Clinical Microbiology in Xylazine-Associated Wound Infections

Injection drug use (IDU) containing xylazine has been associated with the development of chronic necrotic wounds, albeit not all are of infectious etiology. This study describes the clinical microbiology of xylazine-associated wound infections to guide antimicrobial prescribing.

We conducted a retrospective, single-center cohort study of adults hospitalized with xylazine-associated wound infections related to IDU from 1 April 2022 to 1 December 2023. Patients were included if they received antimicrobials for suspected wound infections, along with either a positive urine xylazine test or urine fentanyl test with patient-reported xylazine use. Microbiology results of wound and blood cultures were collected. Antimicrobial spectrum and hospital outcomes were described, including multidrug-resistant organisms' isolation, duration of therapy, in-hospital mortality, and 30-day readmission.

A total of 166 patients were included, of whom 81 had wound cultures and 153 had blood cultures collected; more than half had positive cultures (93/166 [56.0%]). Most wound cultures were positive (78/81 [96.3%]), compared to 25.5% of blood cultures (39/153). Approximately 40% of wound cultures were obtained operatively. Gram-positive organisms were isolated in nearly all wound (73/78 [93.6%]) and blood (37/39 [94.9%]) cultures. The predominant causative organisms were methicillin-resistant Staphylococcus aureus (MRSA) (52/93 [55.9%]) and β-hemolytic streptococci (34/93 [36.6%]). Pseudomonas aeruginosa was isolated in wound cultures of 8 patients, 7 with bone and joint infections.

Empiric antimicrobial coverage for suspected xylazine-associated wound infections should include MRSA and β-hemolytic streptococci coverage. Empiric gram-negative and anaerobic coverage may be warranted for those with higher suspicion of bone and joint involvement.