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Prevalence and correlates of abscesses among a cohort of injection drug users Lloyd-Smith, Elisa; Kerr, Thomas; Hogg, Robert S; Li, Kathy; Montaner, Julio S; Wood, Evan Nov 10, 2005

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ralssBioMed CentHarm Reduction JournalOpen AcceBrief reportPrevalence and correlates of abscesses among a cohort of injection drug usersElisa Lloyd-Smith1,2, Thomas Kerr2,3, Robert S Hogg1,2,3, Kathy Li2, Julio SG Montaner2,3 and Evan Wood*2,3Address: 1Department of Health Care and Epidemiology, Faculty of Medicine; University of British Columbia, 5804 Fairview Ave, Vancouver, Canada, 2British Columbia Centre for Excellence in HIV/AIDS; St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, Canada and 3Department of Medicine; University of British Columbia, 3300 – 950 W. 10th Ave, Vancouver, CanadaEmail: Elisa Lloyd-Smith - esmith@cfenet.ubc.ca; Thomas Kerr - tkerr@cfenet.ubc.ca; Robert S Hogg - bobhogg@cfenet.ubc.ca; Kathy Li - kathyli@cfenet.ubc.ca; Julio SG Montaner - jmontaner@cfenet.ubc.ca; Evan Wood* - ewood@cfenet.ubc.ca* Corresponding author    AbstractRecent studies have indicated that injection-related infections such as abscesses and cellulitisaccount for the majority of emergency room visits and acute hospitalizations accrued by localinjection drug users. The objective of this analysis was to examine the prevalence and correlates ofdeveloping an abscess among a cohort of injection drug users in Vancouver and to identify socio-demographic and drug use variables associated with abscesses at baseline. We examined abscessesamong participants enrolled in a prospective cohort of injection drug users. Categorical variableswere analyzed using the Pearson's chi-square test and continuous variables were analyzed using theWilcoxon signed rank test. Among 1 585 baseline participants, 341 (21.5%) reported having anabscess in the last six months. In a logistic regression model that adjusted for all variables that wereassociated with having an abscess at p < 0.1 in univariate analyses, female gender [odds ratio (OR)= 1.7, [95%CI: 1.2 – 2.4]; p = 0.002), recent incarceration (OR = 1.7, [95%CI: 1.3 – 2.2]; p < 0.001),sex trade involvement (OR = 1.4 [95% CI: 1.0 – 2.0]; p = 0.03), frequent cocaine use (OR = 1.5[95%CI: 1.2 – 2.0]; p = 0.002) and HIV serostatus (OR = 1.5, [95%CI: 1.2 – 2.0]; p = 0.003) werepositively associated with having an abscess. Explanations for these associations require furtherstudy, and interventions are needed to address this highly prevalent concern.FindingsThe Downtown Eastside of Vancouver, Canada is a com-munity characterized by high rates of HIV among injec-tion drug users (IDU), and is also the setting of one ofNorth America's highest volume needle exchange pro-gram (NEP) [1]. Recent studies have indicated that injec-tion-related infections, such as abscesses and cellulitis,ated with the development of abscesses among IDU havenot been well described in settings with widespread accessto sterile injecting equipment and high rates of HIV infec-tion. In particular, abscesses are not characterized in Van-couver. However, abscesses can lead to seriouscomplications including but not limited to osteomyelitis[4], endocarditis [5-7], and septicemia [8,9]. An ongoingPublished: 10 November 2005Harm Reduction Journal 2005, 2:24 doi:10.1186/1477-7517-2-24Received: 20 July 2005Accepted: 10 November 2005This article is available from: http://www.harmreductionjournal.com/content/2/1/24© 2005 Lloyd-Smith et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4(page number not for citation purposes)account for the majority of emergency room visits andacute hospitalizations in local IDU [2,3]. Factors associ-prospective cohort study of IDU in Vancouver allowed forHarm Reduction Journal 2005, 2:24 http://www.harmreductionjournal.com/content/2/1/24an examination of the prevalence and factors associatedhaving an