heroin and Soft-Tissue-Infections

Topics: Epidemics; Heroin; Humans; Narcotics; Skin Diseases, Bacterial; Soft Tissue Infections; Substance Abuse, Intravenous; United States

Unusual human behavior leads to the emergence of new forms of infectious diseases and new routes of infection. In recent years, a new form of anthrax, called injectional anthrax, emerged and was related to 2 human anthrax outbreaks in Europe. The infection was caused by heroin contaminated with anthrax spores. The new form of anthrax differs from the earlier known "natural" forms of the disease in symptoms, length of the incubation period and recommended treatment. Despite medical treatment, the mortality rate in injectional anthrax is about 35%. This article presents an overview of the forms of anthrax infection in humans, with focus on injectional anthrax syndrome, as well as actual recommendations for treatment, including antibiotic therapy, surgery and possibilities of administering anthrax antitoxin. As a source of contamination of heroin have not been identified and new cases of injectional anthrax might occur again in any country in the future.

Topics: Anthrax; Bacillus anthracis; Drug Contamination; Drug Users; Heroin; Humans; Soft Tissue Infections; Substance Abuse, Intravenous

Topics: Cocaine; Heroin; Humans; Hypnotics and Sedatives; Methamphetamine; Skin Diseases; Skin Diseases, Infectious; Soft Tissue Infections; Substance Abuse Detection; Substance-Related Disorders

In 2000, a series of cases of necrotizing fasciitis (NF) among injection users of black tar heroin was observed in our Emergency Department (ED). The description of these cases characterizes the ED presentation of NF, focusing on the sensitivity of physical signs and ED diagnostic tests. All cases of pathologically determined NF in 2000 were prospectively and retrospectively identified and analyzed. Among the 20 patients identified, 20% had fever and 80% were tachycardic in the ED. Most patients, 95%, had elevated white blood cell counts (mean = 37.1 + 23.4 k/ul), 79% had elevated lactate levels, 47% were hyponatremic, and 33% had soft tissue gas on radiograph. Thirty-seven percent of blood cultures and 75% of surgical wound cultures were positive, revealing a variety of organisms. Although tachycardia, leukocytosis, and elevated lactate levels are common in NF patients, fever and soft tissue gas are not. Tests and traditional teaching regarding the "classic" findings of NF should be amended to reflect differences seen in the setting of injection drug use with black tar heroin.

Topics: Emergency Service, Hospital; Fasciitis, Necrotizing; Heroin; Hospitals, Urban; Humans; Injections; Soft Tissue Infections

Intravenous drug use is an increasing social problem. Repeated venepunctures, injection of insoluble substances and needle sharing habits in intravenous drug users result in complications leading to admissions under various medical specialities. Many of these patients, however, manifest soft tissue wounds requiring specialised care from plastic surgeons. Typical presentations include injection site related abscess, cellulitis, necrotising fasciitis and non-healing wounds. We present a series of 11 consecutive cases treated in our unit over a six-month period, to highlight the varied clinical presentations and potential difficulties in their management.

Topics: Adult; Fasciitis, Necrotizing; Follow-Up Studies; Heroin; Humans; Male; Needle Sharing; Risk Assessment; Severity of Illness Index; Soft Tissue Infections; Substance Abuse, Intravenous; Surgical Flaps; United Kingdom; Wound Healing

We present fatal extensive soft tissue infections, a consequence of groin heroin injection, in three subjects, who were 27, 34, and 39 years old and had a history of over 10-, 15-, and 5-years of heroin injection (cases 1, 2, and 3, respectively). In all cases, the first symptoms of the infection appeared at least a week prior, with rapid deterioration on the last day. The hallmark was a disproportion between external and internal findings in the affected thighs. The latter presented as extensively spread suppurative inflammation with soft tissue necrosis. In case 1, subtle skin erythema was present in the left groin, with a wound suggestive of a recent abscess incision and injection-related scarring. However, dissection revealed that inguinal regions and deep soft tissue (including the muscle sheets) of the left thigh, gluteal region, and lower third of the anterior abdominal wall were inflamed with pus, alongside fibrinopurulent peritonitis. Case 2 had pronounced erythema and swelling of the thigh and knee. Diffuse suppuration was observed upon dissection in the inguinal regions, which extended into the iliopsoas muscles, with soft tissue and muscle necrosis. In the abdominal cavity, we detected 150 mL of serofibrinous exudate. Only case 3 had a prominent, 4 × 3.5-cm necrotic skin defect through which pus spontaneously drained. In contrast to the other two, although extensive pus collection within predominantly necrotic thigh's soft tissue was present, the inflammation did not expand above the inguinal ligament, and peritonitis was not observed. Toxicology analysis excluded acute heroin intoxications.

