Epidemiologic and clinical characteristics of infective endocarditis: a single-center retrospective study in the Bronx, New York.

OBJECTIVE: There is paucity of data on the epidemiological, microbiological, and clinical characteristics of patients admitted with infective endocarditis (IE) in the Bronx, New York. PATIENT AND METHODS: We conducted a retrospective study at Jacobi Medical Center, a tertiary care hospital in the Bronx. All adult patients who were hospitalized with a primary diagnosis of new-onset IE between January 1st, 2010 and September 30th, 2020 were included. The primary outcome was in-hospital mortality. A logistic regression model was used to identify baseline variables associated with in-hospital mortality. RESULTS: 182 patients were included in this analysis (female sex: 38.5%, median age: 54 years). 46 patients (25.3%) reported intravenous drug use. 153 patients (84.1%) had positive blood cultures. Staphylococcus aureus (S. aureus) was the most common isolated pathogen (45.1% of monomicrobial IE). Nearly half of the cases secondary to S. aureus were methicillin resistant Staphylococcus aureus (MRSA) (34/69). 164 patients (90.1%) were diagnosed with native valve IE. The mitral valve was involved in 32.4% of patients followed by the aortic valve (19.8%). The in-hospital mortality was 18.1%. The mortality was higher in the cohort 2010-2015 compared to the cohort 2016-2020 (22.1% vs 14.6%). Increasing age, MRSA IE, and active malignancy were the only variables found to have significant association with in-hospital death. CONCLUSION: S. aureus was the most common causative agent and MRSA accounted for about half of the S. aureus IE cases. The incidence of IE in patients with intravenous drug use increased over time, while the median age decreased. The in-hospital death rate was higher in 2010-2015 compared to 2016-2020.

Diagnostic Performance of CT-Guided Bone Biopsies in Patients with Suspected Osteomyelitis of the Appendicular and Axial Skeleton with a Focus on Clinical and Technical Factors Associated with Positive Microbiology Culture Results.

PURPOSE: To assess diagnostic performance of CT-guided percutaneous needle bone biopsy (CTNBB) in patients with suspected osteomyelitis and analyze whether certain clinical or technical factors were associated with positive microbiology results. MATERIALS AND METHODS: All CTNBBs performed in a single center for suspected osteomyelitis of the appendicular and axial skeleton during 2003-2018 were retrospectively reviewed. Specific inclusion criteria were clinical and radiologic suspicion of osteomyelitis. Standard of reference was defined using outcome of surgical histopathology and microbiology culture and clinical and imaging follow-up. Technical and clinical data (needle size, comorbidities, clinical factors, laboratory values, blood cultures) were collected. Logistic regression was performed to assess associations between technical and clinical data and microbiology biopsy outcome. RESULTS: A total of 142 CTNBBs were included (46.5% female patients; age ± SD 46.10 y ± 22.8), 72 (50.7%) from the appendicular skeleton and 70 (49.3%) from the axial skeleton. CTNBB showed a sensitivity of 42.5% (95% confidence interval [CI], 32.0%-53.6%) in isolating the causative pathogen. A higher rate of positive microbiology results was found in patients with intravenous drug use (odds ratio [OR] = 5.15; 95% CI, 1.2-21.0; P = .022) and elevated white blood cell count ≥ 10 × 109/L (OR = 3.9; 95% CI, 1.62-9.53; P = .002). Fever (≥ 38°C) was another clinical factor associated with positive microbiology results (OR = 3.6; 95% CI, 1.3-9.6; P = .011). CONCLUSIONS: CTNBB had a low sensitivity of 42.5% for isolating the causative pathogen. Rate of positive microbiology samples was significantly higher in patients with IV drug use, elevated white blood cell count, and fever.

Elevated troponin level as a predictor of inpatient mortality in patients with infective endocarditis in the Southeast United States.