abscess in this setting.For these analyses, data was collected through the Van-couver Injection Drug Users Study (VIDUS), a prospectivecohort that has been previously described in detail [1].Data from participants who completed baseline question-naires between May 1, 1996 and May 31, 2004 were eval-uated for the present study. Participants were categorizedon the basis of whether or not they reported having anabscess lasting for more than three days during the previ-ous six months. Univariate and multivariable statisticswere applied to determine factors associated with devel-oping an abscess in the previous six months. Categoricalvariables were analyzed using the Pearson's chi-squaretest, and continuous variables were analyzed using theWilcoxon signed rank test. Variables associated with hav-ing an abscess at p < 0.1 were considered in a subsequentlogistic regression analysis.Socio-demographic and drug-using characteristics consid-ered in these analyses as potential risk factors included:age, gender, HIV status, unstable housing, residing in Van-couver's Downtown Eastside, incarceration in the previ-tion, binge drug use, public drug injection, requiring helpwith injections, and methadone maintenance therapy use.Unstable housing was defined as living in a single roomoccupancy hotel, transitional living arrangements, orbeing homeless. Individuals who reported injectingcocaine or heroin once or more a day were defined as fre-quent heroin and cocaine injectors. Bingeing was definedas periods in which drugs were injected more often thanusual. Variable definitions were consistent with previousanalyses [1].Overall, of the 1 585 baseline VIDUS participants, 341(21.5%) reported having an abscess in the last six months.The factors associated with having an abscess at p < 0.1 inunivariate analyses included: female gender (OR = 2.4,[95%CI: 1.8 – 3.0]; p < 0.001); unstable housing (OR =1.3, [95%CI: 1.1 – 1.8]; p = 0.01); recent incarceration(OR = 1.7, [95%CI: 1.3 – 2.1]; p < 0.001); sex tradeinvolvement (OR = 2.4, [95%CI: 1.9 – 3.1]; p < 0.001);frequent heroin use (OR = 1.4, [95%CI: 1.1 – 1.8]; p =0.006); frequent cocaine use (OR = 1.9, [95%CI: 1.5 –2.5]; p < 0.001); residing in Vancouver's Downtown East-side (OR = 1.5, [95%CI: 1.1 – 1.9]; p = 0.003); and HIVserostatus (OR = 1.8, [95%CI: 1.4 – 2.3]; p < 0.001). TableTable 1: Baseline demographic characteristics of IDU stratified by having an abscess in the past six months.Characteristic No abscess past six months n = 1 244Abscess past six months n = 341Odds Ratio (95% CI) p-valueGenderMale 848 (68.2) 162 (47.5)Female 396 (31.8) 179 (52.5) 2.4 (1.9 – 3.0) < 0.001HIV statusNegative 919 (73.9) 209 (61.3)Positive 325 (26.1) 132 (38.7) 1.7 (1.4 – 2.3) < 0.001Unstable housing*No 492 (39.5) 109 (32.0)Yes 752 (60.5) 387 (68.0) 1.3 (1.1 – 1.8) 0.011Recent incarceration*No 861 (69.2) 196 (57.5)Yes 383 (30.8) 145 (42.5) 1.7 (1.3 – 2.1) <0.001DTES residence*No 552 (44.4) 121 (35.5)Yes 692 (55.6) 220 (64.5) 1.5 (1.1 – 1.9) 0.003Sex trade involved*No 942 (75.7) 191 (56.0)Yes 302 (24.3) 150 (44.0) 2.4 (1.9 – 3.1) < 0.001Heroin use*Less than daily 840 (67.5) 203 (59.5)Daily use 404 (32.5) 138 (40.5) 1.4 (1.1 – 1.8) 0.006Cocaine use*Less than daily 858 (69.0) 182 (53.4)Daily use 386 (31.0) 159 (46.6) 1.9 (1.5 – 2.5) < 0.001Note: IDU = injection drug user, DTES = Downtown Eastside Residence. *Indicates behaviour during the six month period prior to the baseline interview.Page 2 of 4(page number not for citation purposes)ous six months, sex trade involvement, borrowing andlending of syringes, frequent heroin and cocaine injec-1 shows the baseline demographic characteristics of IDUstratified by having an abscess or not in the past sixHarm Reduction Journal 2005, 2:24 http://www.harmreductionjournal.com/content/2/1/24months for significant variables considered in the univar-iate analysis.As shown in Table 2, in a logistic regression model thatadjusted for all variables that were associated