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Contaminated street heroin: Relationship to clinical infections
Abstracts in this issue were prepared by residents in the University of Arizona Emergency Medicine Residency Program.
ABSTRACTS Harvey W Meislin, MD, FACEP Co-Editor Chief, Section of Emergency Medicine University of Arizona College of Medicine
Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital
DRUG ABUSE, INFECTION; HEROIN, CONTAMINATION
Contaminated street heroin: Relationship to clinical infections Moustoukas NM, Nichols RL, Smith JW, et al Arch Surg 118:74G749
Oct 1983
Drug overdose and infection are two common reasons for drug addicts to seek emergency medical care. The potential sources for infection include the skin or oral flora of the addict, the drug paraphernalia utilized, or the drug itself. This study examined 31 samples of heroin obtained in New Orleans between July 1979 and June 1980 and determined their bacteriologic burden using standard culture techniques. Chemical analysis was also performed to characterize the "fillers" used. Cultures were obtained from abscess and cellulitis sites of 21 drug users. The results showed that 19 of the 31 samples were contaminated, with Bacillus sp predominating (79%} followed by Aspergillus sp (10%). The fillers included quinine, procaine, caffeine, lactose, and mannitol. When quinine alone was used as a filler, the incidence of contamination was significantly less, indicating that the other fillers were contaminated or that the quinine was antibacterial. Cultures from the patients' soft tissue infections demonstrated skin and oral flora including Streptococcus {37%), Staphylococcus [13%), and coliforms {9%) predominant aerobically, and Bacteroides (11%) and Propionibacterium (6%) predominant anaerobically, Bacillus sp was not a significant pathogen, indicating that the addicts' own oral and dermal microflora were more likely sources for infection than was the contaminated heroin itself. [Editor's note: The bacteriology of most cutaneous abscesses reflects the patients own flora. The region of the body involved and the source of contamination (eg, saliva or needle) give a reasonable spectrum of bacterial contamination.] James H McLaughlin, MD AMOXAPINE, RENAL FAILURE; ACUTE RENAL FAILURE, AMOXAPINE
Amoxapine-associated acute renal failure Jennings AE, Levey AS, Harrington JT Arch fntem Med 143:1525-1527
Aug 1983
Amoxapine is a recently introduced tricyclic antidepressant. Overdose is common due to its use in patients with 13:2 February 1984
serious psychological problems. A case of seizure, rhabdomyolysis, and acute renal failure (ARF) is reported in a 27-year old man following overdose. The renal failure resolved ten days after the ingestion. Although neurological and cardiac toxicity are well-recognized complications of TCA overdose, renal failure is less well appreciated. Nevertheless, a review reveals that of the 111 cases of amoxapine overdose reported to the manufacturer, 12 have been accompanied by ARE Of 12 patients with ARF, seven had seizures and at least three of these had evidence of rhabdomyolysis. Two died. Of the four who had ARF without seizures, three had evidence of rhabdomyolysis or myoglobinuria. A case for a simple, direct relationship among seizures, rhabdomyolysis, and ARF cannot be made. The authors propose that the renal failure may be the result of a direct toxic effect of amoxapine or acute tubular necrosis secondary to rhabdomyolysis or hypotension. Rapid hydration and diuresis are recommended to maintain urine flow to reduce the incidence of ARE Judith Brillman, MD
ASTHMA, STEROIDS; STEROIDS, ASTHMA
Double-blind evaluation of methylprednisolone versus placebo for acute asthma episodes Shapiro GG, Furukawa CT, Pierson WE, et ai Pediatrics 71:510-514 Apr 1983
The authors studied the safety and effectiveness of shortcourse steroids in 28 children with moderate to severe asthmatic attacks. The patients were still symptomatic after therapy, but not ill enough to be hospitalized. Patients were entered into the study if their £EV 1 remained less than 80% of a previous well baseline despite three treatments with beta-agonists. Additionally all children were on chronic theophylline regimens, had not used steroids in the previous two weeks, and took beta-agonists (orally) during the study. A cosyntropin stimulation test was performed on days 1 and 14 to assess adrenal responsiveness. One group (13 patients) was given methylprednisolone in a decreasing dose schedule for eight days. The other 15 patients were treated in the same way except that a placebo pill replaced the methylprednisolone. Follow-up visits occurred 1, 7, and 14 days after the initiation of therapy and included a history, physical examination, and pulmonary function tests. None of the patients in either group returned with an exacerbation during the study. On day 2 both groups had similar mean value
