Bacterial and fungal infections in persons who inject drugs

Persons who inject drugs are at increased risk of bacterial and fungal injecting-related infections due to many physiological, societal, and structural factors. An estimated 15 million persons inject drugs worldwide, with recent increases in the burden of injecting-related infections. Acquisition of these infections has distinct pathophysiology and microbiology related to drug supply, drug composition, and the process of injecting. Clinical management of these infections is complicated by usual factors such as the need for source control and effective antibiotics, as well as the complex challenges faced by persons who inject drugs while in hospital. These challenges include drug withdrawal, difficult pain control related to opioid tolerance, stigma, discrimination, and lack of access to outpatient parenteral antibiotic therapy, which can lead to high rates of patient-directed discharge and non-completion of treatment with subsequent poor outcomes. This review seeks to provide an evidence-based summary of what is known about the risks, epidemiology, microbiology, and presentation of injecting-related bacterial and fungal infections, as well as provide recommendations for treatment, including pharmacological considerations, opportunistic screening, multidisciplinary team care, and approaches to outpatient therapy. It also provides insight into the medicolegal and ethical considerations of care for persons who inject drugs and a first-person perspective of someone with lived experience.