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Management of soft-tissue infections of the upper extremity in parenteral drug abusers
Management of Soft-Tissue Infections of the Upper Extremity in Parenteral Drug Abusers
Philip Biderman, MD and Jonathan R. Hiatt, MD, Los Angeles, California
With the current prevalence of parenteral drug abuse, the general surgeon encounters patients with soft-tissue cellulitis, abscesses, and septic phlebitis at injection sites, often in the upper extremity. Recognizing the serious nature of these infections, he may choose antibiotic regimens based on traditional impressions of predominant bacteriologic action. We reviewed our experience with the management of a group of drug abusers with abscesses in a large metropolitan hospital to establish guidelines for surgical and antimicrobial therapy. Material and Methods The operative records of the Harbor-UCLA Medical Center were reviewed for the 2 year period between mid1981 and 1983. Twenty-three patients requiring operative intervention for treatment of soft-tissue infections of the upper extremity secondary to parenteral drug abuse were identified and their hospital charts were reviewed, noting in particular the operative management, choice of antibiotics, and bacteriologic characteristics of recovered organisms. This report does not include many less serious infections treated on an outpatient basis without surgical consultation and not requiring operating room facilities for adequate treatment. Results
Of the 23 patients, 11 were men and 12 were women, with an average age of 28.2 years (range 20 to 41 years). Fourteen were white, 8 were black, and 1 was Hispanic. Fourteen patients were users of heroin, 5 were users of cocaine, 3 were users of methylphenidate (Ritalin@), 2 were users of amphetamines, and 1 was a user of secobarbital (SecoFrom the Departments of Surgery, Harbor-UCLA and UCLA Medical Centers, Los Angeles, California. ReaUeStS for reorints should be addressed to Jonathan Ft. Hiatt. MD. 7raunk and Emergency Surgery Service, Room 72-182 CHS, UCLA kdi: cal Center, Los Angeles, California 90024. Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Palm Springs, California, January 1719, 1966.
526
nale). Three of these patients injected multiple drugs. Average temperature at admission was 100.4’ F (range 97.3 to 103.8’ F). Average white blood cell count was 15,400 cells/mm3 (range 5,800 to 27,800 cells/mm3). Blood cultures were negative in 15 patients from whom specimens were obtained prior to beginning antibiotic therapy. Wound specimens were obtained for culture prior to beginning antibiotic therapy in 22 patients. Growth was seen in 21 of the specimens (Table I). Multiple organisms were retrieved from the wounds of 15 patients and a single organism from 6 patients (streptococci in 4 patients, Staphylococcus aureus in 1 patient, and an anaerobe in 1 patient). One specimen had no growth, and one wound was not tested. Seventyseven percent of the specimens (17 of 22 patients) showed at least one strain of nongroup D streptococci and 59 percent (13 of 22 patients) had anaerobic isolates. Only one specimen showed Staph. aureus. Twenty patients were begun on empiric antibiotic regimens at the time of admission, consisting of combinations of penicillin, pencillinase-resistant semisynthetic penicillins (methicillin or oxacillin), and aminoglycosides. No bacterial isolates were highly antibiotic resistant. Of 58 isolates, 52 (90 percent) were sensitive to penicillin. The gram-negative aerobes and Staph. aureus were penicillin resistant. All organisms were sensitive to a first-generation cephalosporin, except for two isolates of Enterobacter in a patient who was treated successfully with penicillin alone. All patients were taken to the operating room for surgical debridement, irrigation, and open packing of the wound (Figure 1). In seven patients, an involved vein was identified in the surgical wound and was excised. Pathologically, these veins showed thrombosis (four patients) or purulent thrombophlebitis (three patients). The remaining 16 patients had soft-tissue abscesses only, without obvious involvement of a vein. General or regional
The American Journal of Surgery
infection In Parenteral
TABLE I
Drug Abusers
Bactorlal bolster From 22 Wounds In 22 Patknts
Wound Culture
Patients
Isolates
Aerobic and facultative bacteria Streptococci (nongroup D) Enterobacter Staphylococcus aureus Escherichia coli Eikenella conodens Anaerobes Fusobacterium Peptostreptococcus Peptococcus Eubacterium Dther
22 17 2 1 1 1 13 2 1 1
34 28 3
I3
19
1 1 24 2 1 1
anesthesia was used in every case. Most wounds healed completely by secondary intention with aggressive local care, including packing and whirlpool baths. The affected extremities were immmobilized and elevated. Skin grafts were often recommended by the surgeon to accelerate the healing process when the patient was seen at follow-up, but most of the patients refused to return to the hospital for the second procedure (Figure 2). The average hospital stay was 8 days. Patients were discharged when their wounds showed signs of healthy granulation. The hospital stay was prolonged in seven patients who had received inadequate drainage in the emergency room prior to admission. Their abscesses had been drained through small incisions under local anesthesia. After a period of observation in the hospital, it was clear that more definitive surgical intervention would be needed to eradicate the infections.
