A paradigm shift in the management of injectable drug use related upper extremity infections: Lessons learned during the COVID-19 pandemic

Dear Sir,

The COVID-19 pandemic occurred concurrently with the opioid epidemic and has exacerbated its effects. Illicit substance use and overdoses have increased.1, 2 There has been an increase in the incidence of infection in the upper extremity (UE) related to IV drug use.³ Injectable drug use-related infections (IDURIs) are associated with significant morbidity.⁴ The aim of this study was to evaluate the differences in incidence and management of UE IDURIs in pre-pandemic and pandemic cohorts. We hypothesized that both the incidence and severity of IDURIs increased during the pandemic.

Patients and methods

After institutional review board approval, a retrospective study was performed on adult patients who presented to our hospital system emergency departments with UE IDURIs between January 2019 to March 2021. Patients prior to March 2020 were analyzed in the pre-pandemic group and all others were in the pandemic group. Patients were identified by ICD-10 code. Records were reviewed for demographic, infection, and management data.

Patients were analyzed using Pearson’s Χ² and Fisher’s exact tests where appropriate. Continuous variables were reported as mean and standard deviation and categorical variables were presented as frequencies and percentages. The significance level was set at 0.05. All statistical analyses were performed using SPSS Statistics v28.0 (Armonk, NY).

Results

There were 298 patients that met inclusion criteria, 143 in the pre-pandemic group and 155 in the pandemic group. There was no difference between the groups in age, race, smoking status or comorbidities (Supplemental Table 1). There were more males (110 vs. 84, p = 0.029), more unemployment (p = 0.045) and people with Medicare/Medicaid (p = 0.044) in the pandemic group. Cellulitis and abscess were the most common diagnoses in both groups, but there was no difference in infection diagnosis (p = 0.317) or location between groups (Supplemental Table 2). A culture was obtained in 42% of patients. The most common organisms identified were Staphylococcus and Streptococcus spp.

In the pre-pandemic group, length of stay was increased (2.29 days vs 1.24 days, p = 0.007), and there was a trend toward more ICU admission (p = 0.058) and more infectious disease (ID) consultation (p = 0.075). There was no difference in imaging practices.

Patients were almost twice as likely to receive IV antibiotics pre-pandemic (OR=1.98 [1.21, 3.25]; p = 0.007) and 0.5 times more likely to be treated with oral antibiotics during the pandemic (OR=0.53 [0.32, 0.90]; p = 0.018). During the pandemic, patients were 20% less likely to receive IV antibiotics and 18% more likely to receive oral antibiotics ( Figure 1). The number of patients requiring surgery in both groups was low, 16.8% pre-pandemic and 7.1% during the pandemic. More operative procedures were performed pre-pandemic (OR=2.64 [1.24, 5.61]; p = 0.011) ( Table 1), with 1 patient requiring 3 operations pre-pandemic and the majority of pandemic patients having only 1 operation. Patients were almost 60% less likely to receive an operation during the pandemic.

Figure 1.

Risk estimates of management options for IDURIs of the upper extremity. Data are shown as odds ratio (center dot) and 95% confidence intervals (left and right dots represent lower and upper confidence intervals, respectively). IV = intravenous, I&D = incision and drainage/debridement, NPWT = negative pressure wound therapy, PT/OT = physical therapy/occupational therapy.

Table 1.

Management-related data.

Management	Pre-pandemic (n = 143)	Pandemic (n = 155)	P
Transferred from other hospital, n (%)			0.480
Yes	1 (0.7)	0 (0)
No	142 (99.3)	155 (100)
Length of stay, days (mean± SD)	2.3 ± 2.9	1.3 ± 1.9	0.007**
ICU admission, n (%)			0.058
Yes	6 (4.2)	1 (0.6)
No	137 (95.8)	154 (99.4)
Length of stay, days (mean± SD)	2.5 ± 2.7	11
Imaging obtained, n (%)
XR	75 (52.4)	80 (51.6)	0.908
1	48	48
2	20	25
3	5	3
4 or more	2	4
CT	14 (9.8)	15 (9.7)	1.0
Ultrasound (non-DVT)	12 (8.4)	9 (5.8)	0.498
MRI	6 (4.2)	5 (3.2)	0.763
None	54 (37.7)	63 (40.6)	0.636
Infectious disease consult	64 (44.8)	53 (34.2)	0.075
Incision and drainage (bedside or operative)	54 (37.7)	57 (36.8)	0.905
IV antibiotics	107 (74.8)	93 (60)	0.007**
PICC placed	8 (7.5)	3 (3.2)	0.226
Oral antibiotics	96 (67.1)	123 (79.4)	0.018*
Operation required	24 (16.8)	11 (7.1)	0.011*
1 operation	21	10
2 operations	2	1
3 operations	1	0
Surgery type
Incision and drainage/debridement	24 (100)	11 (100)	0.011*
Skin graft	1 (4.2)	0 (0)	0.480
Negative pressure wound therapy	5 (20.8)	0 (0)	0.025*
Other	1 (4.2)	0 (0)	0.480
PT/OT used	5 (3.5)	0 (0)	0.025*
Left against medical advice	53 (37)	59 (38)	0.905

^*p < 0.05.

^**p < 0.01.

Discussion

This study evaluated trends in the management of UE IDURIs before and during the COVID-19 pandemic. In our study, surgical intervention was low in both groups, but more operations were performed pre-pandemic. This could be due to the pause on surgical procedures at the start of the pandemic that reallocated resources.⁵ Before the pandemic, more patients had multiple operations.

In this study, the incidence and severity of IDURIs did not change during the pandemic, but the management shifted toward a more conservative approach. Length of stay, operations, IV antibiotics, ICU admissions, use of therapy, and ID consultation were all decreased during the pandemic. It’s possible that more efforts were made during the pandemic to reduce unnecessary admissions and other resources likely to be used during hospitalization. Many patients were treated solely by emergency department providers.

To our knowledge, this is the first study to examine the management of IDURIs before and during the COVID-19 pandemic in the United States. A Canadian group examined the frequency with which patients presented to their institution in a 3-month period before and during the pandemic.⁴ The authors found that the total number of cases doubled during the pandemic. This study analyzed a Canadian hospital system and it did not evaluate management of the infection. In our study, we did not find a higher frequency of IDURIs during the pandemic.

There are limitations to our study. Patients reviewed were identified by ICD-10 code and coding errors could lead to an underestimation of patients presenting with IDURIs. This was a retrospective chart review; thus, causation cannot be determined and incomplete documentation may prevent drawing accurate conclusions. This study was performed at an academic medical center in the Midwest and may have limited application to other areas. This study was underpowered to perform regression analysis or control for variables. Conservative management was successful in the management of many IDURIs of the UE during the pandemic but future prospective, comparative outcomes analysis is needed to demonstrate that this shift is a safe and effective treatment option after the pandemic.

Ethical approval

We obtained ethical approval from the institutional review board of the Cleveland Clinic (IRB#21-628).

Funding

None.

Conflict of interest

None.

Appendix A. Supplementary material

Supplementary material

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