BACKGROUND: Despite recent improvement in management, infective endocarditis (IE) continues to be associated with considerable risk of morbidity and mortality. Early identification of predictors of inpatient mortality is key in improving patient outcomes in IE. The aim of our study was to evaluate the role of serum troponin levels measurements as a marker of increased mortality. METHODS: A case-control study included adult patients with IE admitted to a tertiary care hospital in east Tennessee between December 2012 and July 2017. Cases were defined as patients with definitive IE who died in-hospital; controls were patients who did not die in hospital. First patient admission was included only. Data collected included the patients' demographic and baseline clinical information, microbiological data, injection drug use status, elevated serum troponins levels. RESULTS: Two hundred eighty three patients with definitive IE were included; median (IQR) age was 41 (30-57) years, and 153 (54%) patients were men. One-hundred sixty-four (58%) were injection drug users. The most frequent IE type was: 167 (59%) right-sided, 86 (30%) left-sided, 24 (9%) both left and right-sided, and 10 (4%) device related. The most commonly isolated organism was Staphylococcus aureus (n = 141), and 64% were methicillin-resistant. Two-hundred twelve (75%) patients had a troponin level obtained, and 57 (27%) had an elevated troponin value. Thirty-six (13%) patients died in-hospital; in-hospital mortality was associated elevated troponin values (adjusted odds ratio [adjOR], 7.3; 95%CI, 3.3-15.9), and methicillin-resistant S. aureus IE (adjOR 2.6; 95%CI, 1.2-5.8). Forty-four (16%) patients received IE valve surgery, and none of these patients died in the hospital. CONCLUSION: Inpatient mortality was higher in patients with IE and elevated cardiac troponin levels compared to patients with normal levels.

Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London.

BACKGROUND: The United Kingdom is experiencing an increase in drug-related deaths and serious bacterial infections among its most vulnerable citizens. Cuts to essential services, coupled with a growing homeless population, create a challenging environment to tackle this public health crisis. In this paper, we highlight an underexplored environmental constraint faced by people living and injecting drugs on the streets. Access to water for injection is restricted in the UK, due to legislative and financial barriers. Austerity measures, such as public toilet closures, further restrict the ability of people made homeless to access clean water and protect themselves from health harms. METHODS: We generated questionnaire (n = 455) and in-depth qualitative interview (n = 32) data with people who inject drugs in London for the Care and Prevent study. Participants provided detail on their life history; drug use, injecting and living environments; health conditions and care seeking practices. FINDINGS: A high proportion of the survey sample reported lifetime history of street homelessness (78%), bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts highlight unsafe, potentially dangerous, injection practices in semi-public spaces. Multiple constraints to sourcing sterile water for injection preparation were reported. Alternatives to sterile water included puddle water, toilet cistern water, whisky, cola soda and saliva. Participants who injected heroin and crack cocaine together unanimously reported adding water at two stages during injection preparation: first, adding water as a vehicle for heroin (which was then heated); second, adding cold water to the heroin mixture prior to adding the crack cocaine. This new finding of a stage addition of solvent may represent an additional risk of infection. CONCLUSION: Currently, harm reduction equipment and resources for safe injecting are not meeting the needs of people who inject drugs who are street homeless or unstably housed. Preparation of injections with non-sterile water sources could precipitate bacterial and fungal infections, particularly when used without the application of heat. It is crucial that water for injection, also skin cleaning, is made available for the unstably housed and that harm reduction messaging is tailored to speak to the everyday realities of people who prepare and inject drugs in public spaces.

Infective Endocarditis in the Intravenous Drug Use Population at a Tertiary Hospital in Melbourne, Australia.

BACKGROUND: Infective endocarditis has been associated with underlying cardiac pathology and streptococci infections. Intravenous drug use (IVDU) is increasingly implicated as a contributing factor, resulting in a shift to a younger patient demographic, tricuspid valve involvement, severe staphylococcal infection, and unique management challenges. The objective of this study was to describe the clinical features, management and outcomes of patients with IVDU-associated infective endocarditis in the Australian context. METHODS: A retrospective review of all episodes of IVDU-associated infective endocarditis at a tertiary hospital in Melbourne, Australia, from 2008 to 2015, was conducted. Included cases met Duke Criteria for 'definite' or 'possible' infective endocarditis, and had a history of IVDU within 3 months of presentation. Demographic data, substance use history, clinical features, surgical intervention, follow-up, and mortality data was collected. We explored factors associated with surgical intervention, recurrence and mortality. RESULTS: Fifty-five (55) episodes of IVDU-associated infective endocarditis were identified in 46 patients; the median age was 40 years and 58% were male. The tricuspid valve was most commonly affected (38%), and left heart pathology was documented in 53% of cases. Methicillin-sensitive Staphylococcus aureus was the most common pathogen (67%). Thirty-six (36%) per cent of patients underwent surgical intervention, and all patients received antibiotics as a component of treatment, with a median duration of 42 days (IQR 21, 42 days). Heart failure and a vegetation larger than 1 cm were significantly associated with surgical intervention. Total mortality was 14.5%; surgical mortality was 10%. Opioid replacement therapy and the absence of psychiatric co-morbidities were protective factors for surgical intervention and disease recurrence. CONCLUSIONS: In contrast to common perception, left-sided endocarditis was more common than tricuspid valve endocarditis. Left heart pathology is typically a more severe clinical entity, however, our study determined mortality rates remained similar when compared to right heart pathology. Further research is required to assess rates of left sided disease in the IVDU population, and elucidate the relationship between IVDU and left heart pathology.