Chronic parenteral drug abuse threatens the health of more than ‘760,606 Americans [I]. Some complications relate directly to drug injection, and others are the aequelae of drug-related behavior, including blunt and penetrating trauma in criminal encounters, industrial and motor vehicle accidents while intoxicated, and crush injuries with compartment syndromes while lying comatose [2,3]. Other surgical complications include endocarditis, septic pulmonary emboli, ischemic gangrene, mycotic aneurysm, intestinal pseudoobstruction, and soft-tissue infection. Infection is responsible for 27.5 percent of hospital admissions of drug abusers, and the most common of these is abscess formation at the injection site [4]. Therefore, the surgeon in urban practice should expect to encounter these infections, and an effective management strategy is essential. The bacteriologic characteristics of these infections are of particular interest since most patients
Volume 154, November
1987
Ftgure 1. Extensive recurrent Infectton of tfw foreann In a herotn abuser. Skin has been opened w/de/y and the necrotic subcutaneous t/ssueS debrfded. Cutture revealed strefMcocc1 and Escherlchla COIL
Ftgure 2.7Bree weeks later, the pattent returned to the operatktg room for coverage of the granulation wound wtth a splttthickness skht graft from the thtgh.
should receive antibiotic therapy before culture results are returned. The goal of this therapy is control of local cellulitis and prevention of bacteremia when the abscess is drained. Spontaneous bacteremia prior to abscess drainage was not demonstrated in the 15 patients from whom initial blood cultures were obtained. Most infections are polymicrobial(68 percent in our series). Oral organisms characterized the bacteriologic profiles of our patients and those of other investigators [5-71. Streptococci, alone and in combination with anaerobes, were the organisms most commonly found. Fifty-nine percent of our isolates included an anaerobe, which has also been
527
Biderman and Hiatt
reported by other investigators [5]. Although the traditional impression is that Staph. aureus is a prevalent pathogen in these infections [2,6,7, staph ylococci were found in only one of our patients and in only 19 percent of patients described by Webb and Thadepalli [5]; however, they were pres ent in 16 of 30 patients reported by Orangio [6]. Therefore, it is clear that distinct bacteriologic profiles may characterize different populations. These differences have been attributed to use of variable diluents to cut drugs and close contact between persons in a closed drug subculture [2,7]. Tuazon et al [S] concluded that the individual addict was the principal source of offending organisms. The predominance of oral flora is attributed to mouth contact associated with drug and needle preparation. None of the organisms in our experience were highly resistant. Although broad-spectrum antimicrobial regimens were often used, they were never needed, according to the results of wound cultures. Nineteen of 23 infections could have been treated by penicillin alone, as one could predict based upon the bacteriologic characteristics, and all but two organisms were sensitive to a first-generation cephalosporin. The addition of an aminoglycoside would have been appropriate in one patient with an Enterobacter infection, but this patient recovered with penicillin alone. Surgical debridement and drainage is the mainstay of therapy of these soft-tissue infections. Limited drainage in the emergency room may prolong hospitalization unnecessarily, as occurred in seven of our patients. The important aspects of diagnosis and management of the intravenous drug abuser with a soft tissue infection of the upper extremity should include the following: (1) Surveillance by physical examination and laboratory studies for other complications of drug abuse such as endocarditis. (2) Wound culture, by aspiration if necessary, prior to beginning antibiotics. (3) Operative incision, debridement, and drainage under general or regional anesthesia, with search for and excision of involved veins. If a vein is present in the operative field, it should be ligated and excised. Pathologically, these veins contain either thrombus or pus in our experience. (4) Parenteral antibiotic therapy with a first-generation cephalosporin. Knowledge of bacteriologic profiles of these patients may also be helpful. (5) Aggressive local wound care, with packing,
528
frequent dressing changes, and whirlpool hydrotherapy. (6) Immobilization and elevation of the extremity, with frequent examinations to detect spread of infection. (7) Discharge when healthy granulation tissue is present in the base of the wound, and surrounding cellulitis is resolving (usually 6 to 8 days postoperatively). Oral antibiotics should be used for persistence of mild cellulitis in a wound that is otherwise progressing satisfactorily. Skin grafts should be employed selectively. Summary Management of extensive soft-tissue infections of the upper extremity in 23 parenteral drug abusers was reviewed. Bacterial cultures most often revealed oral flora, including streptococcal species in 77 percent of patients and anaerobes in 59 percent. Staph. aureus was present in only one patient. Ninety percent of the organisms were sensitive to penicillin and 98 percent to first-generation cephalosporins. Blood culture specimens, obtained at admission, were negative in 15 patients. All patients responded well to operative debridement, excision of involved veins, and local wound care. Surgical debridement is the mainstay of therapy. We believe that intravenous antibiotic therapy with a first-generation cephalosporin should be used in the acute phase for control of surrounding cellulitis and prevention of bacteremia.
