Demographic Description of the Presentation and Treatment of Lower Extremity Skin and Soft Tissue Infections Secondary to Skin Popping in Intravenous Drug Abusers

The Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons (Impact Factor: 0.85). 03/2014; 53(2):156–159. DOI: 10.1053/j.jfas.2013.12.017

ABSTRACT Skin popping refers to the act of subcutaneous injection of intravenous drugs, a practice that often results in the development of cellulitis and the formation of soft tissue abscesses. Although the foot and ankle represent common injection sites, few data have described the presentation and natural history of this pathologic entity. The objective of the present study was to retrospectively assess the descriptive demographic data of a patient cohort admitted for lower extremity skin and soft tissue infection caused by intravenous drug abuse. Fifty skin popping lesions in 49 patients were identified during a 733-day data collection period (August 1, 2010 to August 31, 2012) that had been treated by the in-patient podiatric surgical service for lower extremity infection caused by intravenous drug abuse at an urban, level-one trauma center. With respect to patient race, our hospital has a typical in-patient census of 55% black patients and 25% white patients. The present patient cohort consisted of 12% black patients and 65% white patients. The mean length of stay was 5.71 ± 3.56 days, and 42 patients (85.71%) underwent some form of surgical debridement, with 31 (63.27%) having undergone a formal procedure in the operating room. Six patients (12.24%) left the hospital against medical advice or refused intervention at some definitive point of care, and 36 (73.47%) did not return for scheduled outpatient follow-up visits. Three cases (6%) resulted in minor amputation. The microbiologic culture data and common antibiotic prescriptions used in the diagnosis and treatment, respectively, of these patients have been summarized. We hope these original descriptive data can be used by other physicians treating patients at similar urban practices to improve the care of these sometimes difficult-to-treat patients and better serve this population as a whole.

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    ABSTRACT: The prevalence of and risk factors for abscesses and cellulitis were investigated among a community sample of injection drug users (IDUs). Participants were interviewed, and those with symptoms were examined. Of 169 IDUs, 54 (32%) had abscesses (n=35), cellulitis (n=5), or both (n=14); 27% had lanced their own abscesses; and 16% had self-treated with antibiotics they purchased on the street. IDUs who skin-popped (injected subcutaneously or intramuscularly) were more likely to have an abscess or cellulitis than those who had injected only intravenously (odds ratio, 4.9; 95% confidence interval, 2.2-11). The likelihood of abscesses and cellulitis increased with frequency of skin-popping and decreased with increasing duration of injection drug use. Abscesses are extremely prevalent among IDUs in San Francisco. Skin-popping is a major risk factor, and self-treatment is common.
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    ABSTRACT: We studied cases of necrotizing fasciitis among injection drug users (IDUs) and non-IDUs who presented at the University of California Davis Medical Center from 1984 through 1999. Of 107 patients, 59 (55%) were IDUs and 48 (45%) non-IDUs. Among IDUs, 32 (54%) recently injected at the site of infection, and 17 patients (29%) presented with an abscess. Among non-IDUs, 17 (35%) reported a recent insect bite and 9 (19%) reported a wound or abrasion at the site of infection. Overall, seventy cases (65%) had > or = 3 debridements, and 31 patients (29%) had > 5% of their total body surface area debrided. Of all patients with necrotizing fasciitis, 16 (15%) did not survive. Among the 59 IDUs, 6 (10%) did not survive, while among non-IDUs, 10 (21%) did not survive. Our results indicate the need for a high index of suspicion for necrotizing fasciitis among patients presenting with cellulitis, a recent insect bite, wound, or recent injection drug use. Preventive interventions for necrotizing fasciitis among IDUs should include street-based education and treatment for abscesses and cellulitis.
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    ABSTRACT: Skin and soft tissue infections (SSTIs) are common among injection drug users (IDUs). Subcutaneous and intramuscular injection ("skin-popping") and the injection of "speedballs" (a mixture of heroin and cocaine) are important risk factors for SSTIs in this patient population. Female IDUs appear to be at greater risk of SSTIs than male IDUs, probably because of more difficult venous access. There are conflicting data regarding the impact of HIV and human T-cell lymphotrophic virus II infection on the risk of SSTIs in IDUs; however, an expanding body of evidence suggests that immunosuppressive effects of the drugs themselves may play a role. Most information regarding the microbiology of SSTIs in IDUs comes from data on skin and subcutaneous abscesses, where Staphylococcus aureus and organisms that originate from the oral flora predominate. Clonal outbreaks and uncommon infections including tetanus, wound botulism, and a sepsis/myonecrosis syndrome due to Clostridium species have been recently reported in IDUs.
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