Associations between echocardiographic manifestations and bacterial species in patients with infective endocarditis: a cohort study.

BACKGROUND: The diagnosis of infective endocarditis (IE) is based on microbiological analyses and diagnostic imaging of cardiac manifestations. Echocardiography (ECHO) is preferred for visualization of IE-induced cardiac manifestations. We investigated associations between bacterial infections and IE manifestations diagnosed by ECHO. METHODS: In this cohort study, data from patients aged 18 years or above, with definite IE admitted at the Karolinska University Hospital between 2008 and 2017 were obtained from Swedish National Registry of Endocarditis. Bacteria registered as pathogen were primarily selected from positive blood culture and for patients with negative blood culture, bacteria found in culture or PCR from postoperative material was registered as pathogen. Patients with negative results from culture or PCR, and patients who did not undergo ECHO during hospital stay, were excluded. IE manifestations diagnosed by ECHO were obtained from the registry. Chi-squared test and two-sided Fisher's exact test was used for comparisons between categorical variables, and student's t test was used for continuous numerical variables. Multivariable analyses were performed using logistic regression. Secular trend analyses were performed using linear regression. Associations and the strength between the variables were estimated using odds ratios (ORs) with 95% confidence intervals (CIs). P < 0.05 was considered significant. RESULTS: The most common bacteria were Staphylococcus aureus (n = 239, 49%) and viridans group streptococci (n = 102, 21%). The most common manifestations were vegetation in the mitral (n = 195, 40%), aortic (n = 190, 39%), and tricuspid valves (n = 108, 22%). Associations were seen between aortic valve vegetations and Enterococcus faecalis among patients with native aortic valves, between mitral valve vegetations and streptococci of group B or viridans group, between tricuspid valve vegetations and S. aureus among patients with intravenous drug abuse, and between perivalvular abscesses as well as cardiovascular implantable electronic device (CIED)-associated IE and coagulase negative staphylococci (all P < 0.05). CONCLUSIONS: Associations were found between certain bacterial species and specific ECHO manifestations. Our study contributes to a better understanding of IE manifestations and their underlying bacterial etiology, which pathogens can cause severe infections and might require close follow-up and surgical treatment.

Analysis of Anthrax Immune Globulin Intravenous with Antimicrobial Treatment in Injection Drug Users, Scotland, 2009-2010.

We studied anthrax immune globulin intravenous (AIG-IV) use from a 2009-2010 outbreak of Bacillus anthracis soft tissue infection in injection drug users in Scotland, UK, and we compared findings from 15 AIG-IV recipients with findings from 28 nonrecipients. Death rates did not differ significantly between recipients and nonrecipients (33% vs. 21%). However, whereas only 8 (27%) of 30 patients at low risk for death (admission sequential organ failure assessment score of 0-5) received AIG-IV, 7 (54%) of the 13 patients at high risk for death (sequential organ failure assessment score of 6-11) received treatment. AIG-IV recipients had surgery more often and, among survivors, had longer hospital stays than did nonrecipients. AIG-IV recipients were sicker than nonrecipients. This difference and the small number of higher risk patients confound assessment of AIG-IV effectiveness in this outbreak.

Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound.

Purulent pericarditis is a rare but devastating disease process and even when treated, carries a poor prognosis. Cardiac tamponade is the most severe complication of purulent pericarditis and without acute surgical intervention, is often fatal. Diagnosis requires pericardiocentesis; however, early consideration of the disease and its complications in the emergency department (ED) can be life-saving. Here, we present a case of an intravenous drug user who presented with altered mental status and a rectal temperature of 105.4°. While in the ED, the patient acutely decompensated. The ED physician performed bedside cardiac ultrasound that a showed pericardial effusion and right ventricle diastolic collapse concerning for cardiac tamponade. The patient underwent urgent pericardiocentesis which revealed 300 ml of purulent fluid. Both blood and pericardial cultures grew methicillin-sensitive Staphylococcus aureus. Despite a complicated hospital course, with appropriate antibiotic coverage and surgical intervention, the patient was discharged in good neurologic condition. This rare case of purulent pericarditis underscores the utility of bedside ultrasound in the ED and the complicated nature of altered mental status in intravenous drug users.

