Queensland Needle and Syringe Program by lindash

VIEWS: 15 PAGES: 41

Queensland Needle and Syringe Program

More Info
									Injection Related
    Injury and
Disease: hospital
  presentations
Andrew Conroy, Research Officer
Queensland Needle & Syringe Program,
Queensland Health
Acknowledgements

 Funded by Australian Department of
  Health and Ageing
 Queensland Health in collaboration with
  NSW Health, Victorian Department of
  Human Services and the Burnet Institute
What are IRID?
 Superficial damage and infections
      e.g. Scarring, bruising, fungal skin infections,
 Soft tissue infections
      e.g. Cellutitis, Abscess
 Systemic infections
      e.g. Septicaemia (blood infection), Septic arithritis’
         (joint infection), Infective endocarditis (infection of
         the heart valves)
 Venous disease
      e.g. Thrombosis (clotted/blocked veins), Chronic
         venous insufficiency (long-term blocked veins)
What are IRID?

 Arterial disease
       Aneurysm,
       peripheral
       ischaemia,
       gangrene, necrosis
 Lymphatic disease
      Lymphoedema
       (‘puffy hand
       syndrome’)
Goals of presentation
 Exploratory descriptive data
 Examine the incidence of injection-related
  abscess, cellulitis and endocarditis,
      In relation to the overall incidence of these
       presentations from any cause
      Patient demography
      Drug use diagnoses
 Provide some estimates of the incidence of
  hospital presentations for a variety IRID
 Look at the relative severity of these diseases, in
  terms of length of hospital stay and resources
  required
Goals of presentation

 Note the limitations of these incidence estimates,
  and touch upon the possible relationship
  between hospital presentations and population
  disease incidence for injectors
 Look at some of the contributors to disease
  incidence and severity, and some possible
  strategies for reducing these
 Describe the content and application of the IRID
  assessment instrument
Hospital data extraction
methods
 ICD-10-AM codes
 Admitted patient data for NSW, Vic and
  Qld
 Three years data: 2003/04 – 2005/06
Hospital data extraction
methods
 Principal diagnosis
      The diagnosis established after the assessment of
       the patient to be chiefly responsible for occasioning
       the patient’s episode of care in hospital
 Additional diagnoses
      A condition or complaint either coexisting with the
       principal diagnosis or arising during the episode of
       care. They are conditions that affect patient
       management in terms of requiring therapeutic
       treatment, diagnostic procedures or increased care
       and/or monitoring
Hospital data extraction
methods
 Principal diagnosis
      The diagnosis established after the assessment of
       the patient to be chiefly responsible for occasioning
       the patient’s episode of care in hospital
 Additional diagnoses
      A condition or complaint either coexisting with the
       principal diagnosis or arising during the episode of
       care. They are conditions that affect patient
       management in terms of requiring therapeutic
       treatment, diagnostic procedures or increased care
       and/or monitoring
Hospital data extraction
methods

 Identification of injection related cases
      No diagnostic category in the ICD for injecting drug
       use
      Mental and behavioural disorders due to drug type
         Opioids, cocaine, stimulants, multiple/other

         Acute intoxication, harmful use, dependence
          syndrome, withdrawal state, psychotic disorder
      Drug use
         Hazardous pattern of drug use in absence of
          disorder that increases risk of harmful
          consequences
Hospital data extraction
methods
Four searches
   1.   The relative incidence of an extensive range of
        conditions, including abscess, cellulitis, septic
        arthritis, septicaemia, endocarditis (PD only)
   2.   Amputation procedures associated with IRID
   3.   Abscess, cellulitis and endocarditis (PD & AD)
        with drug use/drug use disorder recorded
   4.   Abscess, cellulitis and endocarditis (PD & AD)
        without drug use/drug use disorder recorded
    Three key
    IRID
    examined
    in this study
 Abscess and cellulitis
      The most common types of bacterial infections
       among injecting drug users
 Endocarditis
      Injecting drug use has become one of the leading
       causes of endocarditis
      A severe outcome of bacterial infection
         Abscess and cellulitis

 Abscess – A collection of pus under the skin surrounded by
  inflamed tissue
 Cellulitis – A diffuse bacterial infection of the skin resulting in
  the skin becoming red, hot, swollen and tender
 Often occur together
 Occurring with a fever is a sign that the infection may have
  become systemic (entered the bloodstream)
                                  Abscess
                                  Queensland                                                            Victoria

                  2500                         2231                                   2000                         1753
                                    2106                                                                1630
                  2000      1870                                                                1454
Number of cases




                                                                    Number of cases
                                                                                      1500
                                                        All cases                                                           All cases
                  1500
                                                                                      1000
                  1000                                  Drug use                                                            Drug use
                                                        recorded                                                            recorded
                                                                                       500
                   500
                            108      102       105                                              95       109       95
                     0                                                                   0
                          2003/04   2004/05   2005/06                                         2003/04   2004/05   2005/06
                                     Year                                                                Year



