infections in drug users

Infections in Drug UsersInfections in Drug Users

Tahseen J. Siddiqui, M.D

IntroductionIntroduction

• Annually, ~5 % of the global population, or 200 million Annually, ~5 % of the global population, or 200 million people, usepeople, use illicit drugs illicit drugs

• In U.S.19.5 million people 12 yearsIn U.S.19.5 million people 12 years of age or older, or 8.2 of age or older, or 8.2 % of the population, had used% of the population, had used an illicit drug in the prior an illicit drug in the prior month month

• EstimatedEstimated 13 million injection-drug users worldwide, 78% 13 million injection-drug users worldwide, 78% in developing nations in developing nations

• Infections are among the most serious complications of Infections are among the most serious complications of drugdrug use use

• Drug use plays a major role in the transmission of HIV, Drug use plays a major role in the transmission of HIV, STD, viral hepatitis and a diversity of bacterial infectionsSTD, viral hepatitis and a diversity of bacterial infections

Drug Situation: Chicago Drug Situation: Chicago

• Chicago is the major transportation hub and Chicago is the major transportation hub and distribution center for illegal drugs distribution center for illegal drugs throughout the Midwest throughout the Midwest

• drug trafficking groups: Mexico-based poly-drug trafficking groups: Mexico-based poly-drug organizations, Colombian cocaine and drug organizations, Colombian cocaine and heroin trafficking organizations, and heroin trafficking organizations, and Nigerian/West African groups trafficking in Nigerian/West African groups trafficking in Southeast and Southwest Asian heroin.Southeast and Southwest Asian heroin.

• Chicago-based street gangs such as the Chicago-based street gangs such as the Gangster Disciples, Vice Lords, and Latin Gangster Disciples, Vice Lords, and Latin Kings control the distribution and retail sale Kings control the distribution and retail sale of cocaine, heroin, and marijuana of cocaine, heroin, and marijuana

2005 Federal Drug Seizures Cocaine: 2,623.2 kgs. Heroin: 24.1 kgs. Methamphetamine: 14.2 kgs./3,181 du Marijuana: 2,546.2 kgs. Hashish: 3.7 kgs MDMA: 0.3 kgs/78,901 du Meth Lab Incidents: 931

(DEA, state, and local)

DrugsDrugs The Methods of AdmThe Methods of Admininistration istration

MarijuanaMarijuana

• Marijuana Marijuana ("grass"; "pot"; "reefer"; "joint"; "hashish"; ("grass"; "pot"; "reefer"; "joint"; "hashish"; "cannabis"; "weed") - 1 in 3 Americans has used marijuana "cannabis"; "weed") - 1 in 3 Americans has used marijuana at least once and ~10% of the population uses it on a at least once and ~10% of the population uses it on a regular basisregular basis

• Source-the hemp plant (cannabis sativa) and its content of Source-the hemp plant (cannabis sativa) and its content of THCTHC (delta-9-tetrahydrocannabinol) and other cannaboids (delta-9-tetrahydrocannabinol) and other cannaboids found in the leaves and flowering shoots of the plant. found in the leaves and flowering shoots of the plant.

• The effects - may be noted within seconds to minutes after The effects - may be noted within seconds to minutes after inhaling the smoke (from a joint or a pipe) or within 30 to inhaling the smoke (from a joint or a pipe) or within 30 to 60 minutes after ingestion (eating foods containing 60 minutes after ingestion (eating foods containing marijuana such as brownies) marijuana such as brownies)

• SE:SE: Euphoria, relaxation, increased visual, auditory, and Euphoria, relaxation, increased visual, auditory, and taste perceptions and appetite ("munchies") > taste perceptions and appetite ("munchies") > depersonalization, changed body image, incoordination, depersonalization, changed body image, incoordination, disorientation and acute panic reactions- "bad trips" or disorientation and acute panic reactions- "bad trips" or severe paranoia, delirium and hallucinations, blood-shot severe paranoia, delirium and hallucinations, blood-shot eyes; tachycardia, hypertension, bronchodilatation or eyes; tachycardia, hypertension, bronchodilatation or asthma , bronchitis, pharyngitis, and sinusitis, asthma , bronchitis, pharyngitis, and sinusitis,

• Withdrawal effects:Withdrawal effects: agitation agitation, insomnia, anxiety , insomnia, anxiety • Medical properties:Medical properties: treatment of nausea (chemotherapy), treatment of nausea (chemotherapy),

Others claim that appetite stimulant in AIDS or useful in Others claim that appetite stimulant in AIDS or useful in glaucoma. Its active ingredient glaucoma. Its active ingredient (dronabinol)(dronabinol) approved by approved by the FDA for these purposesthe FDA for these purposes

MarijuanaMarijuana

Cocaine Cocaine

• May be inhaled through the nose ("snorting") or dissolved May be inhaled through the nose ("snorting") or dissolved in water and administered intravenously. smokeable form in water and administered intravenously. smokeable form known as freebase or "crack." known as freebase or "crack."

