A controlled-release oral opioid supports S. aureus survival in injection drug preparation equipment and may increase bacteremia and endocarditis risk

• Published in: PloS one 2019-08, Vol.14 (8), p.e0219777-e0219777
• Main Authors: Kasper, Katherine J, Manoharan, Iswarya, Hallam, Brian, Coleman, Charlotte E, Koivu, Sharon L, Weir, Matthew A, McCormick, John K, Silverman, Michael S
• Format: Article
• Language: English
• Subjects: Administration, Oral; Bacteremia; Bacteremia - microbiology; Bacteria; Biology and Life Sciences; Care and treatment; Central nervous system depressants; Contamination; Controlled release; Cookers; Delayed-Action Preparations; Drug abuse; Drug Compounding - instrumentation; Drug resistance; Drug use; Drugs; Endocarditis; Endocarditis, Bacterial - microbiology; Engineering and Technology; Equipment Contamination; Filters; Fluid filters; Hydromorphone - administration & dosage; Immunology; Infective endocarditis; Injection; Injections; Laboratories; Mannitol; Medical research; Medicine; Medicine and Health Sciences; Methicillin; Microbial Viability; Narcotics; Opioids; Oxycodone; Patient outcomes; Prescription drugs; Prescription writing; Reduction; Research and Analysis Methods; Risk; Staphylococcus aureus; Staphylococcus aureus - physiology; Staphylococcus aureus infections; Staphylococcus infections; Streptococcus infections; Survival; Water purification; Water vehicles
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0219777

Injection drug use-associated endocarditis (IDUaIE) incidence in Ontario has recently been associated with hydromorphone prescribing rates. Staphylococcus aureus causes the majority of cases of IDUaIE in Ontario and across North America. Hydromorphone controlled-release (Hydromorphone-CR) requires a complex technique for injection and therefore provides multiple opportunities for contamination. Hydromorphone-CR contains several excipients, which could enhance staphylococcal survival and increase risk of contaminating the injectate. Used injection drug preparation equipment (cookers/filters) was collected from persons who inject drugs (PWID), rinsed with water, and plated on Mannitol salt agar. Bacterial isolates from bacteremic PWID were used to assess the survival of S. aureus and Streptococcus pyogenes on cookers/filters with Hydromorphone-CR, hydromorphone immediate-release (Hydromorphone-IR) or oxycodone controlled-release (Oxycodone-CR). The solutions spiked with S. aureus were heated and the remaining viable bacteria enumerated. S. aureus was detected in 12/87 (14%, 95%CI 8-23%) cookers/filters samples used for injection of Hydromorphone-CR. Hydromorphone-CR was the only opioid associated with greater survival of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) on cookers/filters when compared to sterile water vehicle control. There was a ~2 log reduction in the number of S. aureus that survived when cookers/filters were heated. 14% of all cookers/filters used in the preparation of Hydromorphone-CR were contaminated with S. aureus. Hydromorphone-CR prolongs the survival of MRSA and MSSA in cookers/filters. Heating cookers/filters may be a harm-reduction strategy.