Group A Strep Bloodstream Infections Among People Who Inject Drugs in Vermont, 2020–2023

Invasive group A Streptococcus (GAS) infections had been increasing, according to CDC, and injecting illicit drugs and homelessness are known risk factors. In 2022 and 2023, the University of Vermont Medical Center (UVMMC) noticed a sharp rise in community-acquired GAS bacteremia (bloodstream infection) among adults, and investigated to find ways to improve care.

The rise

A case was Streptococcus pyogenes in a blood culture from a UVMMC patient between January 1, 2020, and October 31, 2023, excluding infections likely acquired in hospital or after recent surgery or childbirth.

Over the same span, emergency department visits rose 19% and admissions less than 2% — far less than the infections.

Cases of GAS bacteremia at UVMMC, 2020–2023. Figure from the report.

Who was affected

Of the 64 cases in 2022–2023, 45 (70%) were in 38 people who inject drugs (currently or previously), the focus of the rest of the report.

• 21 of the 38 were female; the median age was 40.5 (range 22–63).
• In 28 of the 45 cases, the patient was homeless at diagnosis — compared with one of the 19 cases among people who did not inject drugs.
• In 35 cases the patient was injecting at the time; in the other 10, the patient had injected before and was using non-injected drugs.
• Xylazine exposure was self-reported in 12 cases and suspected by a clinician in 7 more, based on wounds typical of xylazine.
• Wounds: 44 of the 45 had skin and soft tissue infections at the same time, and 37 had multiple wounds.
• Missed chances: in the 6 months before diagnosis, 21 of the 38 patients had made 59 visits (one to six each) to UVMMC emergency or urgent care for wound care.

Care and outcomes

Hospital admission for intravenous antibiotics was recommended in every case. In 17 cases, patients had wounds surgically cleaned (debrided), 12 in an operating room and 5 at the bedside. In 23 cases, patients declined admission or left against medical advice. Average stay was 11 days, and two patients died in the hospital.

The xylazine link

The rise followed an increase, first reported in Vermont in late 2021, in xylazine in fatal opioid overdoses. Xylazine narrows blood vessels and reduces blood flow, and has been linked to tissue death (necrosis) at and away from injection sites; it can be present in injected and non-injected drugs. Xylazine wounds may give bacteria a way into the bloodstream, which could partly explain the increase.

What the authors recommended

• Clinicians should consider GAS in people who inject drugs and have signs of bloodstream infection, especially if they have wounds.
• Wound care offered where people who inject drugs can easily reach it might lead to earlier treatment and prevent bloodstream infections.

UVMMC was working to improve links to care for opioid use disorder and wound care, and exploring community wound care with local nongovernmental organizations and public health authorities.

Sources

• Raymond MJ, Wolfe TR, Smith LM. "Notes from the Field: Group A Streptococcus Bacteremia in Persons Who Inject Drugs — Northern Vermont, January 2020–October 2023." Morbidity and Mortality Weekly Report 73(16), Centers for Disease Control and Prevention.