• When mixed with When mixed with heroinheroin, in a single syringe for IV use, , in a single syringe for IV use, the combination is referred to as a "speedball." the combination is referred to as a "speedball."

• SE: Smoking produces an instant and intense but very SE: Smoking produces an instant and intense but very short lived euphoria, local anesthesia, potent CNS short lived euphoria, local anesthesia, potent CNS stimulation, increased confidence, energy, decreased stimulation, increased confidence, energy, decreased inhibitions. extremely pleasurable high, mood swings, inhibitions. extremely pleasurable high, mood swings, depressiondepression, sleep/behavior disorder, memory loss, and , sleep/behavior disorder, memory loss, and social withdrawal. social withdrawal.

Crack cocaineCrack cocaine

• Crack cocaine produced by dissolving Crack cocaine produced by dissolving powdered cocaine in a mixture of water and powdered cocaine in a mixture of water and ammonia or sodium bicarbonate (baking ammonia or sodium bicarbonate (baking soda). The mixture is boiled until a solid soda). The mixture is boiled until a solid substance forms. The solid is removed from substance forms. The solid is removed from the liquid, dried, and then broken into the the liquid, dried, and then broken into the chunks (rocks) that are sold as crack chunks (rocks) that are sold as crack cocaine. cocaine.

Smoking Crack Cocaine

Cocaine Cocaine

CocaineCocaine

HeroinHeroin

• FDA considered heroin abuse to be the # 1 drug FDA considered heroin abuse to be the # 1 drug problem until 1986, when cocaine took the leadproblem until 1986, when cocaine took the lead

• Heroin is still used regularly by 1.5 million in U.S Heroin is still used regularly by 1.5 million in U.S • Most prefer to inject heroin, because the Most prefer to inject heroin, because the

intravenous and subcutaneous routes give a faster, intravenous and subcutaneous routes give a faster, more intense peak effect and because the potency more intense peak effect and because the potency of much street heroin is low of much street heroin is low

• Signs of recent heroin injection are phlebitis and Signs of recent heroin injection are phlebitis and bruises from multiple needlesticks. Long-term bruises from multiple needlesticks. Long-term abuse often causes varying degrees of scarringabuse often causes varying degrees of scarring

HeroinHeroin

• In the liver, heroin undergoes deacetylation to In the liver, heroin undergoes deacetylation to morphine, which is then excreted in the urine. morphine, which is then excreted in the urine. Thus, drug testing for heroin is designed to detect Thus, drug testing for heroin is designed to detect morphine in the urine. As drug testing becomes morphine in the urine. As drug testing becomes increasingly common, it is important to be aware increasingly common, it is important to be aware that commercial poppy seeds may contain enough that commercial poppy seeds may contain enough morphine or codeine to produce positive results on morphine or codeine to produce positive results on urinalysis. urinalysis.

HeroinHeroin

Heroin comes in a white to brown powder or a dark tar-like substance, and is sold in a variety of packaging The most popular form of heroin is a dark tar-like substance called black tar, which is sold in small foil or cellophane packets or in small toy balloons. The most common use of heroin is by injection (called "mainlining" or "shooting"), but in it's powder form it can be inhaled through the nose or smoked.

Black tar heroin and the paraphernalia for Black tar heroin and the paraphernalia for injecting and storing the druginjecting and storing the drug

Paraphernalia for injecting heroin include hypodermic needles, small cotton balls used to strain the drug, and water and spoons or bottle caps used for "cooking" or liquefying the heroin. Paraphernalia for inhaling or smoking heroin includes razor blades, straws, rolled dollar bills, and pipes. The high from the drug usually lasts from four to six hours.

Selected street names and adverse effects of illicit drugsSelected street names and adverse effects of illicit drugs

• CANNABINOIDSCANNABINOIDS • Marijuana and hashish Marijuana and hashish • Bag, Colombian, doobie, dope, grass, hash, Bag, Colombian, doobie, dope, grass, hash,

hump, Jay, joint, lid, Mary Jane, pot, reefer, hump, Jay, joint, lid, Mary Jane, pot, reefer, sinsemilla, weed sinsemilla, weed

• Red eyes, neglect of appearance, loss of Red eyes, neglect of appearance, loss of interest and motivation, possible weight loss interest and motivation, possible weight loss