Annals of Emergency Medicine
139/105
ABSTRACTS Harvey W Meislin, MD, FACEP Co-Editor Chief, Section of Emergency Medicine University of Arizona College of Medicine
Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital
DRUG ABUSE, INFECTION; HEROIN, CONTAMINATION
Contaminated street heroin: Relationship to clinical infections Moustoukas NM, Nichols RL, Smith JW, et al Arch Surg 118:74G749
Oct 1983
Drug overdose and infection are two common reasons for drug addicts to seek emergency medical care. The potential sources for infection include the skin or oral flora of the addict, the drug paraphernalia utilized, or the drug itself. This study examined 31 samples of heroin obtained in New Orleans between July 1979 and June 1980 and determined their bacteriologic burden using standard culture techniques. Chemical analysis was also performed to characterize the "fillers" used. Cultures were obtained from abscess and cellulitis sites of 21 drug users. The results showed that 19 of the 31 samples were contaminated, with Bacillus sp predominating (79%} followed by Aspergillus sp (10%). The fillers included quinine, procaine, caffeine, lactose, and mannitol. When quinine alone was used as a filler, the incidence of contamination was significantly less, indicating that the other fillers were contaminated or that the quinine was antibacterial. Cultures from the patients' soft tissue infections demonstrated skin and oral flora including Streptococcus {37%), Staphylococcus [13%), and coliforms {9%) predominant aerobically, and Bacteroides (11%) and Propionibacterium (6%) predominant anaerobically, Bacillus sp was not a significant pathogen, indicating that the addicts' own oral and dermal microflora were more likely sources for infection than was the contaminated heroin itself. [Editor's note: The bacteriology of most cutaneous abscesses reflects the patients own flora. The region of the body involved and the source of contamination (eg, saliva or needle) give a reasonable spectrum of bacterial contamination.] James H McLaughlin, MD AMOXAPINE, RENAL FAILURE; ACUTE RENAL FAILURE, AMOXAPINE
Amoxapine-associated acute renal failure Jennings AE, Levey AS, Harrington JT Arch fntem Med 143:1525-1527
Aug 1983
Amoxapine is a recently introduced tricyclic antidepressant. Overdose is common due to its use in patients with 13:2 February 1984
serious psychological problems. A case of seizure, rhabdomyolysis, and acute renal failure (ARF) is reported in a 27-year old man following overdose. The renal failure resolved ten days after the ingestion. Although neurological and cardiac toxicity are well-recognized complications of TCA overdose, renal failure is less well appreciated. Nevertheless, a review reveals that of the 111 cases of amoxapine overdose reported to the manufacturer, 12 have been accompanied by ARE Of 12 patients with ARF, seven had seizures and at least three of these had evidence of rhabdomyolysis. Two died. Of the four who had ARF without seizures, three had evidence of rhabdomyolysis or myoglobinuria. A case for a simple, direct relationship among seizures, rhabdomyolysis, and ARF cannot be made. The authors propose that the renal failure may be the result of a direct toxic effect of amoxapine or acute tubular necrosis secondary to rhabdomyolysis or hypotension. Rapid hydration and diuresis are recommended to maintain urine flow to reduce the incidence of ARE Judith Brillman, MD
ASTHMA, STEROIDS; STEROIDS, ASTHMA
Double-blind evaluation of methylprednisolone versus placebo for acute asthma episodes Shapiro GG, Furukawa CT, Pierson WE, et ai Pediatrics 71:510-514 Apr 1983
The authors studied the safety and effectiveness of shortcourse steroids in 28 children with moderate to severe asthmatic attacks. The patients were still symptomatic after therapy, but not ill enough to be hospitalized. Patients were entered into the study if their £EV 1 remained less than 80% of a previous well baseline despite three treatments with beta-agonists. Additionally all children were on chronic theophylline regimens, had not used steroids in the previous two weeks, and took beta-agonists (orally) during the study. A cosyntropin stimulation test was performed on days 1 and 14 to assess adrenal responsiveness. One group (13 patients) was given methylprednisolone in a decreasing dose schedule for eight days. The other 15 patients were treated in the same way except that a placebo pill replaced the methylprednisolone. Follow-up visits occurred 1, 7, and 14 days after the initiation of therapy and included a history, physical examination, and pulmonary function tests. None of the patients in either group returned with an exacerbation during the study. On day 2 both groups had similar mean value
Annals of Emergency Medicine
139/105