Surgical infections in drug addicts

Cutaneous complications of intravenous drug abuse

Injection drug abuse is a world-wide problem responsible for numerous minor to life-threatening and fatal complications. The skin is the tissue most evidently affected by intravenous drug addiction. A wide spectrum of cutaneous complications may occur in intravenous drug users. These include acute or delayed local complications, hypersensitivity reactions, cutaneous manifestations of systemic infections or becoming the site of toxigenic infections. Between 1996 and 2001, in our institution in south-eastern France, we observed cutaneous complications after crushed buprenorphine tablet injections in 13 patients. This paper reviews and classifies adverse effects of parenteral drug abuse on the skin.

Bacterial infections

Non-opportunistic bacterial infections are an important cause of morbidity and mortality for HIV-infected adults and children. Factors associated with increased risk of these include altered B- and T-cell function; altered phagocytic cell function; skin and mucous membrane defects; and use of indwelling vascular catheters, antibiotics, or cytotoxic agents. The pathogens encountered most frequently are S. aureus, S. pneumoniae, H. influenzae, Salmonella sp., and Pseudomonas aeruginosa. Less commonly encountered organisms include Rhodococcus equi, Listeria monocytogenes, Shigella sp., and Nocardia asteroides, Strategies for prevention as well as diagnosis and treatment of these are discussed.

Pyomyositis: a differential diagnosis from sarcoma

A case of pyomyositis, a deep muscle abscess, presenting as a soft tissue sarcoma is reported. Although common in the tropics, this disease is quite rare in the United States. The presentation, diagnosis, and treatment of the problem are discussed and reviewed.

Intravenous drug abuse and the accident and emergency department

A 4-month prospective study of intravenous drug abusers attending an accident and emergency department was performed. A total of 92 patients presented with 104 new complaints. Seventy-eight per cent of patients were under 30 years of age and 28% were female. The primary reason for attendance was related to trauma in 30% of attendances, accidental or deliberate overdose in 26% and as a result of infection in 26%. A total of 37% of all attendances resulted in admission and two patients died in the department. Fifty-four patients (58%) had radioimmunoassay performed for hepatitis B markers and there was evidence of past or ongoing infection in 87% of these patients. Only three patients (5.6%) were HBsAg positive at the time of presentation. Accident and emergency staff should be made aware of the pattern of attendance of intravenous drug abusers and the particular problems they present.

Pharmacokinetics of tobramycin and gentamicin in abusers of intravenous drugs

The kinetics of aminoglycoside elimination were determined in 18 hospitalized narcotics abusers receiving gentamicin or tobramycin for treatment of severe infection. Rapid aminoglycoside elimination (requiring doses of greater than 5 mg/kg per day to maintain adequate drug levels) was noted in 12 of the 18 patients (18 of 27 clearance studies). Patients found to have rapid elimination were younger (P less than 0.01) and had larger drug distribution volumes (P less than 0.005), greater measured creatinine clearances (P less than 0.05), and lower creatinine levels in serum (P less than 0.001) than those with normal elimination. Nevertheless, by regression analysis, age, creatinine levels in serum, creatinine clearances, and drug distribution volumes proved to be unreliable predictors of individual aminoglycoside clearance. Measured drug half-life in serum appeared to be the only reliable predictor of drug clearance (r = 0.93). Patients with rapid drug elimination had aminoglycoside clearances 16 to 43% greater than measured creatinine clearances, suggesting an extraglomerular route of drug elimination. We conclude that in drug abuse patients a significant and clinically unpredictable interpatient variation occurs in aminoglycoside elimination and that accurate serum kinetics are needed to determine therapeutic dosing. In addicts younger than 35 years, with a creatinine level of less than 1.0 mg/100 ml in serum, the risk of inadequate therapy is high if standard dosing guidelines are followed. For this group, initial dosing of 8 mg/kg per day, with a drug half-life determination on the first dose, is recommended. Pharmacokinetic analysis is critical for all drug abusers treated with aminoglycosides for serious infection.