Infective endocarditis in intravenous drug users: a review article.

Approximately 10% of infective endocarditis (IE) involves the right side of the heart with the majority of these cases occurring in intravenous drug users. Patients are less likely to present with classical IE signs of a new murmur and peripheral stigmata, are more frequently immunocompromised and often have significant social difficulties. These factors result in both diagnostic and therapeutic challenges in this patient group that are not often seen in other patient populations with IE.

Development of a filter to prevent infections with spore-forming bacteria in injecting drug users.

BACKGROUND: In heroin injectors, there have been a number of outbreaks caused by spore-forming bacteria, causing serious infections such as anthrax or botulism. These are, most likely, caused by injecting contaminated heroin, and our aim was to develop a filter that efficiently removes these bacteria and is also likely to be acceptable for use by people who inject drugs (i.e. quick, simple and not spoil the hit). METHODS: A prototype filter was designed and different filter membranes were tested to assess the volume of liquid retained, filtration time and efficiency of the filter at removing bacterial spores. Binding of active ingredients of heroin to different types of membrane filters was determined using a highly sensitive analytical chemistry technique. RESULTS: Heroin samples that were tested contained up to 580 bacteria per gramme, with the majority being Bacillus spp., which are spore-forming soil bacteria. To remove these bacteria, a prototype filter was designed to fit insulin-type syringes, which are commonly used by people who inject drugs (PWIDs). Efficient filtration of heroin samples was achieved by combining a prefilter to remove particles and a 0.22 µm filter to remove bacterial spores. The most suitable membrane was polyethersulfone (PES). This membrane had the shortest filtration time while efficiently removing bacterial spores. No or negligible amounts of active ingredients in heroin were retained by the PES membrane. CONCLUSIONS: This study successfully produced a prototype filter designed to filter bacterial spores from heroin samples. Scaled up production could produce an effective harm reduction tool, especially during outbreaks such as occurred in Europe in 2009/10 and 2012.

Mycotic aneurysm of both internal iliac arteries due to Candida albicans.

We report the case of a 21-year-old man, with a Candida-related endocarditis causing multiple emboli and bilateral false aneurysms of the internal iliac arteries. As the distal runoff vasculatures of both internal iliac arteries were occluded, these arteries required ligation. Although there were few consequences with the procedure, multiple emboli and recurrence of endocarditis after cardiac surgery led to the patient's death.

Injectional anthrax - new presentation of an old disease.

Bacillus anthracis infection (anthrax) has three distinct clinical presentations depending on the route of exposure: cutaneous, gastrointestinal and inhalational anthrax. Each of these can lead to secondary bacteraemia and anthrax meningitis. Since 2009,anthrax has emerged among heroin users in Europe,presenting a novel clinical manifestation, 'injectional anthrax', which has been attributed to contaminated heroin distributed throughout Europe; before 2009 only one case was reported. During 2012 and 2013,new cases of injectional anthrax were diagnosed in Denmark, France, Germany, and the United Kingdom.Here we present a comprehensive review of the literature and information derived from different reporting systems until 31 December 2013. Overall 70 confirmed cases were reported, with 26 fatalities (37% case fatality rate).The latest two confirmed cases occurred in March 2013. Thirteen case reports have been published,describing 18 confirmed cases. Sixteen of these presented as a severe soft tissue infection that differed clinically from cutaneous anthrax, lacked the characteristic epidemiological history of animal contact and ten cases required complimentary surgical debridement. These unfamiliar characteristics have led to delays of three to 12 days in diagnosis, inadequate treatment and a high fatality rate. Clinicians' awareness of this recently described clinical entity is key for early 'and successful management of patients.

Cardiac infection and sepsis in 3 intravenous bath salts drug users.

The street drug "bath salts" are psychoactive mixtures of cathinone derivatives. We report 3 cases of disseminated Staphylococcus aureus infection with cardiac involvement (2 endocarditis and 1 pericarditis), secondary to intravenous bath salts use.

Infections with spore-forming bacteria in persons who inject drugs, 2000-2009.

