Bugs and Drugs:Bugs and Drugs:A Review of Infectious A Review of Infectious

Diseases and Diseases and Substance UseSubstance UseDiana L. Sylvestre, MDDiana L. Sylvestre, MD

Assistant Clinical Professor of MedicineAssistant Clinical Professor of Medicine

University of CA, San FranciscoUniversity of CA, San Francisco

Executive DirectorExecutive Director

Organization to Achieve Solutions in Organization to Achieve Solutions in Substance-Abuse (O.A.S.I.S.)Substance-Abuse (O.A.S.I.S.)

Acute Bacterial Acute Bacterial InfectionsInfections

• Responsible for 60% of hospital Responsible for 60% of hospital admissions among IDUsadmissions among IDUs

• ChallengesChallenges– Differentiate occult infection from Differentiate occult infection from

intoxication/withdrawalintoxication/withdrawal– Recognize atypical presentationsRecognize atypical presentations

• Predisposing factorsPredisposing factors– Defective mucociliary funtionDefective mucociliary funtion– MalnutritionMalnutrition– Altered cell-mediated immunityAltered cell-mediated immunity

CellulitisCellulitis• Staph most common, strep is nextStaph most common, strep is next

• Predisposing behaviorsPredisposing behaviors– Mixing drugs with salivaMixing drugs with saliva– Licking needlesLicking needles– Poor injecting and personal hygienePoor injecting and personal hygiene

• Tissue necrosisTissue necrosis– Vasoactive opiatesVasoactive opiates– Cocaine-induced vasospasmCocaine-induced vasospasm– Other contaminantsOther contaminants

Necrotizing FasciitisNecrotizing Fasciitis

– Streptococcus, mixed aer/anaerobesStreptococcus, mixed aer/anaerobes– More likely with “muscling” or “skin More likely with “muscling” or “skin

popping”popping”– Classic presentation: pain way out of Classic presentation: pain way out of

proportion to findings soon after proportion to findings soon after injectinginjecting

– Medical emergencyMedical emergency– Note: increasing incidence of infections Note: increasing incidence of infections

in large skeletal muscles, especially in in large skeletal muscles, especially in patients with HIVpatients with HIV

Bacterial Infections, Bacterial Infections, cont.cont.

• Wound botulismWound botulism– Clostridium toxin causes paralysisClostridium toxin causes paralysis– Classic presentation:Classic presentation:

• Dry, scratchy throat, followed byDry, scratchy throat, followed by• Cranial nerve palsies followed byCranial nerve palsies followed by• Descending paralysisDescending paralysis

– Treatment: Treatment: • Find the sourceFind the source• AntibioticsAntibiotics• Long-term respiratory supportLong-term respiratory support

Bacterial EndocarditisBacterial Endocarditis

–Fever and heart murmurFever and heart murmur

–IDUs younger and without IDUs younger and without preexisting valvular diseasepreexisting valvular disease

–>50% staph, ~15% strep>50% staph, ~15% strep

–More likely to require surgeryMore likely to require surgery

–HIV does not increase riskHIV does not increase risk

Respiratory InfectionsRespiratory Infections

• Predisposing factors:Predisposing factors:– CigarettesCigarettes– AlcoholAlcohol– Altered MS and loss of gag reflexAltered MS and loss of gag reflex– HIVHIV

• Up to 1/3 of IDUs with fever have Up to 1/3 of IDUs with fever have pneumoniapneumonia

• Increased incidence of H flu, S. aureus, Increased incidence of H flu, S. aureus, Ps. aeruginosa relative to non-IDUsPs. aeruginosa relative to non-IDUs

TuberculosisTuberculosis

• IDUs have increased risk of Tb reactivationIDUs have increased risk of Tb reactivation– Reason is unknownReason is unknown

• Increased risk of MDR TBIncreased risk of MDR TB• Cough, blood-tinged sputum, malaiseCough, blood-tinged sputum, malaise• Later: night sweats, wt lossLater: night sweats, wt loss• PPD negative in 25% at diagnosisPPD negative in 25% at diagnosis• 1/6 extrapulmonary risk increased to 60-80% in 1/6 extrapulmonary risk increased to 60-80% in

HIVHIV

TB RecommendationsTB Recommendations

• Yearly PPD unless previously positiveYearly PPD unless previously positive• PPD positive:PPD positive:

– HIV+: 5 mmHIV+: 5 mm• 12 mo chemoprophylaxis with INH, 300mg/d with B612 mo chemoprophylaxis with INH, 300mg/d with B6

