapies can be sent
• If patients do not attend follow-up place plan on CC on what to do if they re-present
• (labs, diagnostic imaging, empiric antimicrobials)

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A small pivot

General Advice

Questions?

Tel: 780-919-7990

E-mail: milan.raval@albertahealthservices.ca

Thanks!

Supplementary Slides

Counselling re: safer injection practices