Since 2000 in the United Kingdom, infections caused by spore-forming bacteria have been associated with increasing illness and death among persons who inject drugs (PWID). To assess temporal and geographic trends in these illnesses (botulism, tetanus, Clostridium novyi infection, and anthrax), we compared rates across England and Scotland for 2000-2009. Overall, 295 infections were reported: 1.45 per 1,000 PWID in England and 4.01 per 1,000 PWID in Scotland. The higher rate in Scotland was mainly attributable to C. novyi infection and anthrax; rates of botulism and tetanus were comparable in both countries. The temporal and geographic clustering of cases of C. novyi and anthrax into outbreaks suggests possible contamination of specific heroin batches; in contrast, the more sporadic nature of tetanus and botulism cases suggests that these spores might more commonly exist in the drug supply or local environment although at varying levels. PWID should be advised about treatment programs, injecting hygiene, risks, and vaccinations.

Profile of infective endocarditis observed from 2003 - 2010 in a single center in Italy.

BACKGROUND: This study aimed to provide a contemporary picture of the epidemiologic, clinical, microbiologic characteristics and in-hospital outcome of infective endocarditis (IE) observed in a single center in Italy. METHODS: We performed a retrospective study of patients with definite or probable IE observed at the "L. Sacco" Hospital in Milan, Italy, from January 1, 2003 through December 31, 2010. RESULTS: 189 episodes of IE in 166 patients were included. The mean number of incident IE in the study period was of 1.27 (range 0.59-1.76) cases per 1000 patients admitted. The median age of the cohort was 57 (interquartile range, 43-72) years, 63% were male and 62.5% had native valve IE. Twenty-six percent were active intravenous drug users (IVDU), 29% had a health care-associated IE and 5% chronic rheumatic disease. Twenty-nine percent of the cases occurred in patients affected by chronic liver disease and 19% in HIV positive subjects. Staphylococcus aureus was the most common pathogen (30%), followed by streptococci. The mitral (34%) and aortic (31%) valves were involved most frequently. The following complications were common: stroke (19%), non-stroke embolizations (25%), heart failure (26%) and intracardiac abscess (9%). Surgical treatment was frequently employed (52%) but in hospital mortality remained high (17%). Health care-associated IE and complications were independently associated with an increased risk of in-hospital death, while surgery was associated with decreased mortality. CONCLUSION: S. aureus emerged as the leading causative organism of IE in a University hospital in northern Italy. Our study confirmed the high in-hospital mortality of IE, particularly if health care associated, and the protective role of surgery.

Anthrax infection among heroin users in Scotland during 2009-2010: a case-control study by linkage to a national drug treatment database.

Using a data-linkage approach, we conducted a case-control study to investigate risk factors in an outbreak of anthrax infection among Scottish heroin users. Factors associated with an increased risk of infection included longer injecting history, receiving opioid substitution therapy, and alcohol consumption. Smoking heroin was associated with lower risk of infection.

Staphylococcus aureus colonization and infection among drug users: identification of hidden networks.

OBJECTIVES: We combined social-network analysis and molecular epidemiology to investigate Staphylococcus aureus among drug users. METHODS: From 2003 through 2005, we recruited adult drug users in Brooklyn, New York. Of 501 individuals recruited, 485 participated. Participants were screened for HIV infection and S. aureus carriage, and they answered a questionnaire assessing risk factors for S. aureus. Participants were asked to nominate up to 10 members of their social networks, and they were invited to recruit nominees to participate. RESULTS: We identified 89 sociocentric risk networks, 1 of which contained 327 (67%) members. One third of participants were either colonized (20%) or infected (19%) with S. aureus. Overall strain similarity was unusually high, suggesting spread within and across networks. In multivariate analysis, 7 health-related and drug-use variables remained independently associated with infection. Moreover, 27% of nominees were not drug users. CONCLUSIONS: We found a large, linked, hidden network among participants, with no discernible clustering of closely related strains. Our results suggest that once a pathogen is introduced into a sociocentric network of active drug users, an identifiable community S. aureus reservoir is likely created, with significant linkages to the general population.

Spatial distribution and characteristics of injecting drug users (IDU) in five Northeastern states of India.