                         4.7 to 5.8 per cent                                                 5.4 to 6.7 per cent
                               Cellulitis
                            Queensland                                                              Victoria

                  6000                         5460                                    7000                         6802
                                                                                                         6486
                                     4863                                                        5906
                  5000      4682                                                       6000
Number of cases




                                                                     Number of cases
                                                                                       5000
                  4000                                   All cases                                                           All cases
                                                                                       4000
                  3000
                                                         Drug use                      3000                                  Drug use
                  2000                                   recorded                                                            recorded
                                                                                       2000
                  1000                          179                                    1000               190
                             152      145                                                        185                182
                    0                                                                     0
                           2003/04   2004/05   2005/06                                         2003/04   2004/05   2005/06
                                      Year                                                                Year




                         3.0 to 3.3 per cent                                                  2.7 to 3.1 per cent
Age distribution (%) of patients with
abscess or cellulitis and no recorded
drug use disorder (2003/04 to 2005/06)

             20

             15
  Per cent




                                                                          Queensland
             10
                                                                          Victoria
             5

             0
                  15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
                                      Age groups
                                Age distribution (%) of cases with abscess
                                or cellulitis, 2003/04 to 2005/06, for
                                patients with opioid or stimulant disorder

                               Queensland                                                                 Victoria

           40                                                                           40

           30                                                                           30
Per cent




                                                                             Per cent
           20                                                                           20

           10                                                                           10

           0                                                                            0
                15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59                        15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
                                    Age groups
                                                                                                                 Age groups



                                                                        Opioids
                                                                        Stimulants
           Abscess – gender distribution

           Queensland                        Victoria



                                                        95, 32%
                   127, 40%


188, 60%
                                       204, 68%




                              Female
                              Male
           Cellulitis – gender distribution

           Queensland                        Victoria



                   160, 34%                             193, 35%




316, 66%                               364, 65%




                              Female
                              Male
Injection-related abscess, by
type of drug use (%)
           50

           40
Per cent




           30
                                                                    Queensland
                                                                    Victoria
           20

           10

           0
                 Opioid    Stimulant   Multiple/Other   Hazardous
                disorder   disorder                      drug use

                Type of drug use disorder/drug use
Injection-related cellulitis, by
type of drug use (%)
           60
           50
           40
Per cent




                                                                    Queensland
           30
                                                                    Victoria
           20
           10
           0
                 Opioid    Stimulant   Multiple/Other   Hazardous
                disorder   disorder                      drug use

                Type of drug use disorder/drug use
             Endocarditis

 Inflammation of the lining of the heart,
   and/or the heart valves, caused by
   infection



                                 o High fever and chills & dehydration
                                 o May develop painful spots on fingers and
                                 toes
                                           These are clumps of bacteria being
                                     thrown off the heart valves and lodging in the
                                     small blood vessels in the fingers and toes
Endocarditis
 Recent skin abscess and cellulitis are risk factors for
  endocarditis
 In the majority of cases caused by S. aureus.
 The skin and orifices (e.g. oral or nasal colonisation)
       20 per cent of healthy people are persistent carriers of S.
        aureus, 60 per cent are intermittent carriers
       Skin cleaning before injection reduces the frequency of
        reported endocarditis
       Hand washing
 IDU with previous history of endocarditis had 11-fold
   increased risk of endocarditis (Spijkerman, et al., 1996)
                Endocarditis
              Queensland                                        Victoria

200                        189                  250
180              167                                                         181
                                                        208        172
160     146                                     200
140
120                                 All cases   150                                   All cases
100
                                    Drug use                                          Drug use
 80                                             100
                                    recorded                                          recorded
 60
 40               25       27                   50      31          30       33
        15
 20
  0                                               0
      2003/04   2004/05   2005/06                     2003/04     2004/05   2005/06




        10.3 to 14.9 per cent                          14.9 to 18.2 per cent
Age distribution (%) of patients with
endocarditis and no recorded drug use
disorder (2003/04 to 2005/06)


             25

             20
  Per cent




             15                                                           Queensland
             10                                                           Victoria

             5

             0
                  15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
                                      Age groups
                            Age distribution of cases with
                            endocarditis, 2003/04 to 2005/06, for
                            patients with opioid or stimulant disorder

                        Queensland                                                                Victoria

           50                                                                    50
           40                                                                    40
Per cent




