Injection Drug Use May Be an Under-Recognized Risk Factor for Candidemia in Colorado

Approximately 1 in 10 patients with candidemia had a history of recent injection drug use based on a surveillance program in the Denver metropolitan area, according to results of a study in Morbidity and Mortality Weekly Report published by the Centers for Disease Control and Prevention.¹

Given the ongoing opioid epidemic, injection drug use has been reported as an increasingly common condition associated with candidemia,² however, little is known about the epidemiology of candidemia in people who inject drugs. Therefore, researchers analyzed data from the Colorado Department of Public Health and Environment’s population-based surveillance for candidemia in the Denver, Colorado, 5-county metropolitan area, encompassing 2.7 million people.

Beginning in May 2017, when the surveillance program began, to August 2018, there were 203 candidemia cases reported. Of the 203 cases, 23 were identified in 22 patients with a history of injection drug use within the 1 year prior to their episode of candidemia. Seven of the 22 patients had disseminated candidiasis with end-organ dysfunction. Researchers noted that 50% experienced homeless or lived in transitional housing, which is a known risk factor for injection drug use. Some comorbidities included hepatitis C infection (n=10), hepatitis B infection (n=1), and HIV infection (n=1).

Candida glabrata, C albicans, and C parapsilosis were the most common Candida species identified. Ten of the 23 cases were identified as community-onset infections, 4 were categorized as community-onset infections with recent exposure to a healthcare setting, 9 patients became infected in the hospital setting, and 6 were observed injecting or attempting to inject drugs while hospitalized.

In the 6 months preceding their candidemia episode, the 22 patients had a mean of 3 previous inpatient or emergency department visits (range = 0-10). Drugs documented in the medical record or identified in urine testing included opioids (n=18), methamphetamines (n=16), cannabinoids (n=7), cocaine (n=6), benzodiazepines (n=4), ecstasy (n=1), and barbiturates (n=1). “These health care encounters provide opportunities for targeted prevention efforts in addition to community-based interventions,” noted the study authors.

Researchers noted that because of the small number patients in this study, results might not be generalizable to other geographic areas.

“Prevention of candidemia and other infections in persons who inject drugs requires both health care and community-based interventions such as education about and resources for reducing [injection drug use], increasing safe injection practices…and initiation of medication-assisted treatment programs for persons injecting opioids,” concluded the authors.

References

1. Barter DM, Johnston HL, Williams SR, Tsay SV, Vallabhaneni S, Bamberg WM. Candida bloodstream infections among persons who inject drugs – Denver Metropolitan Area, Colorado, 2017-2018. MMWR Morb Mortal Wkly Rep. 2019;68(12):285-288.
2. Zhang A, Shrum S, Williams S, et al. The changing epidemiology of candidemia in the United States: injection drug use as an emerging risk factor for candidemia. Presented at: IDWeek 2018; October 3-7, 2018; San Francisco, CA. Abstract 1722.