Topics: Abscess; Groin; Heroin; Humans; Necrosis; Soft Tissue Infections

Necrotizing soft tissue infection (NSTI) is rare and characterized by rapid onset and spread of inflammation and necrosis. The infection starts within the fascia but can rapidly progress to include musculature, subcutaneous fat, and overlying skin. Its presentation is considered a surgical emergency. Persons who use intravenous or subcutaneous opioids are at higher risk of NSTIs.. The purpose of this case report is to describe the positive clinical outcome after consulting with wound specialists and using a dressing regimen to expedite more rapid wound healing, shortened time to skin graft, and improved pain tolerance in a patient with a history of intravenous and subcutaneous heroin use.. The patient presented with an NSTI that required extensive debridement of the bilateral upper extremities. The acute surgical wound service was consulted. A dressing regimen consisting of hypochlorous acid-preserved wound cleansing, followed by carboxymethylcellulose fiber with 1.2% ionic silver covered by hydrocellular foam to promote a moist healing environment, was used to facilitate granulation.. Healthy granulation tissue was noted 6 days after debridement. The improved rate of granulation and the patient's tolerance to dressing changes secondary to decreased pain from these dressings significantly expedited the time to graft and wound healing. The patient underwent split-thickness skin grafting 10 days after debridement. There was 100% uptake of the grafts on postgraft day 8.. The favorable clinical outcome suggests that early consultation with wound specialists and implementation of the dressing regimen were effective in this patient regarding improved pain control and healing. However, because the patient left against medical advice on hospital day 20, the clinical course could not be followed beyond the first few postoperative weeks.

Topics: Bandages; Forearm; Heroin; Humans; Pain; Skin Transplantation; Soft Tissue Infections

On a national level, heroin-related hospital admissions have reached an all-time high. With the foot being the fourth most common injection site, heroin-related lower-extremity infections have become more prevalent owing to many factors, including drug preparation, injection practices, and unknown additives.. We present a 16-month case series in which eight patients with lower-extremity infections secondary to heroin abuse presented to The Jewish Hospital in Cincinnati, Ohio.. Three cases of osteomyelitis were seen. All of the infections were cultured and yielded a wide array of microbes, including. This case series brings to light many considerations in the diagnosis and management of the heroin user, including multivariable attenuation of immunity, existing predisposition to infection backed by unsterile drug preparation and injection practices, innocuous presentation of deep infections, microbial spectrum, and recommendations on antimicrobial intervention, noncompliance, and poor follow-up. By having greater knowledge in unique considerations of diagnosis and treatment, more efficient care can be provided to this unique patient population.

Topics: Adult; Anti-Bacterial Agents; Female; Heroin; Heroin Dependence; Humans; Hyperalgesia; Lower Extremity; Magnetic Resonance Imaging; Male; Middle Aged; Osteomyelitis; Pain Management; Patient Compliance; Radiography; Soft Tissue Infections; Substance Abuse, Intravenous

Skin and soft tissue infections (SSTIs) are prevalent among people who inject heroin (PWIH). Delays in seeking health care lead to increased costs and potential mortality, yet the barriers to accessing care among PWIHs are poorly understood.. We administered a quantitative survey (N = 145) and conducted qualitative interviews (N = 12) with PWIH seeking syringe exchange services in two U.S. cities.. 66% of participants had experienced at least one SSTI. 38% reported waiting two weeks or more to seek care, and 57% reported leaving the hospital against medical advice. 54% reported undergoing a drainage procedure performed by a non-medical professional, and 32% reported taking antibiotics that were not prescribed to them. Two of the most common reasons for these behaviors were fear of withdrawal symptoms and inadequate pain control, and these reasons emerged as prominent themes in the qualitative findings. These issues are often predicated on previous negative experiences and exacerbated by stigma and an asymmetrical power dynamic with providers, resulting in perceived barriers to seeking and completing care for SSTIs.. For PWIH, unaddressed pain and withdrawal symptoms contribute to profoundly negative health care experiences, which then generate motivation for delaying care SSTI seeking and for discharge against medical advice. Health care providers and hospitals should develop policies to improve pain control, manage opioid withdrawal, minimize prejudice and stigma, and optimize communication with PWIH. These barriers should also be addressed by providing medical care in accessible and acceptable venues, such as safe injection facilities, street outreach, and other harm reduction venues.