                                                                      Per cent
           30                                                                    30
           20                                                                    20
           10                                                                    10
           0                                                                     0
                15-   20-   25-   30-   35-   40-   45-   50-   55-                   15-   20-   25-   30-   35-   40-   45-   50-   55-
                19    24    29    34    39    44    49    54    59                    19    24    29    34    39    44    49    54    59
                                   Age groups
                                                                                                         Age groups
          Endocarditis – gender
          distribution
          Queensland                      Victoria



                  22, 33%                            29, 31%




45, 67%                              65, 69%




                            Female
                            Male
Injection-related endocarditis,
by type of drug use (%)
           70
           60
           50
Per cent




           40                                                       Queensland
           30                                                       Victoria

           20
           10
           0
                 Opioid    Stimulant   Multiple/Other   Hazardous
                disorder   disorder                      drug use

                Type of drug use disorder/drug use
Data limitations

 Does not include emergency department
  presentations
 Does not represent the incidence of
  disease across the injecting population
 Is likely to underestimate even the
  incidence of admitted patient cases
     Recognition of drug use; recognition of
      relevance of drug use
     No ICD code for injecting drug use
Hospital admissions and ED
discharges for SFGH

                      Admitted
                      cases
                      represented
                      only 35 to 55
                      per cent of all
                      hospital
                      presentations
       Australian NSP Survey 2006
       (N=501)
                            QLD        VIC
                            % (N)      % (N)

Infection in or around      24 (501)   31 (195)
injection site (> a week)
Medical treatment?          50 (119)   50 (60)
       Australian NSP Survey 2006:
       per cent reporting IRID
Disease type      QLD      VIC
                  N=501    N=195


Abscess           22       30
Septicaemia       8        10
Thrombosis        10       14
Endocarditis      4        4
A variety of IRID
   Endocarditis, and more particularly abscess and
    cellulitis, are common presentations
   However, there are many IRID, including other relatively
    common presentations
           Septicaemia

           Pyogenic/Septic arthritis
                serious infection of joints with pain, fever, chills,
                 inflammation, swelling and loss of function
                a medical emergency because of damage it
                 causes to bone and cartilage, and potential for
                 septic shock
             Principal diagnoses (with drug
             use) – 2003/04 to 2005/06
                    Number IRID        Average
                      cases        days IRID cases    Average     Average
                                        (SD)          days for    cost for
                                                      this        this
                   Qld    Vic     Qld       Vic       condition   condition


Abscess            203    175     4 (4)     5 (5)
Cellulitis         213    286     5 (6)     5 (7)     4           2,800
Endocarditis       45     67      25 (20)   25 (18)   16          13,600
Septicaemia        73     130     11 (12)   14 (22)   9           8,600
Septic arthritis   41     23      9 (9)     13 (14)   6           3,900
Incidence and severity of IRID
 Injection practice:
       drug constituents, injecting environments, syringe re-
        use, injection preparation etc
 Late interventions
 Recurring diseases
       Reluctance/difficulty in presenting to medical services
       Limited understanding of conditions and their
        consequences
       Structure and design of available services
            Psychosocial issues
            Pain management
            Co-existing conditions, eg Hepatitis C
Example of possible service
response
San Francisco General Hospital established the Integrated
  Soft Tissue Infection Services (ISIS) Clinic in 2001
  (Harris & Young, 2002)
      Medical & surgical care integrated with counselling,
       pharmacotherapies and social services
           Clinic staffed by academic faculty surgeons, 3 nurses, a
            drug and alcohol counsellor, a social worker and an
            admin person, with a pain management specialist,
            pharmacist and infectious disease physician available
            for consultation
      3365 patient visits in first year saved around US$8.7m
       through reduced ED visits, hospital stays and operating
       room procedures
IRID Assessment Instrument

 Comprehensive initial assessment
     Screening and interventions
     Disease surveillance, ongoing monitoring
 39 items
     History (6), Recent injection practices (6),
      Injection site issues (6), Local infections (4),
      Systemic infections (8), Venous disease (4),
      Arterial disease (3), Lymphatic disease (1),
      Nerve damage (1)
Some conclusions

 Hundreds of hospital admissions each
  year for treatment of preventable serious
  infections
     Late assessment and treatment
 Admitted patient data probably comprise
  a minority of all cases
     Lack of sensitivity of diagnosis and coding
     ED presentations
     Untreated cases
Some conclusions

 Opioids contribute more to disease incidence
  than other drug classes
      Especially for systemic infection (endocarditis)
      Differs by State – greater contribution of Opioids in
       Vic compared to Qld
      Multiple drug types
      Lack of precision
 Early exposure to disease types that are more
  common later in life
      Increased vulnerability to subsequent disease
Some conclusions

 Exploratory stage of research
      Physical review of charts to verify disease
       incidence and drug use classification
      Recommend injecting drug use item in ICD
      Ongoing monitoring
      Looking toward greater clinical coordination
Andrew_Conroy@health.qld.gov.au

								
To top