Article Text

Social and structural determinants of injecting-related bacterial and fungal infections among people who inject drugs: protocol for a mixed studies systematic review
  1. Thomas D Brothers1,2,
  2. Dan Lewer1,
  3. Matthew Bonn3,
  4. Duncan Webster2,4,
  5. Magdalena Harris5
  1. 1UCL Collaborative Centre for Inclusion Health, Institue of Epidemiology and Health Care, University College London, London, UK
  2. 2Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
  3. 3Canadian Association of People Who Use Drugs, Dartmouth, Nova Scotia, Canada
  4. 4Division of Infectious Diseases, Saint John Regional Hospital, Saint John, New Brunswick, Canada
  5. 5Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to Dr Thomas D Brothers; thomas.brothers{at}


Introduction Injecting-related bacterial and fungal infections are a common complication among people who inject drugs (PWID), associated with significant morbidity and mortality. Invasive infections, including infective endocarditis, appear to be increasing in incidence. To date, preventive efforts have focused on modifying individual-level risk behaviours (eg, hand-washing and skin-cleaning) without much success in reducing the population-level impact of these infections. Learning from successes in HIV prevention, there may be great value in looking beyond individual-level risk behaviours to the social determinants of health. Specifically, the risk environment conceptual framework identifies how social, physical, economic and political environmental factors facilitate and constrain individual behaviour, and therefore influence health outcomes. Understanding the social and structural determinants of injecting-related bacterial and fungal infections could help to identify new targets for prevention efforts in the face of increasing incidence of severe disease.

Methods and analysis This is a protocol for a systematic review. We will review studies of PWID and investigate associations between risk factors (both individual-level and social/structural-level) and the incidence of hospitalisation or death due to injecting-related bacterial infections (skin and soft-tissue infections, bacteraemia, infective endocarditis, osteomyelitis, septic arthritis, epidural abscess and others). We will include quantitative, qualitative and mixed methods studies. Using directed content analysis, we will code risk factors for these infection-related outcomes according to their contributions to the risk environment in type (social, physical, economic or political) and level (microenvironmental or macroenvironmental). We will also code and present risk factors at each stage in the process of drug acquisition, preparation, injection, superficial infection care, severe infection care or hospitalisation, and outcomes after infection or hospital discharge.

Ethics and dissemination As an analysis of the published literature, no ethics approval is required. The findings will inform a research agenda to develop and implement social/structural interventions aimed at reducing the burden of disease.

PROSPERO registration number CRD42021231411.

  • substance misuse
  • infectious diseases
  • social medicine
  • public health
  • public health
  • epidemiology

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  • Twitter @tdbrothers, @danlewer, @matthew__bonn, @pwidpride

  • Contributors This study was conceived by TDB, DL, MB, DW and MH. The pilot search strategy was developed by TDB, and revised with input from DL and MB. TDB, DL and MB will be involved in the data collection for this study. All authors will be involved in data interpretation and analysis. TDB wrote the first draft of this manuscript. All authors provided critical feedback and intellectual input. All authors provided their final approval for the publication of this version of the manuscript. As guarantor, TDB accepts full responsibility for the work and controlled the decision to publish.

  • Funding TDB is supported by the Dalhousie University Internal Medicine Research Foundation Fellowship, Killam Postgraduate Scholarship, Ross Stewart Smith Memorial Fellowship in Medical Research and Clinician Investigator Programme Graduate Stipend (all from Dalhousie University Faculty of Medicine), a Canadian Institutes of Health Research Fellowship (CIHR-FRN# 171 259), and through the Research in Addiction Medicine Scholars (RAMS) Programme (National Institutes of Health/National Institute on Drug Abuse; R25DA033211). DL is funded by a National Institute of Health Research Doctoral Research Fellowship (DRF-2018–11-ST2-016). MB was supported in this work via the Ross Stewart Smith Memorial Fellowship in Medical Research, from Dalhousie University Faculty of Medicine. MH is funded by a National Institute of Health Research Career Development Fellowship (CDF-2016-09-014).

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. These funders had no role in the conduct or reporting of the research.

  • Competing interests MB reports personal fees from AbbVie, a pharmaceutical research and development company, and grants and personal fees from Gilead Sciences, a research-based biopharmaceutical company, outside of the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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