Topics: Abscess; Adult; Cross-Sectional Studies; Female; Heroin; Humans; Male; Middle Aged; Pain; Pain Management; Patient Acceptance of Health Care; Prejudice; Retrospective Studies; Social Stigma; Soft Tissue Infections; Substance Abuse, Intravenous; Substance Withdrawal Syndrome

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.

Topics: Adult; Anthrax; Anti-Bacterial Agents; Antitoxins; Bacillus anthracis; Disease Outbreaks; Drug Therapy, Combination; Drug Users; Female; Heroin; Humans; Immunoglobulin G; Male; Scotland; Soft Tissue Infections; Substance Abuse, Intravenous; Survival Analysis; Treatment Outcome

Little is known about trends in national rates of injection-related skin and soft tissue infections (SSTI) and their relationship to the structural risk environment for heroin users. Use of Mexican-sourced "Black Tar" heroin, predominant in western US states, may have greater risk for SSTI compared with eastern US powder heroin (Colombian-sourced) due to its association with non-intravenous injection or from possible contamination.. Using nationally representative hospital admissions data from the Nationwide Inpatient Sample and heroin price and purity data from the Drug Enforcement Administration, we looked at rates of hospital admissions for opiate-related SSTI (O-SSTI) between 1993 and 2010. Regression analyses examined associations between O-SSTI and heroin source, form and price.. Hospitalization rates of O-SSTI doubled from 4 to 9 per 100,000 nationally between 1993 and 2010; the increase concentrated among individuals aged 20-40. Heroin market features were strongly associated with changes in the rate of SSTI. Each $100 increase in yearly heroin price-per-gram-pure was associated with a 3% decrease in the rate of heroin-related SSTI admissions. Mexican-sourced-heroin-dominant cities had twice the rate of O-SSTI compared to Colombian-sourced-heroin-dominant cities.. Heroin-related SSTI are increasing and structural factors, including heroin price and source-form, are associated with higher rates of SSTI hospital admissions. Clinical and harm reduction efforts should educate heroin users on local risk factors, e.g., heroin type, promote vein health strategies and provide culturally sensitive treatment services for persons suffering with SSTI.

Topics: Adult; Commerce; Costs and Cost Analysis; Female; Heroin; Heroin Dependence; Hospitalization; Humans; Male; Middle Aged; Narcotics; Soft Tissue Infections; United States; Young Adult

There has recently been an outbreak of injectional anthrax infection secondary to contaminated heroin use in the UK and Europe. We present a case of a 37-year-old man presenting with pain and swelling in the groin following injection of heroin into the area. He was initially treated for severe cellulitis, however, he failed to respond to appropriate antimicrobial therapy. He went onto develop a widespread rash; it was then that a diagnosis of injectional anthrax infection was considered. Appropriate investigations were initiated including serum sample and tissue biopsy, and the diagnosis was confirmed. Management included extensive surgical debridement and a prolonged course of combination antibiotic therapy. The authors summarise the important steps in diagnosis and the management options in patients presenting with this life-threatening infection.

Topics: Adult; Anthrax; Bacillus anthracis; Drug Contamination; Heroin; Humans; Illicit Drugs; Male; Soft Tissue Infections; Substance Abuse, Intravenous

Outbreaks of serious infections associated with heroin use in persons who inject drugs (PWIDs) occur intermittently and require vigilance and rapid reporting of individual cases. Here, we give a firsthand account of the cases in London during an outbreak of heroin-associated anthrax during 2009-2010 in the United Kingdom. This new manifestation of anthrax has resulted in a clinical manifestation distinct from already recognized forms. During 2012-13, additional cases of heroin-associated anthrax among PWIDs in England and other European countries were reported, suggesting that anthrax-contaminated heroin remains in circulation. Antibacterial drugs used for serious soft tissue infection are effective against anthrax, which may lead to substantial underrecognition of this novel illness. The outbreak in London provides a strong case for ongoing vigilance and the use of serologic testing in diagnosis and serologic surveillance schemes to determine and monitor the prevalence of anthrax exposure in the PWID community.