References 1. Hunt LG. Prevalence of active heroin use in the U.S. In: Rittenhouse JD, ed. Research monograph no. 16. Washington, DC: U.S. Government Printing Office, 1979: 61-86. 2. Geelhoed GW, Joseph WL. Surgical sequelae of drug abuse. Surg Gynecol Obstet 1974; 139: 749-55. 3. Butterfield WC. Surgical complications of narcotic addiction. Surg Gynecol Obstet 1972; 134: 749-55. 4. White AG. Medical disorders in drug addicts in 200 consecutive admissions. JAMA 1973; 223: 1469-71. 5. Webb D, Thadepalli H. Skin and soft tissue polymicrobial infections from intravenous abuse of drugs. West J Med 1979; 130: 200-4. 6. Orangio GR, Pitlick SD, Della Latta P, et al. Soft tissue infections in parenteral drug abusers. Ann Surg 1984; 199: 97100. 7. Orangio GR, Delia Latta P, Marino C, et al. Infections in parenteral drug abusers: further immunologic studies. Am J Surg 1983; 146: 738-41. 8. Tuazon CV, Hill R, Sheayren JN. Microbiologic study of street heroin and injection paraphernalia. J Infect Dis 1974; 129: 3327-9.
llw Amerlcan Journal of Surgery
Philip Biderman, MD and Jonathan R. Hiatt, MD, Los Angeles, California
With the current prevalence of parenteral drug abuse, the general surgeon encounters patients with soft-tissue cellulitis, abscesses, and septic phlebitis at injection sites, often in the upper extremity. Recognizing the serious nature of these infections, he may choose antibiotic regimens based on traditional impressions of predominant bacteriologic action. We reviewed our experience with the management of a group of drug abusers with abscesses in a large metropolitan hospital to establish guidelines for surgical and antimicrobial therapy. Material and Methods The operative records of the Harbor-UCLA Medical Center were reviewed for the 2 year period between mid1981 and 1983. Twenty-three patients requiring operative intervention for treatment of soft-tissue infections of the upper extremity secondary to parenteral drug abuse were identified and their hospital charts were reviewed, noting in particular the operative management, choice of antibiotics, and bacteriologic characteristics of recovered organisms. This report does not include many less serious infections treated on an outpatient basis without surgical consultation and not requiring operating room facilities for adequate treatment. Results
Of the 23 patients, 11 were men and 12 were women, with an average age of 28.2 years (range 20 to 41 years). Fourteen were white, 8 were black, and 1 was Hispanic. Fourteen patients were users of heroin, 5 were users of cocaine, 3 were users of methylphenidate (Ritalin@), 2 were users of amphetamines, and 1 was a user of secobarbital (SecoFrom the Departments of Surgery, Harbor-UCLA and UCLA Medical Centers, Los Angeles, California. ReaUeStS for reorints should be addressed to Jonathan Ft. Hiatt. MD. 7raunk and Emergency Surgery Service, Room 72-182 CHS, UCLA kdi: cal Center, Los Angeles, California 90024. Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Palm Springs, California, January 1719, 1966.
