Transcript Febrile faux pas - Exchange Supplies

Infections in drug injectors
Clostridium species and
others
Nick Beeching
Tropical & Infectious Disease Unit
Royal Liverpool University Hospital
Liverpool School of Tropical Medicine
[email protected]
Plan of talk
• Outline of non viral infections and sources
• Clinical examples of technique related
infections
• Contaminated substance related anaerobic
clostridial infections:
– Tetanus
– Botulism
– Septic shock (Cl novyi etc)
• Lessons & prevention
Tropical IVDU related infections
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Malaria
Melioidosis
American trypanosomiasis (Chagas disease)
Leishmaniasis (Spanish IVDU)
Syphilis
Hepatitis B & C
HIV
All blood borne/technique related
© N Beeching
© N Beeching
Candida endophthalmitis
• Candida sp are
natural
commensals in
citrus fruits
• Sudden
blindness
Non viral infections
• Usually staphylococci (75%) and/or
streptococci from skin
• NB MRSA emerging in IVDU in UK
• Anaerobes from mouth
• Faecal organisms from groin area
• Fungi from lemon juice
• Contaminants from drugs
• Anaerobes with muscle popping
Murphy EL et al. J Inf Dis 2001; 33: 35-40
Bassetti S, Battegay M. Infection 2004; 32: 163-9
Generalised infections
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Bacteraemia (septicaemia)
Pneumonia & lung abscess
Endocarditis (heart valves)
Other deep abscesses
Septic arthritis
Osteomyelitis
etc
DVT audit
• 6 years 1996- 2001
• University Hospital Aintree
• All DVTs in people aged 18-40
• IVDU in 158/251 (62.9 %) of all admissions
• Soft tissue infections in 60/96 (61.2%) IVDU
• Bacteraemia was found in 33/80 (41.3%) of blood
cultures taken
Syed FF & Beeching NJ. QJ Med 2005; 98: 139-45
Jenkins N et al (submitted for publication)
Anaerobic infections in
British IDU – early 2000s
• 2000 Necrotising fasciitis & sepsis
Clostridium novyi 44/108 died
• 2002 Botulism (Cl botulinum)
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2002 18
2003 8
2004 40
Different Clostridial toxins have different local
and geralised efects
Patient 1 40 M Window cleaner
• 29 Oct 2003
• 2 days L elbow 8 x 8 cm cellulitis after
injecting heroin
• Rx Methadone 50 ml, heroin £15
(20 year career)
• Oral penicillin, flucloxacillin, metronidazole
• 30 Oct – Improving enough to have illicit
heroin injection
Not so good……
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Day 7
stiff L arm
cannot swallow methadone
agitated
stiffness in neck
Day 7
• Examination
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arched back & neck (opisthotonus)
sweating
agitated
cannot open mouth or stick out tongue
• T36.8 P100 BP 140/76
• No response diazepam, procyclidine
Diagnosis: severe tetanus
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Resuscitation – IV line, fluids, 02
Antibiotics – IV pen G, metronidazole
Sedation – more IV diazepam
Intubate & ventilate
Antitetanus toxoid 5,750 units (IM)
as 23 x 250 u (1ml)
Routine debridement of wounds
Transfer to intensive care
ICU progress
• Initially settled on sedation
• Severe arm/leg spasms within 24 hours
• Paralysed (atracuronium) days 2-24
– cardiac arrest on early withdrawal day 14
• Labile BP & pulse
– Esmolol, metoprolol & clonidine tried
ICU continued
• Continued spasms
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CSF, EEG, CT head normal
Phenytoin stopped
Magnesium infusions to keep Mg++ >4
Resulting hypocalcaemia
• Increased secretions week 3
• Coagulase neg Staph bacteraemia
Transfer ID Ward Day 45
• Still has trismus, flexed L arm, 45 degree
• contractures both feet, limb spasms
– Rx Dantrolene
– Standing with physio day 63
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Frozen L shoulder
Tracheostomy removed day 70
Intermediate care days 88-100 (4 Feb)
Follow-up - drug free, still a bit stiff
Infection issues
• No memory of tetanus immunizations
• Anti-tetanus IgG levels after TIG and first
immunization <0.04 u/ml (Protection > 0.11u/ml)
• Started on course of 3 immunizations
• Remembers unusual “score” of heroin from
outside dealer – drugs had been buried
• Tetanus not cultured
• Hepatitis A & B immune, current HCV, HIV
negative
Wound isolates
Cl novyi
Cl histolyticum
Cl baratii
Cl perfringens
All sensitive to metronidazole & penicillin
Patient 2. 48M Gardner
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IDU > 20 year
Skin popper > 5 year
Methadone 60 ml plus £15 heroin
Polydrug use in past
Shares heroin with female partner only (citric
acid solvent)
• 3 suppliers of “brown” (heroin from Asia), no
new ones
• Decrease in quality since Dec 2003
Jan 2004 Emergency room
• 2 days back pain
agitated
• 1 day lock jaw
• Exam infected wound sites
trismus, rigid neck
blepharospasm & limb spasms
Isolates
• Cl tetani
• Staph aureus
• Beta Haem Group A
streptococcus
• Mixed anaerobes