– HIV-: 10 mmHIV-: 10 mm• 6 mo chemoprophylaxis with INH/B66 mo chemoprophylaxis with INH/B6

– If PPD+, R/O active TB: CXR, culturesIf PPD+, R/O active TB: CXR, cultures

• INH, rifampin, pyrazinamide: liver toxicityINH, rifampin, pyrazinamide: liver toxicity• Rifampin lowers methadone levelsRifampin lowers methadone levels

STDsSTDs

• Higher rates ofHigher rates of– SyphilisSyphilis

• Annual RPR recommendedAnnual RPR recommended

– HPVHPV• Increased risk of cervical cancer with certain Increased risk of cervical cancer with certain

serotypesserotypes

– Chlamydia and GCChlamydia and GC• Cervical culture/DNA, urine screen availableCervical culture/DNA, urine screen available

Hepatitis A/BHepatitis A/B

• HAV: fecal-oral transmissionHAV: fecal-oral transmission

• HBV: Most common cause of reported cases HBV: Most common cause of reported cases of acute hepatitis of acute hepatitis

• Transmitted Transmitted sexuallysexually, by blood, and vertically, by blood, and vertically

• Chronic infection in <5% adults, >90% Chronic infection in <5% adults, >90% perinatallyperinatally

Hepatitis DHepatitis D

• Defective virus, only occurs in presence of Defective virus, only occurs in presence of active HBVactive HBV

• More aggressive diseaseMore aggressive disease

• HBV vaccination is protectiveHBV vaccination is protective

HIVHIV

• In US:In US:– 750,000 cases750,000 cases– 40,000 new infections per year40,000 new infections per year

• 26% due to IDU, 19% male, 6% female26% due to IDU, 19% male, 6% female• 25% of HIV-infected persons in the US are 25% of HIV-infected persons in the US are

coinfected with HCVcoinfected with HCV• 50-93% of HIV-infected IDUs are coinfected50-93% of HIV-infected IDUs are coinfected

AIDSAIDS

• Over the past few years, the numbers of newly Over the past few years, the numbers of newly reported cases of AIDS in IDUs has surpassed reported cases of AIDS in IDUs has surpassed the numbers in MSMthe numbers in MSM

• Women with AIDS:Women with AIDS:– 42% from IDU42% from IDU

• Men with AIDS:Men with AIDS:– 22% from IDU22% from IDU

• Most common reason for death: liver disease Most common reason for death: liver disease (HCV)(HCV)

HIV in IDUsHIV in IDUs

• Increasing reports of significant HIV Increasing reports of significant HIV infection rates in non-injection drug usersinfection rates in non-injection drug users– Probably sexual transmissionProbably sexual transmission– Disinhibiting effects of:Disinhibiting effects of:

• Alcohol, amphetamines, cocaine, inhalantsAlcohol, amphetamines, cocaine, inhalants

• Substantially increased seroprevalence Substantially increased seroprevalence rates in crack usersrates in crack users

HIV in IDUsHIV in IDUs

• Among IDUs, the risk of HIV infection increases with:Among IDUs, the risk of HIV infection increases with:– Duration of injection drug useDuration of injection drug use– Frequency of needle sharingFrequency of needle sharing– Number of sharing partners, especially in shooting galleriesNumber of sharing partners, especially in shooting galleries– Little or no condom useLittle or no condom use– Multiple sexual partnersMultiple sexual partners– Comorbid psychiatric conditions such as ASPDComorbid psychiatric conditions such as ASPD– Use of cocaine in injectable form or smoked as crackUse of cocaine in injectable form or smoked as crack– Use of injection drugs in a geographic location with a high Use of injection drugs in a geographic location with a high

prevalence of HIV infection.prevalence of HIV infection.

Preventing Transmission Preventing Transmission in IDUsin IDUs

• Needle exchange effective at reducing HIV Needle exchange effective at reducing HIV transmission and does not increase use of transmission and does not increase use of injection drugsinjection drugs

• Counsel re: heterosexual transmissionCounsel re: heterosexual transmission• No breastfeedingNo breastfeeding

HIV TestsHIV Tests

• HIV antibodies appear 2-12 weeks after HIV antibodies appear 2-12 weeks after infectioninfection

• HIV RNA:HIV RNA:– Determine prognosis (primary)Determine prognosis (primary)

•   CD4+ T cell count is best indicator of the CD4+ T cell count is best indicator of the immediate state of immunologic immediate state of immunologic competence in a patient with HIVcompetence in a patient with HIV

