Wound infections There have been increasing numbers of bacterial infections in people who inject drugs across England. Of particular concern is the rise in infections caused by Group A Strep (GAS; Streptococcus pyogenes) and Staph aureus (Staphylococcus aureus) leading to hospitalisations and serious consequences including limb amputations and deaths. The increase has been seen in people who inject drugs, in homeless people and people in prison. This resource gives information on signs and symptoms of these infections, and ways to prevent infection.

Staphylococcus aureus (S. aureus or “Staph aureus”) and Streptococcus pyogenes (commonly referred to as Group A Streptococcus or GAS) are bacteria found in the nose, throat, skin, groin or anal area. People may carry these bacteria and have no symptoms of illness. However, infection can occur when these bacteria enter the body via a wound (including a drug injecting site), sore or a break in the skin. The infection can be caused by a person’s own bacteria or bacteria acquired from someone else or from the environment including through contact with contaminated surfaces and objects like soft furnishings, bedding or towels.

These bacteria can be passed from person-to-person through direct contact or through breathing in respiratory droplets from someone carrying the bacteria, as well as through sharing drug paraphernalia (such as injecting equipment, spoons, filters, pipes to smoke drugs etc). Drugs or their wraps can also be contaminated with bacteria.

1 Signs and symptoms S. aureus and GAS can cause a range of infections from mild skin and throat infections to life-threatening invasive infection. These infections can take hold in many areas of the body including skin and soft tissue, respiratory tract, bone/joint and bloodstream infection. The symptoms of S. aureus and GAS infection vary depending on the type of infection but they might include: • High fever, chills • Shortness of breath, fast • Heat, swelling, redness, aches breathing, difficulty breathing and pain around wound, joint or • Coughing up mucus muscles • Pain in chest • Pus and/or unpleasant smell • Headache from site of wound • Unexplained ‘bruising’ or rash • Wound that will not heal • Sore throat, difficulty • Skin abscess – painful collection swallowing of pus in a lump under the skin • Sore ear(s) • Cellulitis – red, painful, hot, • Vomiting, nausea and diarrhoea swollen, tender, blistered skin • Severe abdominal pain • Fast heartbeat • Severe fatigue/tiredness • Dizziness, confusion, • Severe muscle pain disorientation Not all of these symptoms need to be present Staff, and people who use street drugs, should be aware of these symptoms.

If someone has symptoms Left untreated, these infections often become progressively worse and can lead to death. Early identification and treatment is vital and will also reduce the likelihood of the infection being passed to someone else. If someone who uses drugs has a combination of the symptoms mentioned above they should seek medical attention from their GP, or by calling NHS 111 or – if symptoms are severe – going straight to hospital. In an emergency call 999. 2 Risk reduction advice for people who use drugs • Wash hands and maintain good o filter the drug before personal hygiene (including injecting washing clothes, bedding and o don’t re-use filters and don’t towels) lick needles before using • Consider oral use of substances them (used filters and saliva such as wrapping in cigarette are full of bacteria) paper and swallowing (called o ensure the drug is injected bombing) or smoking as an directly into a vein – try to alternative to injecting and avoid missed hits - snorting intramuscular and sub- • If injecting: cutaneous injections can cause tissue damage, which o wash hands helps bacterial infection to o Clean the skin before develop injecting with water and o avoid groin injection soap or an alcohol swab o avoid always using the same o use new injecting equipment injection site for every injection • If possible, stop drug use altogether o only use a small amount of (support person to look at their citric if it is needed to treatment options) or encourage to dissolve the drug (don’t use take breaks from injecting an acidifier if injecting (smoking, bombing etc) to reduce stimulants, which are usually vein damage acidic anyway)

If someone feels unwell, or has a combination of the symptoms of S. aureus or GAS infection (see above), seek medical advice quickly

What are Staphylococcus bacteria? Staphylococcus aureus is part of drug use, touching broken skin the body’s natural bacterial with unclean hands etc.) and S. microflora. It can be found in the aureus infections can be broadly nose or on people’s skin, groin or classified into two groups: skin anal area. Most of the time S. and soft tissue infections and aureus does not cause problems invasive infection. to the person carrying it but can be passed on from person to People with S. aureus infection person. can develop serious conditions such as blood stream S. aureus infections are caused infection, endocarditis or when bacteria get into a break, abscesses covering the damage or cut in the skin (such body (not just at injecting sites). as a break caused by injecting

What are Streptococcus bacteria? Streptococcal infections can vary symptoms of illness. GAS can be in severity from mild throat passed on from person to infections to life threatening person. conditions. People with GAS infection can The streptococcal bacterium develop serious, life-threatening most often associated with conditions such as cellulitis, people who use drugs is Group A pneumonia, blood stream Streptococcus (GAS), also known infection (including septicaemia) as Streptococcus pyogenes. and necrotising fasciitis, People can carry this bacterium meningitis or bone/joint in the nose, throat, skin, anal and infection. genital areas and may have no

4 How someone who uses drugs becomes infected with S. aureus and/or GAS

Person to person substance especially by injecting drug use (intravenous, intra The most common way for an muscular, subcutaneous), snorting individual to become infected by and rectal drug use. Smoking and either S. aureus or GAS is person oral use of any drug carry less of a to person spread. Bacteria can risk of invasive infection compared spread through respiratory to other methods of drug use. droplets in the coughs or sneezes of someone with an infection or It is important to mention S. aureus through contact with infected and/ or GAS is not visible to the eye wounds or sores on the skin of therefore a person would not be someone carrying the organism. able to tell if their drug is contaminated. Injecting drug use Sharing drug paraphernalia Injecting frequently, missed hits and injecting into the groin are all It is also possible to become factors increasing the risk of infected with GAS and S. aureus by people’s own bacteria (S. aureus sharing injecting equipment*, and GAS) entering the body via spoons, filters, snorters (for wounds associated with injecting. inhaling drugs up the nose) and pipes (for smoking drugs) due to Contaminated substance unwashed hands contaminating Although less common, in some these objects. cases the substance being used or * Sharing of injecting equipment its packaging/wrap could be also increases the risk of contaminated with S. aureus and / contracting a blood borne virus for or GAS. If this is the case an example, hepatitis C and HIV. individual would be susceptible to infection through using the

5 Treatment of infection S. aureus and GAS infections can It is important to take the full be treated with antibiotics. course of antibiotics if However, the more severe the prescribed, even if feeling better infection the more intensive the before they are finished, treatment becomes. Most otherwise the infection may not people who have invasive be fully treated and a partly infections are admitted to treated infection can return. hospital due to the severity of the condition. Drug treatment and recovery If a person wants to stop using Encourage people to contact drugs and finds they cannot, their drug service or GP, call NHS treatment should be considered. 111 or look at talktofrank.com. Risk to staff Due to both bacteria being easily Should a staff member come into spread from person-to-person it contact with someone who signs is essential that staff practice of infection - for example, by good hygiene. Staff working with touching an infected site or being exposed to the pus that it a person who has an infection produces, they should wash their caused by S. aureus or GAS can hands thoroughly using warm reduce their chances of infection water and soap, or alcohol hand by: gel if soap and water are not available. • Washing hands regularly • Keeping any cuts clean and Follow your local protocol on infection control advice and who covered to contact if appropriate. • Practising good personal hygiene Spread of infection from person- to-person is reduced after a • Following local infection person with the infection has control advice been receiving antibiotics for 24 hours or longer. For information on drugs and where to get help: • Call NHS 111 6 • Visit talktofrank.com