Usually it's a fever that tips you off. Do not blow it off.
Would you believe it? Using drugs intravenously is bad.
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. Cotton, which can be used for a filter, contains Enterobacter by way of a weevil that lives, and craps, in cotton.
- Aspiration pneumonia, especially of they lose consciousness.
- If they are needle lickers (it slides in more easily), oral streptococci and HACEK are a possibility. It they use tap or toilet water to mix their drugs (and they do) E. coli, Pseudomonas, and Serratia.
- Skin poppers can get gas gangrene from Clostridium perfringens, C. novyi (PubMed)and diphtheria, there is 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 Enterobacter. Turns out that Enterobacter can infect cotton crops, and it gets there by way of stink bugs(PubMed).
- Heroin is a source of Candida (disseminated disease), aspergillus and Mucor (both can cause brain abscess). Local mixed bacterial or S. aureus soft tissue abscesses, especially if they miss the vein.
After blood cultures are obtained and appropriate fluid collections are sampled, an anti-staphylococcal antibiotic and something for gram negative rods is started. Penicillin PLUS (nafcillin OR oxacillin) PLUS gentamicin has been traditional. Oxacillin OR vancomycin PLUS a third generation cephalosporins 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).
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.
Relevant links to my Medscape blog