BACKGROUND: Injecting drugs is the major driving force of human immunodeficiency virus (HIV) epidemic in Northeastern India. We have assessed the spatial distribution of locations where injecting drug users (IDU) congregate, as well as the risk behaviour and key characteristics of IDUs to develop new strategies strengthening intervention measures for HIV prevention in this region. METHODS: Locations of IDUs congregation for buying and injecting drugs were identified through Key Informants (KI). Verification of the location and its characteristics were confirmed through field visits. We also conducted semi-structured and structured interviews with IDUs to learn more about their injecting behaviour and other characteristics. RESULTS: Altogether, 2462 IDU locations were identified in 5 states. The number of IDU locations was found to be greater in the states bordering Myanmar. Private houses, parks, abandoned buildings, pharmacies, graveyards, and isolated places were the most frequently chosen place for injecting drugs. Many injecting locations were visited by IDUs of varying ages, of which about 10-20% of locations were for females. In some locations, female IDUs were also involved in sex work. Sharing of needle and syringes was reported in all the states by large proportion of IDUs, mainly with close friends. However, even sharing with strangers was not uncommon. Needle and syringes were mainly procured from pharmacies, drug peddlers and friends. Lack of access to free sterile needles and syringes, and inconsistent supplies from intervention programs, were often given as the cause of sharing or re-use of needles and syringes by IDUs. Most of the IDUs described a negative attitude of the community towards them. CONCLUSION: We highlight the injection of drugs as a problem in 5 Northeastern India states where this is the major driving force of an HIV epidemic. Also highlighted are the large numbers of females that are unrecognized as IDUs and the association between drug use and sex work. Understanding of risk behaviours and other key characteristics of IDUs in the region will help in strengthening harm reduction efforts that can prevent HIV transmission.

Skin and Soft Tissue Infections in Persons Who Inject Drugs.

Persons who inject drugs are at high risk for skin and soft tissue infections. Infections range from simple abscesses and uncomplicated cellulitis to life-threatening and limb-threatening infections. These infections are predominantly caused by gram-positive organisms with Staphylococcus aureus, Streptococcus pyogenes, and other streptococcal species being most common. Although antimicrobial therapy has an important role in treatment of these infections, surgical incision, drainage, and debridement of devitalized tissue are primary. Strategies that decrease the frequency of injection drug use, needle sharing, use of contaminated equipment, and other risk behaviors may be effective in preventing these infections in persons who inject drugs.

The provision of non-needle/syringe drug injecting paraphernalia in the primary prevention of HCV among IDU: a systematic review.

BACKGROUND: Sharing drug injecting paraphernalia other than needles and syringes (N/S) has been implicated in the transmission of Hepatitis C virus (HCV) among injecting drug users (IDU). We aimed to determine whether the provision of sterile non-N/S injecting paraphernalia reduces injecting risk behaviours or HCV transmission among IDU. METHODS: A systematic search of seven databases and the grey literature for articles published January 1989-February 2010 was undertaken. Thirteen studies (twelve observational and one non-randomized uncontrolled pilot intervention) were identified and appraised for study design and quality by two investigators. RESULTS: No studies examined the association between the provision of non-N/S injecting paraphernalia and incident HCV infection. One cross-sectional study found that individuals who frequently, compared to those who infrequently, used sterile cookers and water, were less likely to report prevalent HCV infection. Another found no association between the uptake of sterile non-N/S injecting paraphernalia and self-reported sharing of this paraphernalia. The remaining observational studies used attendance at needle and syringe exchange programmes (NSP) or safer injection facilities (SIF) that provided non-N/S injecting paraphernalia as a proxy measure. Eight studies presented adjusted odds ratios, ranging from 0.3 to 0.9, suggesting a reduced likelihood of self-reported sharing of non-N/S injecting paraphernalia associated with use of NSP or SIF. There was substantial uncertainty associated with these estimates however. Three unadjusted studies reported a reduction in the prevalence of sharing of non-N/S injecting paraphernalia over time among NSP users. Only one study reported an adjusted temporal trend in the prevalence of sharing non-N/S injecting paraphernalia, finding higher rates among non-NSP users than NSP users at each time point, and a greater reduction in sharing among non-NSP than NSP users over time. Study limitations included the use of convenience samples, self-reported exposure and outcome measures, flawed classification of the exposed and unexposed groups, and inadequate adjustment for potential confounding variables. CONCLUSIONS: The evidence to demonstrate that the provision of sterile non-N/S injecting paraphernalia reduces HCV transmission or modifies injecting risk behaviours is currently limited by an insufficient volume and quality of studies. Further research is required to inform practice and policy in this area.