© N Beeching
Tetanus in IDU
1876 Morphine addict Southsea (Lancet)
1879 Death in Dublin (BMJ)
1950s 15% of Chicago tetanus is in IDU (100%
mortality)
1960s Higher incidence & mortality in New York
(muscle/skin popping)
1990s IDU account for 55% cases in California
(black tar heroin from Mexico)
18% elsewhere in USA
1984-2000 2/175 cases in England
2002
1 in Scotland
MMWR 20 June 2003; 52 (SS3): 1- 7; Rushdy AA et al . Epidemiol Infect
2003;130:71-7 7 ; SCIEH Weekly 2002; 36: 19
20 cases in Feb CDR
www.hpa.org.uk
July 2003 – March 2004
•22 cases notified
•2 fatal
•13 (59%) female
•Median ages: Males 37, Females 32
Summary of tetanus outbreak
New phenomenon in the UK
Severe disease in most of 22 patients
Most patients no immunity and/or history of immunizations
Mainly skin poppers, older and more females
No specific drug dealer implicated, but North West
(Liverpool) key role
Suggests contamination at source in UK
Various organisms isolated
Almost all severe (10% death so far) and expensive to care
for
Beeching NJ & Crowcroft NS. BMJ 2005; 330: 208-9
Tetanus summary
• Prevention is essential in this group who
do not always access health care
• Role of general practice, emergency
rooms, drug dependency units in
immunizing
Prevention
• Passive immunization – TIG for wounds
• Active immunization x 5
– Maybe extend for IDU ?
– Or for those >50?
• Promotion of less, and safer, injecting
MMWR 20 June 2003; 52 (SS3): 1-7
Difficulty speaking…..
28 male IVDU
– IVDU 7 years heroin & cocaine
– insulin dependent diabetic
Seen in emergency room
– Incoherent
– Assumed to be due to drug influence
Over next 4 hours
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Cannot open eyes
Dribbling
Speech worse
Slump
• Respiratory arrest
• Ventilated in ICU for 4 weeks
• Non specific lesions on legs from skin
popping
Outcome
• Diagnosis of botulism confirmed by
nerve conduction & EMG studies of
upper limb
• Given antitoxin late
• Survived prolonged stay in ICU
Botulinum Toxin
Product of anaerobic Clostridium botulinum
7 types, A to G
–Man A, B, E
–Ducks D
–Horses C
•Commonest source is poorly preserved food
•Lethal dose for man <1 µg
•Incubation period <1->5 days
•Blocks messages from nerve to muscle
•Takes 2-4 months to recover function
Symptoms and signs of
botulism
•Descending paralysis
Affects muscles with highest innervation first
•Four D’s
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Diplopia: double vision
Dysphagia: difficulty swallowing
Dysarthria: impaired speech enunciation (tongue, face)
Dysphonia: impaired speech production (larynx)
•Paralysis and respiratory arrest
•Dose dependent
Practical antitoxin use
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Test dose for hypersensitivity
Therapeutic dose
Repeat therapeutic dose if symptoms deteriorate
Will not reverse existing pathology!
Cardiovascular and ventilatory support may be
required
Brett MM et al. J Med Microbiol 2004; 53: 555-61
Shock
31 female IVDU
– 10 year history f injecting
– Multiple injection abscesses
• Presents to ER with 1 day history
– Unwell
– Pain in leg
• Examination
– Hypotensive shock
– Small boggy abscess in buttock
Progress
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Circulatory collapse
High white count
Intubated & ventilated
Broad spectrum antibiotics
Dies 12 hours later
• Autopsy
– Liquified abscess with Clostridium novyi
Clostridial infections
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Gas gangrene
Offensive, black, rapidly progressive
Complication of wound infections
High mortality
– Cl novyi
– Cl perfringens
– Cl histolyticum
Associations in IVDU
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Muscle popping
Older patients
Females
Higher purity heroin
Sharing filters
• Point source outbreaks and sporadic
McGuigan C et al. J Med Microbiol 2002; 51: 971-7
Jones JA et al. J Med Microbiol 2002; 51: 978-84
Lessons
Bacterial infections are common and preventable
Safe storage of “clean” drugs
Clean needles & syringes
Clean diluents
No lemon juice
General hygiene
Wash hands
Cleaning of skin
No sharing
No needle licking
Avoid muscle popping
Immunisation (tetanus)
Final message
• Keep open mind in abnormal behaviour in
IVDU
– Botulism (4 D’s diplopia, dysarthria,
dysphonia, dsyphagia)
– Tetanus stiff neck, arms, abdo, back, jaw
– Novyi infection necrotising fasciitis/shock
Acknowledgements
• Patients for permission to show their details
• Celia Jukka Liverpool/Southport for MRSA data
• V Hope, F Ncube, L Desouza, M Brett, N
Crowcroft, S Hahne, J McLaughlin (HPA)
• Anaerobic Reference Unit, Cardiff
• D Goldberg, HPS for information on Scottish
cases
• Health Protection Units in England, NHS boards in
Scotland and the National Public Health Service
for Wales
• Clinicians and microbiologists who have notified
cases and provided further details