• OPIATESOPIATES • Heroin Heroin • Black tar, China white, dog food, dreamer, Black tar, China white, dog food, dreamer,

dust, H, horse, junk, scag, smack dust, H, horse, junk, scag, smack • Addiction, severe withdrawal symptoms, Addiction, severe withdrawal symptoms,

loss of appetite, death from overdose loss of appetite, death from overdose


• STIMULANTSSTIMULANTS • Cocaine Cocaine • Bernice, blow, C, coke, crank, flake, freeze, jam, Bernice, blow, C, coke, crank, flake, freeze, jam,

lady, leaf, snow, stardust, toot, white ladylady, leaf, snow, stardust, toot, white lady• Addiction, hypertension, sleeplessness, Addiction, hypertension, sleeplessness,

restlessness, anxiety, lung and nasal damage, restlessness, anxiety, lung and nasal damage, intense high followed by frequent dysphoria, loss intense high followed by frequent dysphoria, loss of appetite, intense psychological dependence, of appetite, intense psychological dependence, death from overdose death from overdose


• Amphetamines Amphetamines • Bennies, black beauties, copilots, crank, crystal, Bennies, black beauties, copilots, crank, crystal,

dexies, eye opener, footballs, glass, hearts, ice, ice dexies, eye opener, footballs, glass, hearts, ice, ice cream, lid, meth, moth, quartz, speed, upperscream, lid, meth, moth, quartz, speed, uppers

• Addiction, hypertension, loss of appetite, Addiction, hypertension, loss of appetite, paranoia, hallucinations, coma, convulsions, paranoia, hallucinations, coma, convulsions, excessive irritability, nervousness, mood swings, excessive irritability, nervousness, mood swings, hyperactivity, brain damage, death from overdose hyperactivity, brain damage, death from overdose


• HALLUCINOGENSHALLUCINOGENS • Lysergic acid diethylamide (LSD) Acid,Lysergic acid diethylamide (LSD) Acid,• barrels, blotters, blue heaven, California sunshine, barrels, blotters, blue heaven, California sunshine,

cubes, domes, flats, frogs, lids, microdot, purple cubes, domes, flats, frogs, lids, microdot, purple haze, sugar cubes, windowpanes haze, sugar cubes, windowpanes

• Dilated pupils, hallucinations, illusions, mood Dilated pupils, hallucinations, illusions, mood swings, flashback, breaks from reality, emotional swings, flashback, breaks from reality, emotional breakdown breakdown



• Mescaline and psilocybin Mescaline and psilocybin • Buttons, cactus, magic mushrooms, mesc, Buttons, cactus, magic mushrooms, mesc,

TMA (a mixture of mescaline, LSD, and TMA (a mixture of mescaline, LSD, and marijuana) marijuana)

• Dilated pupils, hallucinations, illusions, Dilated pupils, hallucinations, illusions, mood swings, breaks from reality, mood swings, breaks from reality, emotional breakdown emotional breakdown


• Phencyclidine (PCP) Phencyclidine (PCP) • Angel dust, clicker, crystal, dummy dust, hog, Angel dust, clicker, crystal, dummy dust, hog,

horse, killer, krystal joints, love, mint weed, horse, killer, krystal joints, love, mint weed, PeaCe Pill, sherms, super grass, weed PeaCe Pill, sherms, super grass, weed

• Slurred speech, blurred vision, confusion, Slurred speech, blurred vision, confusion, agitation, aggression, ataxia, anxiety, depression, agitation, aggression, ataxia, anxiety, depression, impaired memory and perception, acute psychosis, impaired memory and perception, acute psychosis, convulsions, increased heart rate and blood convulsions, increased heart rate and blood pressure, death from accidents or overdose pressure, death from accidents or overdose


• Methylated amphetamines Methylated amphetamines • ("designer drugs") Adam, China white, ("designer drugs") Adam, China white,

ecstasy, Eve, love drug, MDA, X, XTCecstasy, Eve, love drug, MDA, X, XTC• Hypertensive crisis, hallucinations, nausea, Hypertensive crisis, hallucinations, nausea,

confusion, sleeplessness, increased blood confusion, sleeplessness, increased blood pressure, profuse sweating, mood elevation pressure, profuse sweating, mood elevation

Crystal MethamphetamineCrystal Methamphetamine

• ““Ice and Glass” colorless, odorless form of d-Ice and Glass” colorless, odorless form of d-methamphetamine resembles small fragments of methamphetamine resembles small fragments of glass or shiny blue-white "rocks" of various sizes. glass or shiny blue-white "rocks" of various sizes.

• has a higher purity level and may produce even has a higher purity level and may produce even longer-lasting and more intense physiological longer-lasting and more intense physiological effects than the powdered form of the drug. effects than the powdered form of the drug.

• typically is smoked using glass pipes similar to typically is smoked using glass pipes similar to pipes used to smoke crack cocaine. pipes used to smoke crack cocaine.

• Crystal methamphetamine also may be injected. Crystal methamphetamine also may be injected.

