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Abscesses of the upper extremity from drug abuse by injection
Abscesses of the Upper Extremity From Drug Abuse by Injection Mark H. Gonzalez, MD, Jeffrey Carst, MD, Paul Nourbash, Joseph Pulvirenti, MD, Robert F. Hall, Jr, MD, Chicago, IL A 4-year
retrospective
drug abuse by injection
review of 59 consecutive
upper extremity
being the forearm. All abscesses were treated with incision,
drainage, and intravenous
ics. Seventeen patients required more than one debridement; itis, osteomyelitis, munodeficiency
septic arthritis, virus testing,
common organisms Nineteen
abscesses associated with
is reported. There were 57 patients, with the most common location
or septic tenosynovitis.
and nine results
to be streptococcus,
Thirty-one
were positive.
Staphylococcus
percent of the abscesses had anaerobes cultured.
antibiot-
nine were complicated by fascipatients had human im-
Bacteriology
aureus,
showed the most
and Eikenella
corrodens.
Most of the organisms
cultured
were common oral or skin flora. (J Hand Surg 1993;18A:868-870.)
Abscesses of the upper extremity secondary to drug abuse by injection are a common problem in the urban hospital.’ These infections are frequently superimposed on medical problems such as malnutrition, hepatitis, and acquired immunodeficiency syndrome (AIDS). Poor medical care among this population as well as poor medical compliance further increase the risk of complications. A 4-year retrospective review of all patients admitted to Cook County Hospital with upper extremity abscesses was performed to elucidate the pathology and treatment of this illness. Materials
and Methods
All cases of injection abscesses admitted from July 1987 to July 1991 were reviewed retrospectively. The review included location of abscess, pathology, bacteriology, and treatment. From the University of Illinois, Department of Orthopaedics, and Section of Hand Surgery, Section of Retrovirology, and Division of Orthopaedic Surgery, Cook County Hospital, Chicago, IL. Received for publication Dec. 12, 1992; accepted in revised form April 14, 1993. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mark H. Gonzalez, MD, Division of Orthopaedic Surgery, Cook County Hospital, Room 620, Main Building, Chicago, IL 60612. 868
The Journal of Hand Surgery
The abscesses were incised and drained, leaving the wounds open to granulate. Extensive wounds were skin grafted with partial thickness skin grafts, which were applied several days after debridement. Necrotizing fasciitis was treated with wide debridement of necrotic fascia using extensile incisions. Patients were started on cephalexin and penicillin empirically and switched to appropriate antibiotics based on culture results. The patients were discharged when the wounds showed healthy, pink, granulation tissue without persistent drainage or cellulitis. Results Fifty-seven consecutive patients with 59 abscesses were identified (one patient had abscesses on two different occasions and another presented with bilateral abscesses). The average age was 39 years, with a range of 23-63 years. There were 36 men and 21 women. All abscesses were due to skin popping or intravenous drug injection. The drugs the patients admitted to injecting were cocaine (50 patients), heroin (35 patients), amphetamines (2 patients), hydromorphone HCl (1 patient), morphine (1 patient), and methylphenidate HCl (1 patient). Thirty-three out of 57 patients admitted to alcohol abuse of at least a pint of liquor or wine daily. Fifteen patients admitted to having had a previous abscess, and two patients had previously been
The Journal