HAARTHAART

• HHighly-ighly-aactive ctive aanti-nti-rretroviral etroviral ttherapyherapy• Has resulted in marked declines in the Has resulted in marked declines in the

majority of AIDS-defining conditionsmajority of AIDS-defining conditions• HAART involves the use of 3 or more HAART involves the use of 3 or more

antiviral medications, typically in 2 antiviral medications, typically in 2 categoriescategories

Reverse Transcriptase Reverse Transcriptase InhibitorsInhibitors

• NRTI’s: nucleoside analoguesNRTI’s: nucleoside analogues– AZT, ddI, ddC, d4T, 3TC, ABCAZT, ddI, ddC, d4T, 3TC, ABC– Nonselective, serious side effectsNonselective, serious side effects– Methadone may reduce blood levels: ddI, stavudineMethadone may reduce blood levels: ddI, stavudine

• NNRTI’s: non-nucleoside RTIsNNRTI’s: non-nucleoside RTIs– Nevirapine, delarvadine, efavirenzNevirapine, delarvadine, efavirenz– Very selective for HIV-1 RTVery selective for HIV-1 RT– Rash, neuropsychiatric toxicityRash, neuropsychiatric toxicity– Methadone level reduced: nevirapine, efavirenzMethadone level reduced: nevirapine, efavirenz

Protease InhibitorsProtease Inhibitors

• Saquinavir, indinavir, ritonavir, nelfinavir, Saquinavir, indinavir, ritonavir, nelfinavir, amprenavir amprenavir

• Ritonavir “boosting” is commonRitonavir “boosting” is common

• Lipodystrophy syndrome:Lipodystrophy syndrome:– Hyperlipidemia, insulin resistanceHyperlipidemia, insulin resistance– Fat redistributionFat redistribution

• Methadone level reducedMethadone level reduced– Ritonavir, nelfinavir, lopinavirRitonavir, nelfinavir, lopinavir

Hepatitis CHepatitis C

• 4 million cases in US, 170 million worldwide4 million cases in US, 170 million worldwide• 60% of new and existing cases related to IDU60% of new and existing cases related to IDU• Seroprevalence in IDU 65-96%Seroprevalence in IDU 65-96%• Transmitted by blood: needles, syringes, Transmitted by blood: needles, syringes,

cottons, cookers, rinsewatercottons, cookers, rinsewater• Sexual transmission rare, ~5%Sexual transmission rare, ~5%

– STD’s, multiple sexual partnersSTD’s, multiple sexual partners

• Vertical transmission rare, ~5%Vertical transmission rare, ~5%

Hepatitis CHepatitis C

• 8-16% develop cirrhosis after 2 decades8-16% develop cirrhosis after 2 decades

• Accelerated disease with HIVAccelerated disease with HIV

• Accelerated disease with EtOHAccelerated disease with EtOH

• Drug use not known to accelerate natural Drug use not known to accelerate natural coursecourse

HCV TestingHCV Testing• LFT’s normal persistently in ~1/4 with active diseaseLFT’s normal persistently in ~1/4 with active disease• HCV antibody: HCV antibody: EXPOSURE, EXPOSURE, NOT active infectionNOT active infection

– ~25% spontaneously clear~25% spontaneously clear• HCV viral loadHCV viral load

– Indicates ACTIVE disease, not extent of diseaseIndicates ACTIVE disease, not extent of disease• HCV genotypeHCV genotype

– By far the best predictor of response to therapyBy far the best predictor of response to therapy– Determines length of therapyDetermines length of therapy

HCV TreatmentHCV Treatment

• Cornerstone of treatment is interferon/ribavirin Cornerstone of treatment is interferon/ribavirin combination therapy for 24-48 weekscombination therapy for 24-48 weeks

• Interferon administered by injectionInterferon administered by injection

• Ribavirin administered PORibavirin administered PO

• Outcome measure: Outcome measure: – Sustained virologic response (SVR) Sustained virologic response (SVR)

• Lack of virus 6 months after completing therapyLack of virus 6 months after completing therapy• 54-56% with current therapy54-56% with current therapy

Needlestick InjuriesNeedlestick Injuries

• Risk of transmission from needlestick injury Risk of transmission from needlestick injury is is HIV<HCV<HBVHIV<HCV<HBV::

– 0.3% with HIV0.3% with HIV

– 1.8% with HCV (6x higher)1.8% with HCV (6x higher)

– 6-30% with HBV (50x higher)6-30% with HBV (50x higher)

VaccinationsVaccinations

• dT every 10 yearsdT every 10 years– > 5 years if tetanus-prone wound> 5 years if tetanus-prone wound

• HAVHAV

• HBVHBV

• Pneumovax:Pneumovax:– >50, HIV>50, HIV

• FluFlu