526
nale). Three of these patients injected multiple drugs. Average temperature at admission was 100.4’ F (range 97.3 to 103.8’ F). Average white blood cell count was 15,400 cells/mm3 (range 5,800 to 27,800 cells/mm3). Blood cultures were negative in 15 patients from whom specimens were obtained prior to beginning antibiotic therapy. Wound specimens were obtained for culture prior to beginning antibiotic therapy in 22 patients. Growth was seen in 21 of the specimens (Table I). Multiple organisms were retrieved from the wounds of 15 patients and a single organism from 6 patients (streptococci in 4 patients, Staphylococcus aureus in 1 patient, and an anaerobe in 1 patient). One specimen had no growth, and one wound was not tested. Seventyseven percent of the specimens (17 of 22 patients) showed at least one strain of nongroup D streptococci and 59 percent (13 of 22 patients) had anaerobic isolates. Only one specimen showed Staph. aureus. Twenty patients were begun on empiric antibiotic regimens at the time of admission, consisting of combinations of penicillin, pencillinase-resistant semisynthetic penicillins (methicillin or oxacillin), and aminoglycosides. No bacterial isolates were highly antibiotic resistant. Of 58 isolates, 52 (90 percent) were sensitive to penicillin. The gram-negative aerobes and Staph. aureus were penicillin resistant. All organisms were sensitive to a first-generation cephalosporin, except for two isolates of Enterobacter in a patient who was treated successfully with penicillin alone. All patients were taken to the operating room for surgical debridement, irrigation, and open packing of the wound (Figure 1). In seven patients, an involved vein was identified in the surgical wound and was excised. Pathologically, these veins showed thrombosis (four patients) or purulent thrombophlebitis (three patients). The remaining 16 patients had soft-tissue abscesses only, without obvious involvement of a vein. General or regional
The American Journal of Surgery
infection In Parenteral
TABLE I
Drug Abusers
Bactorlal bolster From 22 Wounds In 22 Patknts
Wound Culture
Patients
Isolates
Aerobic and facultative bacteria Streptococci (nongroup D) Enterobacter Staphylococcus aureus Escherichia coli Eikenella conodens Anaerobes Fusobacterium Peptostreptococcus Peptococcus Eubacterium Dther
22 17 2 1 1 1 13 2 1 1
34 28 3
I3
19
1 1 24 2 1 1
anesthesia was used in every case. Most wounds healed completely by secondary intention with aggressive local care, including packing and whirlpool baths. The affected extremities were immmobilized and elevated. Skin grafts were often recommended by the surgeon to accelerate the healing process when the patient was seen at follow-up, but most of the patients refused to return to the hospital for the second procedure (Figure 2). The average hospital stay was 8 days. Patients were discharged when their wounds showed signs of healthy granulation. The hospital stay was prolonged in seven patients who had received inadequate drainage in the emergency room prior to admission. Their abscesses had been drained through small incisions under local anesthesia. After a period of observation in the hospital, it was clear that more definitive surgical intervention would be needed to eradicate the infections.
Chronic parenteral drug abuse threatens the health of more than ‘760,606 Americans [I]. Some complications relate directly to drug injection, and others are the aequelae of drug-related behavior, including blunt and penetrating trauma in criminal encounters, industrial and motor vehicle accidents while intoxicated, and crush injuries with compartment syndromes while lying comatose [2,3]. Other surgical complications include endocarditis, septic pulmonary emboli, ischemic gangrene, mycotic aneurysm, intestinal pseudoobstruction, and soft-tissue infection. Infection is responsible for 27.5 percent of hospital admissions of drug abusers, and the most common of these is abscess formation at the injection site [4]. Therefore, the surgeon in urban practice should expect to encounter these infections, and an effective management strategy is essential. The bacteriologic characteristics of these infections are of particular interest since most patients
Volume 154, November
1987
Ftgure 1. Extensive recurrent Infectton of tfw foreann In a herotn abuser. Skin has been opened w/de/y and the necrotic subcutaneous t/ssueS debrfded. Cutture revealed strefMcocc1 and Escherlchla COIL
Ftgure 2.7Bree weeks later, the pattent returned to the operatktg room for coverage of the granulation wound wtth a splttthickness skht graft from the thtgh.