treated for endocarditis. Human immunodeficiency virus (HIV) testing was performed on 31 patients. and 9 results were positive. The locations of the abscesses were forearm (35), hand (15), arm (5), wrist (3), and finger (1). Thirtyfive of the patients had a white count greater than 10.0 at presentation. Thirty patients had temperature elevation above 99.5”F. Forty abscesses required one incision and drainage, 12 required 2 procedures, 4 required 3 procedures, 2 required 4 procedures, and 1 patient’s abscess required 8 procedures. Six patients underwent the split skin graft for coverage after an initial incision and drainage. Three patients developed necrotizing fasciitis of the forearm. One of these patients (who underwent eight procedures) did not respond to multiple debridements and developed fasciitis extending about the shoulder into the chest wall. This patient underwent a shoulder disarticulation. The other two patients each required three debridements and both were skin grafted. Two of the three were tested and both were HIV-positive. Three patients presented with osteomyelitis of the radius or ulna; one patient had bilateral involvement. In each case the abscesses were of greater than b-months duration, with circumferential skin lesions and exposed necrotic desiccated bone. One patient underwent a unilateral elbow disarticulation, and another underwent bilateral elbow disarticulations. Both of the patients had severe involvement of the radius and the ulna with no retained function. A third patient had isolated involvement of the ulna with a large open wound. This patient refused further treatment after incision and drainage and signed out against medical advice. Two patients developed septic arthritis of the wrist from adjacent abscesses. Both were treated with arthrotomy and debridement. A single patient had an abscess on the finger that developed into flexor tenosynovitis. This was treated by incision and drainage of the abscess and placement of inflow/ outflow catheters into the flexor sheath for 3 days. Bacteriology showed streptococcus, Staphyloco~us uureus. and Eikenella corrodens to be the most common organisms (Table 1). There were also several anaerobic organisms cultured. Most of the flora were common colonizers of the skin or oral cavity. Several patients admitted to licking needles prior to injection, a practice thought to account for the presence of oral flora in the cultures. Eleven out of 59 abscesses had anaerobes cultured. Six patients had no organism cultured, several of whom admitted to taking oral antibiotics prior to treatment at our institution.
of Hand
Surgery
/ Vol.
18A No. 5 September
Table 1. Bacteriology Streptococcus
~
1993
________
Organism
No. of Patients
viridans
28 19
P-hemolytic streptococcus (not group A or B) Staphylococcus aureus Eikenella corrodens Bacteroides melaninogenicus
17 I5 7
Group A streptococcus
6
Bacteroides intermedius Staphylococcus epidermitis
2 2
Coagulase-negative staphylococcus Peptostreptococcus
2 2
Morganella
I 1 1 I 1 1 I I I 1
morganii
Diptheroids Bacillus species E.scherichia coli Peptococcus sacharolyticus Bacteroides oris Providencia stuartii
Enterococci Proteus mirabilis Bacteroides fragilis Hemophilus influenzae
No growth ~~~ _...~..
~ ._.~~~
The patients streptococcus streptococcus Streptococcus
869
I 6
with necrotizing fasciitis all had cultured-two with p-hemolytic (not group A or B) and one with viridans.
Eighteen blood cultures were performed in febrile patients and three were positive. The average hospital admission was 15 days, with a range of 2-65 days. Eight patients signed out against medical advice. Long-term follow-up evaluation was impossible because of the transient nature of this population. Discussion Abscesses associated with drug abuse by injection are common because of practices of sharing needles, reusing needles, licking needles, and an overall lack of aseptic technique. 2.3 The infecting organisms are common oral and skin flora.4.5 Organisms have also been cultured from confiscated drugs.‘j Previous studies frequently isolated anaerobes in these abscesses.s In our own population, 20% of the abscesses had anaerobes cultured. The frequent finding of Eikenella corrodens (25% in our study) has not been previously reported. Based on the bacteriology, we recommend initial treatment to be a combination of a first-generation cephalosporin and penicillin, or a combination such as ticarcillin and clavulanic acid. They provide wide coverage for Gram-positive bacteria, Eikenella corrodens, and anaerobes.