EpidemiologyEpidemiology

• Most bacterial infections among drug users are Most bacterial infections among drug users are caused by commensal flora, with caused by commensal flora, with Staphylococcus Staphylococcus aureusaureus and and streptococcusstreptococcus. .

• Outbreaks caused by unusual organisms,Outbreaks caused by unusual organisms, such as such as clostridiaclostridia species and species and Pseudomonas aeruginosaPseudomonas aeruginosa,, indicateindicate a particular drug or drug-use behavior a particular drug or drug-use behavior

• Skin and soft-tissueSkin and soft-tissue infections are most common infections are most common• Study of injection-drug users in SanStudy of injection-drug users in San Francisco Francisco

found that found that 32 %32 % had an abscess, cellulitis, had an abscess, cellulitis, or both or both


• Injection-drug users whoInjection-drug users who lack viable veins for use lack viable veins for use commonly resort to commonly resort to "skin popping""skin popping" (subcutaneous or (subcutaneous or intramuscular injection) and have higher risk of soft-tissue intramuscular injection) and have higher risk of soft-tissue infection infection

• Injecting Injecting "speedballs""speedballs" (mixtures of cocaine and heroin) (mixtures of cocaine and heroin) and and HIVHIV infection were also associated with infection were also associated with skin abscesses skin abscesses

• Using dirty needles, failing to clean theUsing dirty needles, failing to clean the skin before skin before injection, and injection, and "booting""booting" (repeatedly flushing and (repeatedly flushing and pulling pulling back during injection) may also increase the risk ofback during injection) may also increase the risk of abscess abscess

• An upsurge in skin infections, primarily abscesses, as wellAn upsurge in skin infections, primarily abscesses, as well

as, necrotizing fasciitis among injection-drug users has as, necrotizing fasciitis among injection-drug users has been caused by been caused by CA-MRSACA-MRSA


• Infective Endocarditis (IE): Infective Endocarditis (IE): incidence 1.5 toincidence 1.5 to 3.3 cases per 1000 injection-drug 3.3 cases per 1000 injection-drug users per year users per year

• Colonization with Colonization with S. aureus, S. aureus, history of IE, HIV (<200 CD4) and cocaine use - history of IE, HIV (<200 CD4) and cocaine use - contributecontribute

• Community-AcquiredCommunity-Acquired Pneumonia:Pneumonia: ((AspirationAspiration))10-fold increase, smoking, malnutrition, HIV infection contribute10-fold increase, smoking, malnutrition, HIV infection contributePulmonary TuberculosisPulmonary Tuberculosis: Risk factors > crowded living conditions (homeless: Risk factors > crowded living conditions (homeless

shelters, "crack" cocaine houses and "shootingshelters, "crack" cocaine houses and "shooting galleries"), delays in diagnosis, galleries"), delays in diagnosis, poor adherence to treatmentpoor adherence to treatment and HIV/AIDSand HIV/AIDS

• ““Shotgunning"Shotgunning" (smoking and inhaling (smoking and inhaling a drug and then expelling the smoke into a drug and then expelling the smoke into another person's mouth),another person's mouth), a common practice among smokers of crack cocaine a common practice among smokers of crack cocaine

• InhalingInhaling cocaine also predisposes drug users to upper respiratory tractcocaine also predisposes drug users to upper respiratory tract infections, infections, including including SinusitisSinusitis and and SeptalSeptal Abscesses Abscesses

PathogenesisPathogenesis

• Bacteria causes infections in drug users are Bacteria causes infections in drug users are acquired:acquired:• Drug user's commensal floraDrug user's commensal flora • OrganismsOrganisms contaminating the drugs, drug contaminating the drugs, drug

adulterants, or paraphernaliaadulterants, or paraphernalia

Role of Commensal FloraRole of Commensal Flora

• Drug users have a higher rate of nasal or skin colonizationDrug users have a higher rate of nasal or skin colonization with with S. aureusS. aureus

• InfectionsInfections occur when commensal flora is introduced into the occur when commensal flora is introduced into the surroundingsurrounding tissues or bloodstream through injection tissues or bloodstream through injection

• Poor hygienePoor hygiene may exacerbate the risk - fail to clean may exacerbate the risk - fail to clean injection injection sites. injecting at heavily colonized sites (femoral vein- gram-sites. injecting at heavily colonized sites (femoral vein- gram-negative flora), crushing capsules/tablets in mouth whennegative flora), crushing capsules/tablets in mouth when

preparing them for IV injection, blowing outpreparing them for IV injection, blowing out needle clots or needle clots or licking needles to facilitate injection (oral streptococcal and licking needles to facilitate injection (oral streptococcal and anaerobic species)anaerobic species)