Topics: Adult; Anthrax; Anti-Bacterial Agents; Bacillus anthracis; Disease Outbreaks; Female; Heroin; Humans; London; Male; Middle Aged; Soft Tissue Infections

Anthrax had become extremely rare in Europe, but in 2010 an outbreak of anthrax among heroin users in Scotland increased awareness of contaminated heroin as a source of anthrax. We present the first two Danish cases of injectional anthrax and discuss the clinical presentations, which included both typical and more unusual manifestations.. The first patient, a 55-year old man with HIV and hepatitis C virus co-infection, presented with severe pain in the right thigh and lower abdomen after injecting heroin into the right groin. Computed tomography and ultrasonographic examination of the abdomen and right thigh showed oedematous thickened peritoneum, distended oedematous mesentery and subcutaneous oedema of the right thigh. At admission the patient was afebrile but within 24 hours he progressed to severe septic shock and abdominal compartment syndrome. Cultures of blood and intraperitoneal fluid grew Bacillus anthracis. The patient was treated with meropenem, clindamycin, ciprofloxacin and metronidazole. Despite maximum supportive care including mechanical ventilation, vasopressor treatment and continuous veno-venous hemodiafiltration the patient died on day four.The second patient, a 39-year old man with chronic hepatitis C virus infection, presented with fever and a swollen right arm after injecting heroin into his right arm. The arm was swollen from the axilla to the wrist with tense and discoloured skin. He was initially septic with low blood pressure but responded to crystalloids. During the first week, swelling progressed and the patient developed massive generalised oedema with a weight gain of 40 kg. When blood cultures grew Bacillus anthracis antibiotic treatment was changed to meropenem, moxifloxacin and metronidazole, and on day 7 hydroxycloroquin was added. The patient responded to treatment and was discharged after 29 days.. These two heroin-associated anthrax cases from Denmark corroborate that heroin contaminated with anthrax spores may be a continuous source of injectional anthrax across Europe. Clinicians and clinical microbiologists need to stay vigilant and suspect anthrax in patients with a history of heroin use who present with soft tissue or generalised infection. Marked swelling of affected soft tissue or unusual intra-abdominal oedema should strengthen clinical suspicion.

Topics: Adult; Anthrax; Bacillus anthracis; Denmark; Drug Contamination; Edema; Heroin; Humans; Male; Middle Aged; Sepsis; Soft Tissue Infections; Substance Abuse, Intravenous

This report describes the investigation and management of an unprecedented outbreak of severe illness among injecting drug users (IDUs) in Scotland during April to August 2000. IDUs with severe soft tissue inflammation were prospectively sought among acute hospitals and a mortuary in Scotland. Cases were categorised as definite or probable: probable cases had severe injection site inflammation or multi-system failure; definite cases had both. Information about clinical course, mortality, post-mortem findings and laboratory data was gathered by standardised case-note review and interview. Sixty cases were identified--23 definite and 37 probable. Most had familial or social links with each other and 50 were from Glasgow. Median age was 30 years; 31 were female. The majority, especially definite cases, injected heroin/citric acid extravascularly. Of definite cases, 20 died (87% case-fatality rate; 13 after intensive care), 15 had necrotising fasciitis, 22 had injection site oedema and 13 had pleural effusion. Median white cell count was 60 x 10(9)/L. Of 37 probable cases, three died (8% case-fatality rate). Overall, the most frequently isolated pathogen was Clostridium novyi type A (13 cases: 8 in definite cases). The findings are consistent with an infection resulting from injection into soft tissue of acidified heroin contaminated with spore-forming bacteria. Toxin production led to a severe local reaction and, in many, multi-system failure.

Topics: Adult; Autopsy; Clostridium Infections; Disease Outbreaks; Drug Contamination; Edema; Fasciitis, Necrotizing; Female; Heroin; Humans; Leukocyte Count; Male; Middle Aged; Multiple Organ Failure; Pleural Effusion; Practice Guidelines as Topic; Scotland; Soft Tissue Infections; Substance-Related Disorders

A molecular epidemiologic investigation was performed on a cluster of severe necrotizing Clostridium infections in 5 injection drug users admitted to an urban community hospital. Interviews with survivors suggested a point source of infection. Pulsed-field gel electrophoresis of SmaI restriction digests was performed to determine the molecular relatedness of clinically obtained isolates and isolates obtained from heroin samples and the home environment. A common clonal strain was found in Clostridium sordellii isolates from 2 socially unrelated patients and from drug paraphernalia. Clonality of a Clostridium perfringens strain from another patient isolate was identical to an isolate from a syringe found in her home. Other C perfringens isolates from patients, heroin, and the environment were determined to be polyclonal. We postulate that rapid recognition and public health notification led to rapid resolution of the outbreak.

Topics: Adult; Clostridium Infections; Clostridium perfringens; Debridement; Disease Outbreaks; Female; Heroin; Humans; Male; Molecular Epidemiology; Necrosis; San Francisco; Soft Tissue Infections; Substance Abuse, Intravenous

Topics: Heroin; Humans; Injections, Intramuscular; Injections, Subcutaneous; Risk Factors; Soft Tissue Infections; Substance Abuse, Intravenous