Infectious Disease Compendium

Intravenous Drug User Infection


Usually it's a fever that tips you off there is an infection. Do not ignore it.

Epidemiologic Risks

Would you believe it? Using drugs intravenously is bad.

Heroin is a rich microbiologic stew (PubMed)(PubMed) and can grow everything from Aspergillus to Clostridia. They often say that heroin is 'contaminated' with micro-organisms, which suggests that the producers are using high-quality production methods to make the drugs. Right. Just look black tar heroin. No way is that even remotely sterile (PubMed).

I have never seen either meth or cocaine cultured and, given how meth is produced (PubMed), it looks inhospitable to microbial growth.

I have had patients use tap water, toilet water, spit, old blood, puddle water, river water and more to mix their drugs.

Although not an injection drug, marijuana can contain aspergillus (PubMed) or mucor and can cause pulmonary disease in poor hosts. And there was an outbreak of TB due to hotboxing, where everyone sits in a car to share the second-hand smoke (PubMed).


Drugs and their paraphernalia are a rich source for many bacterial and fungi. Remember that while S. aureus predominates, they can get any bug anywhere.

- Virus: HIV, all forms of hepatitis (Hepatitis B, Hepatitis C, Hepatitis D).

- STDs: (sex is how the habit is often supported) especially Gonorrhea and syphilis.

- Bacteria Infections: left and righted sided endocarditis from S. aureus and other organisms. An IVDA are 16x more likely to get invasive MRSA (PubMed).

- Aspiration pneumonia, especially if they lose consciousness.

- If they are needle lickers (it slides in more easily), oral streptococci and HACEK are a possibility.

- If they use tap or toilet water to mix their drugs (and they do) E. coli, Pseudomonas, and Serratia. Serratia was big in San Francisco in the 1970'w, likely because the US miliary sprayed the Bay area with Serratia in the 1950s to see how a 'non-pathogen' would spread in an urban environment (PubMed)

- Skin poppers can get gas gangrene from Clostridium perfringens, C. novyi (PubMed) and diphtheria, there is a cutaneous disease in heroin users amongst others (PubMed)(PubMed).

There is a case in a heroin user with sepsis from an injection site infection (PubMed) and an ongoing outbreak of cutaneous diphtheria in Scotland (PubMed) and England (PubMed).

- Black tar heroin is associated with wound botulism (PubMed) and some will get it more than once. Can you say addicting?

- If they strain the heroin through cotton, the cotton can cause a fever either from a reaction to the cotton or can be due to Pantoea. (PubMed). Cotton balls, which are not sterile, can contain Pantoea by way of a weevil that lives, and craps, in cotton (PubMed) Stink bug poop. What a way to get an infection.

- Heroin is a source of Candida (disseminated disease) as is lemon juice, sometimes used to dissolve heroin (PubMed). IVDA is a risk for Candidemia, at least in the US NE (PubMed) and Denver, where it often occurs as part of a polymicrobial bacteremia (PubMed).

- Aspergillus and Mucor (both can cause brain abscess).

- Local mixed bacterial or S. aureus soft tissue abscesses, especially if they miss the vein.

Joints, disc spaces, and epidural space are popular areas for hematogenous seeding. If the eye is involved, worry about fungi (Candida, Aspergillus) and B. cerus.

In IVDU, "Septic arthritis is more often caused by MRSA, MSSA, and Serratia sp., and is more prone to involve the sacroiliac, acromioclavicular, sternoclavicular, and facet joints."(Pubmed)."

Empiric Therapy

After blood cultures are obtained and appropriate fluid collections are sampled, an anti-staphylococcal antibiotic and something for gram-negative rods are started. Penicillin PLUS (nafcillin OR oxacillin) PLUS gentamicin has been the traditional choice, but in the era of MRSA, vancomycin PLUS a third-generation cephalosporin OR a quinolone is also reasonable.


As a rule, a shooter with a fever should probably be admitted pending the results of blood cultures. Look for pus to drain.

TTE on IVDA in the outpatient setting will often have valve pathology and 5% will have vegetations without endocarditis (PubMed).

Endocarditis is a bad disease in this population, having a 16% one-year all-cause mortality (PubMed).


Even though they abuse themselves and rob us to pay for their habit, and often treat us like crap, once they are in our care we need to treat them with the respect and care we would extend to national monuments. I love being a doctor. Oh yeah. I bet they want lots of narcs.

Curious Cases

Relevant links to my Medscape blog

Coke Does Not Always Add Life

Coke Adds Life?

IVDA. A Bad Lifestyle Except For The Fungi

No Longer Tired


Another Just So Story?

Life Lessons


Real World, Perfect World


Bad Technique


I don’t care what the literature says, it’s still a bad idea.

Misleading Packaging

Eau de toilette

Last Update: 04/02/20.