• Equipment may be rinsed only with water, or saliva or even Equipment may be rinsed only with water, or saliva or even with toilet waterwith toilet water

Sharing of Drug ParaphernaliaSharing of Drug Paraphernalia

• Studies suggest that Studies suggest that S. aureusS. aureus and and Streptococcus pyogenesStreptococcus pyogenes transmits through drug-use networks and shared drug transmits through drug-use networks and shared drug paraphernaliaparaphernalia

• In the first U.S. outbreak of In the first U.S. outbreak of CA-MRSACA-MRSA among among injection-drug injection-drug users, the epidemic strain was cultured fromusers, the epidemic strain was cultured from a needle used by one a needle used by one of the patients of the patients

• In Boston outbreak of In Boston outbreak of S. aureusS. aureus bacteremia in injection-drug bacteremia in injection-drug users causedusers caused by a single strain ,injected by a by a single strain ,injected by a "street"street doctor"doctor" at the at the same same "shooting gallery""shooting gallery" using the gallery's using the gallery's drug paraphernaliadrug paraphernalia

• Study showed 26 %) of inhalationalStudy showed 26 %) of inhalational drugs users had nasal drugs users had nasal colonizationcolonization with with S. aureusS. aureus and 8 % of their and 8 % of their inhalational inhalational paraphernalia were positive for paraphernalia were positive for S. aureusS. aureus. (Quagliarello. (Quagliarello et al)et al)

Transmission through Drugs or Transmission through Drugs or Drug AdulterantsDrug Adulterants and and Drug PreparationDrug Preparation

• Black-tar heroin becomesBlack-tar heroin becomes contaminated with contaminated with clostridial sporesclostridial spores when when mixed with adulterants (e.g.,mixed with adulterants (e.g., methamphetamine or strychnine) or methamphetamine or strychnine) or diluted ("cut") with substancesdiluted ("cut") with substances such as dextrose or dyed paper such as dextrose or dyed paper

• The iv combination of pentazocineThe iv combination of pentazocine (an analgesic) and (an analgesic) and tripelennamine (an antihistamine), referredtripelennamine (an antihistamine), referred to as "Ts and Blues," or to as "Ts and Blues," or TaBsTaBs, which was popular in Chicago, which was popular in Chicago in the late 1970s, caused an in the late 1970s, caused an outbreak of infectiveoutbreak of infective endocarditis due to endocarditis due to P. aeruginosaP. aeruginosa at Cook County at Cook County HospitalHospital - The tablets were crushed- The tablets were crushed and then mixed with warm tap and then mixed with warm tap water before injection water before injection

• A series of groinA series of groin abscesses due to abscesses due to S. milleriS. milleri in Scotland, where in Scotland, where it it was common to crush buprenorphine (an opioid) and temazepamwas common to crush buprenorphine (an opioid) and temazepam (a (a benzodiazepine) between the teeth and then inject it afterbenzodiazepine) between the teeth and then inject it after cleaning cleaning the skin with saliva the skin with saliva

Gordon R and Lowy F. N Engl J Med 2005;353:1945-1954

Organisms Responsible for Bacterial Infections in Drug Users

Skin, Soft-Tissue & Musculoskeletal InfectionsSkin, Soft-Tissue & Musculoskeletal Infections

• Result fromResult from nonsterile injections, sharing of equipment, nonsterile injections, sharing of equipment, poor personalpoor personal hygiene, subcutaneous injection into deltoid hygiene, subcutaneous injection into deltoid muscles and thighs and injection into the veinsmuscles and thighs and injection into the veins of the neck of the neck or groin.or groin.

• Staphylococcus aureusStaphylococcus aureus is the main agent, (replacing is the main agent, (replacing Candida Sp. & Pseudomonas) followedCandida Sp. & Pseudomonas) followed by various by various streptococci, aerobic gram-negative rods, anaerobicstreptococci, aerobic gram-negative rods, anaerobic cocci, cocci, and bacilli A syndrome of severe dermatitis, eosinophilia, and bacilli A syndrome of severe dermatitis, eosinophilia, and dermatopathicand dermatopathic lymphadenopathy has recently been lymphadenopathy has recently been described in two intravenousdescribed in two intravenous drug users with dual infection drug users with dual infection with HIV with HIV


• Community-associated MRSACommunity-associated MRSA should be should be considered as a potential cause of skin & soft considered as a potential cause of skin & soft tissue abscesses in all injection drug userstissue abscesses in all injection drug users

• Septic arthritisSeptic arthritis and and osteomyelitisosteomyelitis, (vertebral , (vertebral spine/knee/sternoclavicularspine/knee/sternoclavicular and sacroiliac joints) and sacroiliac joints) from hematogenous seeding or local extension of from hematogenous seeding or local extension of a skin or soft-tissue infection a skin or soft-tissue infection