should receive antibiotic therapy before culture results are returned. The goal of this therapy is control of local cellulitis and prevention of bacteremia when the abscess is drained. Spontaneous bacteremia prior to abscess drainage was not demonstrated in the 15 patients from whom initial blood cultures were obtained. Most infections are polymicrobial(68 percent in our series). Oral organisms characterized the bacteriologic profiles of our patients and those of other investigators [5-71. Streptococci, alone and in combination with anaerobes, were the organisms most commonly found. Fifty-nine percent of our isolates included an anaerobe, which has also been
527
Biderman and Hiatt
reported by other investigators [5]. Although the traditional impression is that Staph. aureus is a prevalent pathogen in these infections [2,6,7, staph ylococci were found in only one of our patients and in only 19 percent of patients described by Webb and Thadepalli [5]; however, they were pres ent in 16 of 30 patients reported by Orangio [6]. Therefore, it is clear that distinct bacteriologic profiles may characterize different populations. These differences have been attributed to use of variable diluents to cut drugs and close contact between persons in a closed drug subculture [2,7]. Tuazon et al [S] concluded that the individual addict was the principal source of offending organisms. The predominance of oral flora is attributed to mouth contact associated with drug and needle preparation. None of the organisms in our experience were highly resistant. Although broad-spectrum antimicrobial regimens were often used, they were never needed, according to the results of wound cultures. Nineteen of 23 infections could have been treated by penicillin alone, as one could predict based upon the bacteriologic characteristics, and all but two organisms were sensitive to a first-generation cephalosporin. The addition of an aminoglycoside would have been appropriate in one patient with an Enterobacter infection, but this patient recovered with penicillin alone. Surgical debridement and drainage is the mainstay of therapy of these soft-tissue infections. Limited drainage in the emergency room may prolong hospitalization unnecessarily, as occurred in seven of our patients. The important aspects of diagnosis and management of the intravenous drug abuser with a soft tissue infection of the upper extremity should include the following: (1) Surveillance by physical examination and laboratory studies for other complications of drug abuse such as endocarditis. (2) Wound culture, by aspiration if necessary, prior to beginning antibiotics. (3) Operative incision, debridement, and drainage under general or regional anesthesia, with search for and excision of involved veins. If a vein is present in the operative field, it should be ligated and excised. Pathologically, these veins contain either thrombus or pus in our experience. (4) Parenteral antibiotic therapy with a first-generation cephalosporin. Knowledge of bacteriologic profiles of these patients may also be helpful. (5) Aggressive local wound care, with packing,
528
frequent dressing changes, and whirlpool hydrotherapy. (6) Immobilization and elevation of the extremity, with frequent examinations to detect spread of infection. (7) Discharge when healthy granulation tissue is present in the base of the wound, and surrounding cellulitis is resolving (usually 6 to 8 days postoperatively). Oral antibiotics should be used for persistence of mild cellulitis in a wound that is otherwise progressing satisfactorily. Skin grafts should be employed selectively. Summary Management of extensive soft-tissue infections of the upper extremity in 23 parenteral drug abusers was reviewed. Bacterial cultures most often revealed oral flora, including streptococcal species in 77 percent of patients and anaerobes in 59 percent. Staph. aureus was present in only one patient. Ninety percent of the organisms were sensitive to penicillin and 98 percent to first-generation cephalosporins. Blood culture specimens, obtained at admission, were negative in 15 patients. All patients responded well to operative debridement, excision of involved veins, and local wound care. Surgical debridement is the mainstay of therapy. We believe that intravenous antibiotic therapy with a first-generation cephalosporin should be used in the acute phase for control of surrounding cellulitis and prevention of bacteremia.
References 1. Hunt LG. Prevalence of active heroin use in the U.S. In: Rittenhouse JD, ed. Research monograph no. 16. Washington, DC: U.S. Government Printing Office, 1979: 61-86. 2. Geelhoed GW, Joseph WL. Surgical sequelae of drug abuse. Surg Gynecol Obstet 1974; 139: 749-55. 3. Butterfield WC. Surgical complications of narcotic addiction. Surg Gynecol Obstet 1972; 134: 749-55. 4. White AG. Medical disorders in drug addicts in 200 consecutive admissions. JAMA 1973; 223: 1469-71. 5. Webb D, Thadepalli H. Skin and soft tissue polymicrobial infections from intravenous abuse of drugs. West J Med 1979; 130: 200-4. 6. Orangio GR, Pitlick SD, Della Latta P, et al. Soft tissue infections in parenteral drug abusers. Ann Surg 1984; 199: 97100. 7. Orangio GR, Delia Latta P, Marino C, et al. Infections in parenteral drug abusers: further immunologic studies. Am J Surg 1983; 146: 738-41. 8. Tuazon CV, Hill R, Sheayren JN. Microbiologic study of street heroin and injection paraphernalia. J Infect Dis 1974; 129: 3327-9.
llw Amerlcan Journal of Surgery