870
Gonzalez et al. / Upper Extremity Injection Abscesses
These infections are generally isolated to the soft tissues and respond to wide incision and drainage.3 However, recurrences are common after initial, seemingly adequate, incision and drainage. In our series, 19 out of 59 abscesses required more than one surgical debridement. Complications noted included necrotizing fasciitis, osteomyelitis, and flexor tenosynovitis. Necrotizing fasciitis is an uncommon but very serious infection that can be limbor life-threatening. Early aggressive debridement with wide debridement is necessary. Nine of the 31 patients tested in our series were HIV-positive. HIV status was compared with number of debridements required, length of hospitalization, and multiplicity of organisms isolated (single vs multiple). No significant correlation was noted. Two of the three patients who developed necrotizing fasciitis were tested and both were HIV-positive. HIV infection may predispose patients to acquired infections and should always be considered in this population.’ The risk to the surgeon is considerable and maintenance of the strictest precautions are necessary. Because of the heavy exposure of these patients, even a recent negative HIV test does not rule out HIV infection.’ Noncompliance makes the care of these patients difficult. Eight of our patients signed out against medical advice. We hospitalized our patients for a rather extended period (mean, 15 days)
because outpatient follow-up was virtually impossible. Few patients kept their follow-up appointments. Abscesses secondary to illicit drug injection require urgent surgical debridement, appropriate antibiotic therapy, and follow-up care until resolution. Complicated infections with the development of osteomyelitis or necrotizing fasciitis are frequent and often require multiple debridements. Because of a high rate of HIV infection, strict technique to protect operating room personnel is mandatory.
References 1. White A. Medical disorders in drug addicts. JAMA 1973;223: 1469-71. 2. Geelhoed GW, Joseph WL. Surgical sequelae of drug abuse. Surg Gynecol Obstet 1974;139:749-55. 3. Biderman P, Hiatt JR. Management of soft tissue infections of the upper extremity in parenteral drug abusers. Am J Surg 1987;154:526-8. 4. Organio GR, Pitlick SD, Latta PD et al. Soft tissue infections in parenteral drug abusers. Ann Surg 1984; 199:97-100. 5. Webb D, Thadepalli H. Shin and soft tissue polymicrobial infections from intravenous abuse of drugs. West J Med 1979:130:200-4. 6. Tauzon CU, Hill R, Sheagren JN. Microbiologic study of street heroin and injection paraphernalia. J Int Dis 1974;129:327-9. 7. Cohen PT, Sande M. AIDS knowledge base. Waltham. MA: Medical Publishing Group, 1990.
retrospective
drug abuse by injection
review of 59 consecutive
upper extremity
being the forearm. All abscesses were treated with incision,
drainage, and intravenous
ics. Seventeen patients required more than one debridement; itis, osteomyelitis, munodeficiency
septic arthritis, virus testing,
common organisms Nineteen
abscesses associated with
is reported. There were 57 patients, with the most common location
or septic tenosynovitis.
and nine results
to be streptococcus,
Thirty-one
were positive.
Staphylococcus
percent of the abscesses had anaerobes cultured.
antibiot-
nine were complicated by fascipatients had human im-
Bacteriology
aureus,
showed the most
and Eikenella
corrodens.
Most of the organisms
cultured
were common oral or skin flora. (J Hand Surg 1993;18A:868-870.)
