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Key Features

Essentials of Diagnosis

  • Common infections that occur with greater frequency in persons who inject drugs

    • Skin infections

    • Hepatitis A, B, C, D

    • Aspiration pneumonia

    • Tuberculosis

    • Pulmonary septic emboli

    • Sexually transmitted diseases

    • HIV/AIDS

    • Infective endocarditis

    • Osteomyelitis

    • Septic arthritis

General Considerations

SKIN INFECTIONS

  • Associated with poor hygiene and use of nonsterile injection technique

  • Most common organisms

    • Staphylococcus aureus (including methicillin-resistant strains)

    • Oral flora (streptococci, Eikenella, Fusobacterium, Peptostreptococcus)

  • Enteric gram-negative organisms are less common except in those who inject into the groin

HEPATITIS

  • Very common among persons who inject drugs habitually

  • Transmissible both by the parenteral (hepatitis B, C, and D) and by the fecal–oral route (hepatitis A)

  • Multiple episodes of hepatitis with different agents can occur

ASPIRATION PNEUMONIA

  • Results from altered consciousness associated with drug use

  • Mixed aerobic and anaerobic mouth flora are usually involved

TUBERCULOSIS

  • Infection with HIV has fostered the spread of tuberculosis

PULMONARY SEPTIC EMBOLI

  • From venous thrombi or right-sided endocarditis

SEXUALLY TRANSMITTED DISEASES

  • Related to the practice of exchanging sex for drugs

  • Syphilis, gonorrhea, and chancroid are the most common

HIV/AIDS

  • High incidence among persons who inject drugs, among their sexual contacts, and among the offspring of infected women

INFECTIVE ENDOCARDITIS

  • Most common organisms

    • S aureus

    • Candida (usually C albicans or C parapsilosis)

    • Enterococcus faecalis

    • Other streptococci

    • Gram-negative bacteria (especially Pseudomonas and Serratia marcescens)

  • Right-sided heart involvement

    • Common

    • Infection of more than one valve is not infrequent

OTHER VASCULAR INFECTIONS

  • Septic thrombophlebitis

  • Mycotic aneurysms result from direct trauma to a vessel with secondary infection

  • Aneurysms result from hematogenous spread of organisms

OSTEOMYELITIS AND SEPTIC ARTHRITIS

  • Osteomyelitis usually results from hematogenous distribution of injected organisms or septic venous thrombi

  • While staphylococci—often methicillin-resistant—are common organisms, also found are Serratia, Pseudomonas, Candida (often not C albicans), and other pathogens rarely encountered in spontaneous bone or joint disease

Demographics

  • More than 775,000 persons in the United States are estimated to have used injection drugs in the past year

Clinical Findings

Symptoms and Signs

SKIN INFECTIONS

  • Cellulitis and subcutaneous abscesses occur most commonly, particularly in association with subcutaneous ("skin-popping") or intramuscular injections and the use of cocaine and heroin mixtures (probably due to ischemia)

  • Myositis, clostridial myonecrosis, and necrotizing fasciitis occur infrequently but are life-threatening

  • Wound botulism in association with black tar heroin occurs sporadically but often in clusters

RIGHT-SIDED INFECTIVE ENDOCARDITIS
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