with havingan abscess at p < 0.1 in univariate analyses, female gender[odds ratio (OR) = 1.7, [95% CI: 1.2 – 2.4]; p = 0.002),recent incarceration (OR = 1.7, [95% CI: 1.3 – 2.2]; p <0.001), sex trade involvement (OR = 1.4 [95% CI: 1.0 –2.0]; p = 0.030), frequent cocaine use (OR = 1.5 [95% CI:1.2 – 2.0]; p = 0.002) and HIV serostatus (OR = 1.5, [95%CI: 1.2 – 2.0]; p = 0.003) were independently and posi-tively associated with having an abscess.Our results indicate female gender, recent incarceration,sex trade involvement, frequent cocaine use and HIVserostatus are positively associated with developing anabscess. These results are consistent with results from astudy in Amsterdam where female gender and prostitu-tion among women, as well as, frequent cocaine use wereidentified as independently and positively associated withskin abscesses [10]. In addition, the association betweenHIV-positive status and having an abscess has been notedelsewhere, and is understandable given that HIV-positiveindividuals may have a heightened susceptibility to bacte-rial infections [11,12]. Furthermore, high risk of infec-tious complications, such as endocarditis from abscesses[10], occur among HIV infected individuals [11].Abscesses are a common consequence of injection druguse [13-15]. The present study demonstrates that wide-spread access to sterile syringes through high-volume nee-dle exchanges and a medically supervised safer injectionfacility may not be sufficient to prevent high rates ofabscesses among IDU in Vancouver. In addition, our find-ings demonstrate the need for educational and structuralinterventions to improve rates of sterile injecting [16,17].ative of Vancouver IDU [18], VIDUS is not a random sam-ple. Second, the study relied on self-report, and therefore,the results could be susceptible to socially desirablereporting although we know of no reason why reportingabscesses would be subject to this concern. Third, thecross-sectional nature of this study precludes any conclu-sions regarding causal relationships between the variablesstudied and the outcome of interest. Further prospectivestudy is needed to assess predictors of abscess in this set-ting.In summary, 21.5% of IDU participating in this studyreported having an abscess in the previous six months.Results from this study indicate female gender, recentincarceration, sex trade involvement, frequent cocaine useand HIV serostatus are independently and positively asso-ciated with developing an abscess in injection drug users.Given the potential health complications arising frombacterial infections our findings highlight the need for theexpansion of programs to promote safer injection prac-tices.Competing interestsThe author(s) declare that they have no competing inter-ests.Authors' contributionsElisa Lloyd-Smith, Thomas Kerr and Evan Wood designedthe study. Kathy Li conducted the statistical analysis. ElisaLloyd-Smith drafted the manuscript and incorporated allsuggestions. All coauthors made significant contributionsto the conception and design of the analyses, interpreta-tion of the data and drafting of the manuscript, and theyall approved the version to be published.AcknowledgementsWe would particularly like to thank the VIDUS participants for their will-ingness to participate in the study. We also thank Drs. Kevin Craib, Richard Harrigan, Cari Miller, David Patrick, Mark Tyndall, Martin Schechter, Will Table 2: Logistic regression of factors associated with having an abscessCharacteristic Odds Ratio 95% C.I. p-valueGender(Female vs Male) 1.7 (1.4 – 2.4) 0.002Frequent cocaine use(Yes vs No) 1.5 (1.2 – 2.0) 0.002Recent incarceration(Yes vs No) 1.7 (1.3 – 2.2) <0.001Sex trade involvement(Yes vs No) 1.5 (1.1 – 2.1) 0.030HIV serostatus(Yes vs No) 1.5 (1.2 – 2.0) 0.003Page 3 of 4(page number not for citation purposes)Our study has limitations. First, although previousresearch has indicated that the VIDUS cohort is represent- Small, Patricia Spittal, & Steffanie