Abscesses of the upper extremity secondary to drug abuse by injection are a common problem in the urban hospital.’ These infections are frequently superimposed on medical problems such as malnutrition, hepatitis, and acquired immunodeficiency syndrome (AIDS). Poor medical care among this population as well as poor medical compliance further increase the risk of complications. A 4-year retrospective review of all patients admitted to Cook County Hospital with upper extremity abscesses was performed to elucidate the pathology and treatment of this illness. Materials
and Methods
All cases of injection abscesses admitted from July 1987 to July 1991 were reviewed retrospectively. The review included location of abscess, pathology, bacteriology, and treatment. From the University of Illinois, Department of Orthopaedics, and Section of Hand Surgery, Section of Retrovirology, and Division of Orthopaedic Surgery, Cook County Hospital, Chicago, IL. Received for publication Dec. 12, 1992; accepted in revised form April 14, 1993. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mark H. Gonzalez, MD, Division of Orthopaedic Surgery, Cook County Hospital, Room 620, Main Building, Chicago, IL 60612. 868
The Journal of Hand Surgery
The abscesses were incised and drained, leaving the wounds open to granulate. Extensive wounds were skin grafted with partial thickness skin grafts, which were applied several days after debridement. Necrotizing fasciitis was treated with wide debridement of necrotic fascia using extensile incisions. Patients were started on cephalexin and penicillin empirically and switched to appropriate antibiotics based on culture results. The patients were discharged when the wounds showed healthy, pink, granulation tissue without persistent drainage or cellulitis. Results Fifty-seven consecutive patients with 59 abscesses were identified (one patient had abscesses on two different occasions and another presented with bilateral abscesses). The average age was 39 years, with a range of 23-63 years. There were 36 men and 21 women. All abscesses were due to skin popping or intravenous drug injection. The drugs the patients admitted to injecting were cocaine (50 patients), heroin (35 patients), amphetamines (2 patients), hydromorphone HCl (1 patient), morphine (1 patient), and methylphenidate HCl (1 patient). Thirty-three out of 57 patients admitted to alcohol abuse of at least a pint of liquor or wine daily. Fifteen patients admitted to having had a previous abscess, and two patients had previously been
The Journal
treated for endocarditis. Human immunodeficiency virus (HIV) testing was performed on 31 patients. and 9 results were positive. The locations of the abscesses were forearm (35), hand (15), arm (5), wrist (3), and finger (1). Thirtyfive of the patients had a white count greater than 10.0 at presentation. Thirty patients had temperature elevation above 99.5”F. Forty abscesses required one incision and drainage, 12 required 2 procedures, 4 required 3 procedures, 2 required 4 procedures, and 1 patient’s abscess required 8 procedures. Six patients underwent the split skin graft for coverage after an initial incision and drainage. Three patients developed necrotizing fasciitis of the forearm. One of these patients (who underwent eight procedures) did not respond to multiple debridements and developed fasciitis extending about the shoulder into the chest wall. This patient underwent a shoulder disarticulation. The other two patients each required three debridements and both were skin grafted. Two of the three were tested and both were HIV-positive. Three patients presented with osteomyelitis of the radius or ulna; one patient had bilateral involvement. In each case the abscesses were of greater than b-months duration, with circumferential skin lesions and exposed necrotic desiccated bone. One patient underwent a unilateral elbow disarticulation, and another underwent bilateral elbow disarticulations. Both of the patients had severe involvement of the radius and the ulna with no retained function. A third patient had isolated involvement of the ulna with a large open wound. This patient refused further treatment after incision and drainage and signed out against medical advice. Two patients developed septic arthritis of the wrist from adjacent abscesses. Both were treated with arthrotomy and debridement. A single patient had an abscess on the finger that developed into flexor tenosynovitis. This was treated by incision and drainage of the abscess and placement of inflow/ outflow catheters into the flexor sheath for 3 days. Bacteriology showed streptococcus, Staphyloco~us uureus. and Eikenella corrodens to be the most common organisms (Table 1). There were also several anaerobic organisms cultured. Most of the flora were common colonizers of the skin or oral cavity. Several patients admitted to licking needles prior to injection, a practice thought to account for the presence of oral flora in the cultures. Eleven out of 59 abscesses had anaerobes cultured. Six patients had no organism cultured, several of whom admitted to taking oral antibiotics prior to treatment at our institution.
of Hand
Surgery
/ Vol.
18A No. 5 September
Table 1. Bacteriology Streptococcus
~
1993
________
Organism
No. of Patients
viridans
28 19
P-hemolytic streptococcus (not group A or B) Staphylococcus aureus Eikenella corrodens Bacteroides melaninogenicus
17 I5 7
Group A streptococcus
6
Bacteroides intermedius Staphylococcus epidermitis
2 2
Coagulase-negative staphylococcus Peptostreptococcus
2 2
Morganella
I 1 1 I 1 1 I I I 1
morganii
Diptheroids Bacillus species E.scherichia coli Peptococcus sacharolyticus Bacteroides oris Providencia stuartii
Enterococci Proteus mirabilis Bacteroides fragilis Hemophilus influenzae
No growth ~~~ _...~..
