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Improving responses to skin & soft tissues infections among people who inject drugs.

Public Health Institute

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Prof V D Hope , Dr H R Sumnall Applications accepted all year round Self-Funded PhD Students Only

About the Project

Skin & soft tissues infections (SSTIs) among people who inject drugs (PWID) are a substantial health problem.[1] They result from the difficulties in maintaining good injection practice and hygiene in the environments were illicit psychoactive drugs (such as heroin) are typically consumed. Infection risks and issues with accessing healthcare are compounded among PWID by the high levels of homelessness, concurrent mental health issues, and marginalisation.[2] SSTIs can be due to wide range of micro-organisms, but they are often due to streptococcal (e.g. iGAS) and staphylococcal (e.g. MRSA) infections. There is evidence that hospital admissions for SSTIs among PWID have increased markedly during recent years[3] and there is also an ongoing problem with outbreaks of MRSA and iGAS infections among PWID.[5,6]
Annually more than a third of PWID in the UK report having an SSTIs,[1,6] and these infections, if untreated or poorly treated, can have severe sequalae (include septicaemia, endocarditis & necrotizing fasciitis).[1] Repeated infections are common, and are associated with long term health problems, disfigurement, disability, and psychological issues.[7] SSTIs among PWID thus result in a considerable burden for healthcare systems;[8] though no recent total UK cost estimates are available, estimates from 2009 indicated annual inpatient costs in England of between £54-84 million.[9]
Initial symptoms are typically abscesses, open sores, and/or cellulitis, and these can usually be easily treated through provision of appropriate ‘wound care’ in the community.[1] Delays in seeking treatment, which are common, and ineffective treatment (including self-treatment) can result in more severe infections and complications.[8] The factors impacting on healthcare seeking, and so effective wound care, are currently unclear as globally these have rarely been examined.
This PhD will look at how responses to SSTIs among people injecting psychoactive drugs can be improved. The focus would be on understanding the facilitators and barriers to promptly accessing, and appropriately utilising, healthcare for SSTIs among PWID in England or Wales, and how the barriers to care can be overcome. It would aim to identify incremental developments to community-based interventions that could improve effective early treatment of SSTIs among PWID, and then access the acceptability of such developments.

The research for this PhD would involve a mixed methods approach, including a literature review, quantitative and qualitative data collection and/or analyses. The research would focus on a defined geographic area (such as a local authority) and could use a realist evaluation framework.

Funding Notes

This project is for UK self funded students only


1. Larney S, Peacock A, Mathers BM, Hickman M, Degenhardt L. A systematic review of injecting-related injury and disease among people who inject drugs. Drug Alcohol Depend. 2017 Feb 1;171:39-49
2. Harris M, Rhodes T. Hepatitis C treatment access and uptake for people who inject drugs: a review mapping the role of social factors. Harm Reduct J. 2013 May 7;10:7
3. Lewer D, Harris M, Hope V. Opiate Injection-Associated Skin, Soft Tissue, and Vascular Infections, England, UK, 1997-2016. Emerg Infect Dis. 2017 Aug;23(8):1400-1403.
4. Bundle N, Bubba L, Coelho J, Kwiatkowska R, Cloke R, King S, Rajan-Iyer J, Courtney-Pillinger M, Beck CR, Hope V, Lamagni T, Brown CS, Jermacane D, Glass R, Desai M, Gobin M, Balasegaram S, Anderson C. .Ongoing outbreak of invasive and non-invasive disease due to group A Streptococcus (GAS) type emm66 among homeless and people who inject drugs in England and Wales, January to December 2016. Euro Surveill. 2017 Jan 19;22(3). pii: 30446.
5. Packer S, Pichon B, Thompson S, Neale J, Njoroge J, Kwiatkowska RM, Oliver I, Telfer M, Doumith M, Buunaaisie C, Heinsbroek E, Hopewell-Kelly N, Desai M, Hope V, Williams OM, Kearns A, Hickman M, Gobin M. Clonal expansion of community-associated meticillin-resistant Staphylococcus aureus (MRSA) in people who inject drugs (PWID): prevalence, risk factors and molecular epidemiology, Bristol, United Kingdom, 2012 to 2017. Euro Surveill. 2019 Mar;24(13).
6. Hope VD, Marongiu A, Parry JV, Ncube F. The extent of injection site infection in injecting drug users: findings from a national surveillance study. Epidemiol Infect. 2010 Oct;138(10):1510-8
7. Harris M, Brathwaite R, Scott J, Gilchrist G, Ciccarone D, Hope V, McGowan CR. Drawing attention to a neglected injecting-related harm: a systematic review of AA amyloidosis among people who inject drugs. Addiction. 2018 Apr 26. doi: 10.1111/add.14257.
8. Hope VD, Ncube F, Parry JV, Hickman M. Healthcare seeking and hospital admissions by people who inject drugs in response to symptoms of injection site infections or injuries in three urban areas of England. Epidemiol Infect. 2015 Jan;143(1):120-31
9. Marks M, Pollock E, Armstrong M, Morris-Jones S, Kidd M, Gothard P, Noursadeghi M, Doherty JF. Needles and the damage done: reasons for admission and financial costs associated with injecting drug use in a Central London Teaching Hospital. J Infect. 2013 Jan; 66(1):95-102.

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