Strathdee, for their research assistance, and Bonnie Devlin, John Charette, Caitlin Johnston, Vanessa Volkommer, Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2005, 2:24 http://www.harmreductionjournal.com/content/2/1/24Steve Kain, Dave Isham, Nancy Lalibarte, Sue Currie and Peter Vann for their administrative assistance. The study was supported by the US National Institutes of Health (R01 DA011591-04A1) and CIHR grant (MOP-67262). Elisa Lloyd-Smith is supported by a Junior Graduate Student-ship from the Michael Smith Foundation for Health Research.References1. Wood E, Tyndall MW, Spittal PM, Li K, Hogg RS, Montaner JS,O'Shaughnessy MV, Schechter MT: Factors associated with persistenthigh-risk syringe sharing in the presence of an established needleexchange programme.  Aids 2002, 16:941-943.2. Kerr T, Wood E, Grafstein E, Ishida T, Shannon K, Lai C, Montaner J,Tyndall MW: High rates of primary care and emergencydepartment use among injection drug users in Vancouver.  JPublic Health (Oxf) 2004.3. Palepu A, Tyndall MW, Leon H, Muller J, O'Shaughnessy MV, Schech-ter MT, Anis AH: Hospital utilization and costs in a cohort ofinjection drug users.  Cmaj 2001, 165:415-420.4. Roszler MH, McCarroll KA, Donovan KR, Rashid T, Kling GA: Thegroin hit: complications of intravenous drug abuse.  Radio-graphics 1989, 9:487-508.5. DeWitt DE, Paauw DS: Endocarditis in injection drug users.  AmFam Physician 1996, 53:2045-2049.6. DiNubile MJ: Short-course antibiotic therapy for right-sidedendocarditis caused by Staphylococcus aureus in injectiondrug users.  Ann Intern Med 1994, 121:873-876.7. Miro JM, Moreno A, Mestres CA: Infective Endocarditis in Intra-venous Drug Abusers.  Curr Infect Dis Rep 2003, 5:307-316.8. Hankins C, Palmer D, Singh R: Unintended subcutaneous andintramuscular injection by drug users.  Cmaj 2000,163:1425-1426.9. Williamson N, Archibald C, Van Vliet JS: Unexplained deathsamong injection drug users: a case of probable Clostridiummyonecrosis.  Cmaj 2001, 165:609-611.10. Spijkerman IJ, van Ameijden EJ, Mientjes GH, Coutinho RA, van denHoek A: Human immunodeficiency virus infection and otherrisk factors for skin abscesses and endocarditis among injec-tion drug users.  J Clin Epidemiol 1996, 49:1149-1154.11. Selwyn PA, Alcabes P, Hartel D, Buono D, Schoenbaum EE, Klein RS,Davenny K, Friedland GH: Clinical manifestations and predic-tors of disease progression in drug users with human immu-nodeficiency virus infection.  N Engl J Med 1992, 327:1697-1703.12. Flanigan TP, Hogan JW, Smith D, Schoenbaum E, Vlahov D, SchumanP, Mayer K: Self-reported bacterial infections among womenwith or at risk for human immunodeficiency virus infection.Clin Infect Dis 1999, 29:608-612.13. Brown PD, Ebright JR: Skin and Soft Tissue Infections in Injec-tion Drug Users.  Curr Infect Dis Rep 2002, 4:415-419.14. Murphy EL, DeVita D, Liu H, Vittinghoff E, Leung P, Ciccarone DH,Edlin BR: Risk factors for skin and soft-tissue abscesses amonginjection drug users: a case-control study.  Clin Infect Dis 2001,33:35-40.15. Binswanger IA, Kral AH, Bluthenthal RN, Rybold DJ, Edlin BR: Highprevalence of abscesses and cellulitis among community-recruited injection drug users in San Francisco.  Clin Infect Dis2000, 30:579-581.16. Ross MW, Wodak A, Stowe A, Gold J: Explanations for sharinginjection equipment in injecting drug users and barriers tosafer drug use.  Addiction 1994, 89:473-479.17. Wood E, Kerr T, Montaner JS, Strathdee SA, Wodak A, Hankins CA,Schechter MT, Tyndall MW: Rationale for evaluating NorthAmerica's first medically supervised safer injecting facility.Lancet Infect Dis 2004, 4:301-306.18. Tyndall MW, Craib KJ, Currie S, Li K, O'Shaughnessy MV, SchechterMT: Impact of HIV infection on mortality in a cohort of injec-tion drug users.  J Acquir Immune Defic Syndr 2001, 28:351-357.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 4 of 4(page number not for citation purposes)

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