~ ._.~~~
The patients streptococcus streptococcus Streptococcus
869
I 6
with necrotizing fasciitis all had cultured-two with p-hemolytic (not group A or B) and one with viridans.
Eighteen blood cultures were performed in febrile patients and three were positive. The average hospital admission was 15 days, with a range of 2-65 days. Eight patients signed out against medical advice. Long-term follow-up evaluation was impossible because of the transient nature of this population. Discussion Abscesses associated with drug abuse by injection are common because of practices of sharing needles, reusing needles, licking needles, and an overall lack of aseptic technique. 2.3 The infecting organisms are common oral and skin flora.4.5 Organisms have also been cultured from confiscated drugs.‘j Previous studies frequently isolated anaerobes in these abscesses.s In our own population, 20% of the abscesses had anaerobes cultured. The frequent finding of Eikenella corrodens (25% in our study) has not been previously reported. Based on the bacteriology, we recommend initial treatment to be a combination of a first-generation cephalosporin and penicillin, or a combination such as ticarcillin and clavulanic acid. They provide wide coverage for Gram-positive bacteria, Eikenella corrodens, and anaerobes.
870
Gonzalez et al. / Upper Extremity Injection Abscesses
These infections are generally isolated to the soft tissues and respond to wide incision and drainage.3 However, recurrences are common after initial, seemingly adequate, incision and drainage. In our series, 19 out of 59 abscesses required more than one surgical debridement. Complications noted included necrotizing fasciitis, osteomyelitis, and flexor tenosynovitis. Necrotizing fasciitis is an uncommon but very serious infection that can be limbor life-threatening. Early aggressive debridement with wide debridement is necessary. Nine of the 31 patients tested in our series were HIV-positive. HIV status was compared with number of debridements required, length of hospitalization, and multiplicity of organisms isolated (single vs multiple). No significant correlation was noted. Two of the three patients who developed necrotizing fasciitis were tested and both were HIV-positive. HIV infection may predispose patients to acquired infections and should always be considered in this population.’ The risk to the surgeon is considerable and maintenance of the strictest precautions are necessary. Because of the heavy exposure of these patients, even a recent negative HIV test does not rule out HIV infection.’ Noncompliance makes the care of these patients difficult. Eight of our patients signed out against medical advice. We hospitalized our patients for a rather extended period (mean, 15 days)
because outpatient follow-up was virtually impossible. Few patients kept their follow-up appointments. Abscesses secondary to illicit drug injection require urgent surgical debridement, appropriate antibiotic therapy, and follow-up care until resolution. Complicated infections with the development of osteomyelitis or necrotizing fasciitis are frequent and often require multiple debridements. Because of a high rate of HIV infection, strict technique to protect operating room personnel is mandatory.
References 1. White A. Medical disorders in drug addicts. JAMA 1973;223: 1469-71. 2. Geelhoed GW, Joseph WL. Surgical sequelae of drug abuse. Surg Gynecol Obstet 1974;139:749-55. 3. Biderman P, Hiatt JR. Management of soft tissue infections of the upper extremity in parenteral drug abusers. Am J Surg 1987;154:526-8. 4. Organio GR, Pitlick SD, Latta PD et al. Soft tissue infections in parenteral drug abusers. Ann Surg 1984; 199:97-100. 5. Webb D, Thadepalli H. Shin and soft tissue polymicrobial infections from intravenous abuse of drugs. West J Med 1979:130:200-4. 6. Tauzon CU, Hill R, Sheagren JN. Microbiologic study of street heroin and injection paraphernalia. J Int Dis 1974;129:327-9. 7. Cohen PT, Sande M. AIDS knowledge base. Waltham. MA: Medical Publishing Group, 1990.