• Injecting in high-risk areas suchInjecting in high-risk areas such as the jugular vein as the jugular vein ("pocket shot") and femoral vein ("groin("pocket shot") and femoral vein ("groin hit")hit")

• More likelyMore likely to be polymicrobial or anaerobic to be polymicrobial or anaerobic


• From transient rheumatologicFrom transient rheumatologic prodrome of hepatitis B prodrome of hepatitis B antigenemia to chronic amyloidosisantigenemia to chronic amyloidosis

• Cocaine can cause muscle and skin infarction and rhabdomyolysis after Cocaine can cause muscle and skin infarction and rhabdomyolysis after

"free-basing" cocaine, sometimes with renal failure and shock after "free-basing" cocaine, sometimes with renal failure and shock after

intravenous injection or inhalation of free-base cocaine (crack) or both intravenous injection or inhalation of free-base cocaine (crack) or both

• Rhabdomyolysis and shock has been reported due to intravenous Rhabdomyolysis and shock has been reported due to intravenous

methamphetamine or phenmetrazine or with heroin.methamphetamine or phenmetrazine or with heroin.

HeroinHeroinSkin, Soft-Tissue & Musculoskeletal InfectionsSkin, Soft-Tissue & Musculoskeletal Infections

Heroin Heroin Skin, Soft-Tissue & Musculoskeletal InfectionsSkin, Soft-Tissue & Musculoskeletal Infections


Soft-Tissue Abscess on the Leg of an Injection-Drug User. "Track" marks from injections extend along the calf.

Provided courtesy of Robert Gwizdala.CA-MRSA PDF

MRI in an Injection-Drug User with Vertebral Osteomyelitis Involving T6–T7 (Arrow) with an Adjacent Epidural Abscess. Culture grew Enterobacter cloacae.

Endovascular InfectionsEndovascular Infections

• Infective endocarditis, septicInfective endocarditis, septic thrombophlebitis (septic PE), mycotic thrombophlebitis (septic PE), mycotic aneurysms (subclavian, carotid and pulmonary arteries) , and sepsis, aneurysms (subclavian, carotid and pulmonary arteries) , and sepsis, are among theare among the most serious complications of injection-drug use most serious complications of injection-drug use

• InfectiveInfective endocarditisendocarditis is most commonly due to is most commonly due to S. aureus (including S. aureus (including MRSA) MRSA) and involves the tricuspid valve in 70 % ofand involves the tricuspid valve in 70 % of patientspatients

• Other organasims-streptococci, gram-negative bacilli (Other organasims-streptococci, gram-negative bacilli (Pseudomonas Pseudomonas aeruginosa-use of pentazocine and tripelennamine ("T's and blues") in aeruginosa-use of pentazocine and tripelennamine ("T's and blues") in Detroit ), Serratia (San Francisco), Detroit ), Serratia (San Francisco), respiratory flora, respiratory flora, CandidaCandida, , anaerobes-anaerobes- polymicrobial infections polymicrobial infections

• Symptoms may include fever, dyspnea, pleuritic chestSymptoms may include fever, dyspnea, pleuritic chest pain, and cough pain, and cough • The mortality rateThe mortality rate < < 5 percent (high in AIDS)5 percent (high in AIDS)• Treatment for 2-4 weeks of ABX therapy Treatment for 2-4 weeks of ABX therapy

(Nafcillin/Vancomycin/D(Nafcillin/Vancomycin/Daptomycin/,aptomycin/, Gentamicin/Rifampin) Gentamicin/Rifampin)

Tricuspid Endocarditis & Tricuspid Endocarditis & Septic Pulmonary Emboli Septic Pulmonary Emboli

Right-sided staphylococcal endocarditis and multiple embolic pyogenic abscesses

Petechial rash due to right-sided staph endocarditis

Tricuspid valve endocarditis with Staphylococcus aureus, and multiple septic pulmonary emboli, prominent in the right upper lobe with both solid and cavitary appearance.

Parasternal long axis view from a transthoracic echocardiogram. There is a small curvilinear vegetation on the mitral valve as indicated

Septicemia and Disseminated Infections Septicemia and Disseminated Infections (Other Than Endocarditis)(Other Than Endocarditis)

• Group A, ß-hemolyticGroup A, ß-hemolytic, streptococcal septicemia (skin colonization) with, streptococcal septicemia (skin colonization) with high high fever, toxicity, and renal failure from either septic thrombophlebitisfever, toxicity, and renal failure from either septic thrombophlebitis or cellulitisor cellulitis

• Candida parapsilosisCandida parapsilosis has been isolated has been isolated from street heroin containers and from street heroin containers and injection apparatus injection apparatus

• Disseminated Disseminated Candida albicansCandida albicans infection described in Europe during the 1980s infection described in Europe during the 1980s had its source in the contaminated lemon juice used to dissolve the brown heroin had its source in the contaminated lemon juice used to dissolve the brown heroin

• AspergillusAspergillus and and mucormycoticmucormycotic [zygomycotic]) brain & renal abscesses (HIV) - [zygomycotic]) brain & renal abscesses (HIV) - AspergillusAspergillus has been detected in contaminated has been detected in contaminated street heroin street heroin

• Disseminated Disseminated RhodococcusRhodococcus equiequi infection, infection, listeriosislisteriosis, , nocardiosisnocardiosis (pulmonary (pulmonary

and brain abscess), relapsing and brain abscess), relapsing SalmonellaSalmonella septicemia, and pyomyositis in septicemia, and pyomyositis in intravenous drug users with advancedintravenous drug users with advanced HIV infection HIV infection

• Pericarditis due to Pericarditis due to Bacillus cereusBacillus cereus has been described has been described in intravenous drug user in intravenous drug user with renal insufficiency on hemodialysis.with renal insufficiency on hemodialysis. Bacillus cereusBacillus cereus spores were recovered spores were recovered from street heroin andfrom street heroin and his injection paraphernalia his injection paraphernalia

Respiratory Tract InfectionsRespiratory Tract Infections

• Drug users have increased incidence of bacterial pneumonia, Drug users have increased incidence of bacterial pneumonia, especiallyespecially that due to that due to Haemophilus influenzaeHaemophilus influenzae

• Aspiration pneumonia Aspiration pneumonia as well as CAP pneumoniaas well as CAP pneumonia caused by caused by S. S. pneumoniaepneumoniae, , H. influenzaeH. influenzae, , S. aureusS. aureus,, and and Klebsiella pneumoniaeKlebsiella pneumoniae are are among the most common reasonsamong the most common reasons for hospitalization for hospitalization

• Unusual organismsUnusual organisms include include Corynebacterium equiCorynebacterium equi (now (now Rhodococcus Rhodococcus equiequi) and) and NocardiaNocardia

• Undiagnosed HIV can first becomeUndiagnosed HIV can first become evident as evident as PCPPCP pneumonia. pneumonia. • SepticSeptic pulmonary emboli producpulmonary emboli producining pneumonias and lung abscesses in g pneumonias and lung abscesses in

Tricuspid endocarditisTricuspid endocarditis• Tuberculosis Tuberculosis with HIV in crack users - presentwith HIV in crack users - presentining withg with pneumonia pneumonia

atypicallyatypically (i.e., without cavitary lesions), PPD negative. Only hilar or (i.e., without cavitary lesions), PPD negative. Only hilar or mediastmediastininal lymphadenopathyal lymphadenopathy

Non Infectious Pulmonary ComplicationsNon Infectious Pulmonary Complications

• Crack cocianeCrack cociane inhalation causes focal air-space disease, inhalation causes focal air-space disease, atelectasis, atelectasis, alveolar hemorrhage, pneumothorax,alveolar hemorrhage, pneumothorax, pneumomediastinum, bronchiolitis pneumomediastinum, bronchiolitis obliterans, organizingobliterans, organizing pneumonia (BOOP), pulmonary infarction, and pneumonia (BOOP), pulmonary infarction, and pulmonary edema. pulmonary edema.

• Pulmonary edema - anPulmonary edema - an important feature of important feature of heroin heroin abuse and a major cause abuse and a major cause of deathof death

• Injecting insoluble additives or fillers (Injecting insoluble additives or fillers (talc and starchtalc and starch) can produce chronic granulomatous ) can produce chronic granulomatous

inflammation and angiothrombosis and even delayed emphysemainflammation and angiothrombosis and even delayed emphysema

• ““Pocket shot"Pocket shot" - - injection into the supraclavicular fossa in an attempt to hit the jugular, injection into the supraclavicular fossa in an attempt to hit the jugular,

subclavian, or brachiocephalic veins can causesubclavian, or brachiocephalic veins can cause pneumo-hemothorax and pyopneumothorax, pneumo-hemothorax and pyopneumothorax,

cellulitis, abscess, or a large hematoma forming a pseudoaneurysmcellulitis, abscess, or a large hematoma forming a pseudoaneurysm

Cocaine induced eosinophilic lung Cocaine induced eosinophilic lung diseasedisease

fever, bronchoconstriction, hypoxaemia, pulmonary

infiltrates, and serum and bronchoalveolar lavage fluid eosinophilia after inhaling crack cocaine, resolved promptly after treatment with corticosteroids.

Cocaine Lung

Toxic oedema prsented as six month history of malaise and recently increasing haemoptysis

Pulmonary edema

Pulmonary haemorrhage

Pulmonary barotrauma (Air escaping lungs by holding in crack smoke)

Foreign bodies in lungs

'Crack Lung' - Cough, shortness breath, fever,

Talc in the lung

Drug abuse. Injecting drugs (heroin, methamphetamine, cocaine...) that are frequently "cut" with talc will cause serious damage

Septicemia and Disseminated InfectionsSepticemia and Disseminated Infections

Clostridial infections Clostridial infections

• A unique association exists between clostridial A unique association exists between clostridial infections andinfections and the use of the use of black-tar heroinblack-tar heroin, a form of , a form of heroin produced in Mexico heroin produced in Mexico

• Botulism:Botulism: Epidemic of wound botulism occurred Epidemic of wound botulism occurred inin California durCalifornia duriningg the 1990s (Skin Popping)the 1990s (Skin Popping)

• Tetanus:Tetanus: (heroin skin popping) due to contamination of (heroin skin popping) due to contamination of drugs with drugs with Clostridium tetaniClostridium tetani

• C. sordelliiC. sordellii:: Necrotizing fasciitis with toxic shock Necrotizing fasciitis with toxic shock syndrome syndrome

• C. novyiC. novyi and and C. perfringensC. perfringens also causes soft-tissue also causes soft-tissue infection in injection-drug users infection in injection-drug users

Pulmonary and Cardiovascular Complications of IV Drug UsePulmonary and Cardiovascular Complications of IV Drug Use

Charles E. Cherubin and Joseph D. Sapira

Gordon R and Lowy F. N Engl J Med 2005;353:1945-1954

Initial Management of Bacterial Infectious Syndromes among Suspected Drug Users

Syphilis and Other Sexually Transmitted DiseasesSyphilis and Other Sexually Transmitted Diseases

• Number of persons with syphilisNumber of persons with syphilis is now increasing and the is now increasing and the major component of this epidemiologicmajor component of this epidemiologic wave is the drug wave is the drug user user

• A substantial proportion of intravenous drug users areA substantial proportion of intravenous drug users are part part of the HIV-infected population, the problems of diagnosisof the HIV-infected population, the problems of diagnosis

and treatment of syphilis are more complicated – and treatment of syphilis are more complicated – (Seronegative(Seronegative secondary syphilis occurs in HIV-infected secondary syphilis occurs in HIV-infected persons) persons)

• Gonorrhea, pelvic inflammatory disease, cervical Gonorrhea, pelvic inflammatory disease, cervical dysplasia,dysplasia, chancroid, and nongonorrheal urethritis are also chancroid, and nongonorrheal urethritis are also seen more frequentlyseen more frequently in the intravenous drug user in the intravenous drug user

ReferencesReferences

• Bacterial Infections in Drug UsersBacterial Infections in Drug UsersRachel J. Gordon, M.D., M.P.H., and Franklin D. Lowy, M.D. Rachel J. Gordon, M.D., M.P.H., and Franklin D. Lowy, M.D. Volume Volume 353:1945-1954353:1945-1954November 3, 2005November 3, 2005 Number 18Number 18

• DEA Multimedia library.DEA Multimedia library.• National Drug Intelligence Center (NDIC) National Drug Intelligence Center (NDIC)

(www.usdoj.gov/ndic/pubs3/3843/images/photo1.jpg) (www.usdoj.gov/ndic/pubs3/3843/images/photo1.jpg) • www.interpol.int/Public/Drugs/cocaine/image2.jpg www.interpol.int/Public/Drugs/cocaine/image2.jpg • www.chp.ca.gov/dre/images/cocaine/cocaine4.gif www.chp.ca.gov/dre/images/cocaine/cocaine4.gif • www.chp.ca.gov/dre/html/heroin.htmlwww.chp.ca.gov/dre/html/heroin.html • www.stopdrugs.org/images/heroin2.jpg www.stopdrugs.org/images/heroin2.jpg • http://www.emedicine.com/emerg/topic164.htm#section~pictureshttp://www.emedicine.com/emerg/topic164.htm#section~pictures• Injecting Drug Use: Injecting Drug Use: http://www.emedicine.com/med/topic586.htmhttp://www.emedicine.com/med/topic586.htm• Thorax, Vol 47, 478-479, Copyright © 1992 by Thorax. Thorax, Vol 47, 478-479, Copyright © 1992 by Thorax. • The Medical Complications of Drug Addiction and the Medical Assessment of the Intravenous Drug The Medical Complications of Drug Addiction and the Medical Assessment of the Intravenous Drug

User: 25 Years LaterUser: 25 Years Later, , Charles E. Charles E. CherubinCherubin 15 November 1993 | Volume 119 Issue 10 | Pages 1017-1028 15 November 1993 | Volume 119 Issue 10 | Pages 1017-1028

infections in drug users

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