Bugs and Drugs:

Slide 1:Bugs and Drugs:A Review of Infectious Diseases and Substance Use

Diana L. Sylvestre, MD Assistant Clinical Professor of Medicine University of CA, San Francisco Executive Director Organization to Achieve Solutions in Substance-Abuse (O.A.S.I.S.)

Slide 2:Acute Bacterial Infections

Responsible for 60% of hospital admissions among IDUs Challenges Differentiate occult infection from intoxication/withdrawal Recognize atypical presentations Predisposing factors Defective mucociliary funtion Malnutrition Altered cell-mediated immunity Atypical presentations because of altered host defenses, intercurrent alcohol, and drugsAtypical presentations because of altered host defenses, intercurrent alcohol, and drugs

Slide 3:Cellulitis

Staph most common, strep is next Predisposing behaviors Mixing drugs with saliva Licking needles Poor injecting and personal hygiene Tissue necrosis Vasoactive opiates Cocaine-induced vasospasm Other contaminants

Slide 4:Necrotizing Fasciitis

Streptococcus, mixed aer/anaerobes More likely with �muscling� or �skin popping� Classic presentation: pain way out of proportion to findings soon after injecting Medical emergency Note: increasing incidence of infections in large skeletal muscles, especially in patients with HIV Muscle infections resemble tropical pyomoysitis, are usually caused by staphMuscle infections resemble tropical pyomoysitis, are usually caused by staph

Slide 5:Bacterial Infections, cont.

Wound botulism Clostridium toxin causes paralysis Classic presentation: Dry, scratchy throat, followed by Cranial nerve palsies followed by Descending paralysis Treatment: Find the source Antibiotics Long-term respiratory support

Slide 6:Bacterial Endocarditis

Fever and heart murmur IDUs younger and without preexisting valvular disease >50% staph, ~15% strep More likely to require surgery HIV does not increase risk

Slide 7:Respiratory Infections

Predisposing factors: Cigarettes Alcohol Altered MS and loss of gag reflex HIV Up to 1/3 of IDUs with fever have pneumonia Increased incidence of H flu, S. aureus, Ps. aeruginosa relative to non-IDUs

Slide 8:Tuberculosis

IDUs have increased risk of Tb reactivation Reason is unknown Increased risk of MDR TB Cough, blood-tinged sputum, malaise Later: night sweats, wt loss PPD negative in 25% at diagnosis 1/6 extrapulmonary risk increased to 60-80% in HIV MDR: resistant to INH, rifampinMDR: resistant to INH, rifampin

Slide 9:TB Recommendations

Yearly PPD unless previously positive PPD positive: HIV+: 5 mm 12 mo chemoprophylaxis with INH, 300mg/d with B6 HIV-: 10 mm 6 mo chemoprophylaxis with INH/B6 If PPD+, R/O active TB: CXR, cultures INH, rifampin, pyrazinamide: liver toxicity Rifampin lowers methadone levels

Slide 10:STDs

Higher rates of Syphilis Annual RPR recommended HPV Increased risk of cervical cancer with certain serotypes Chlamydia and GC Cervical culture/DNA, urine screen available Hbcore ab is positive in all acute and chronic cases Treatment: lamivudine, high dose ifn, adefovirHbcore ab is positive in all acute and chronic cases Treatment: lamivudine, high dose ifn, adefovir

Slide 11:Hepatitis A/B

HAV: fecal-oral transmission HBV: Most common cause of reported cases of acute hepatitis Transmitted sexually, by blood, and vertically Chronic infection in <5% adults, >90% perinatally DNA Virus Incubation period 6-24 weeksDNA Virus Incubation period 6-24 weeks

Slide 12:Hepatitis D

Defective virus, only occurs in presence of active HBV More aggressive disease HBV vaccination is protective

Slide 13:HIV

In US: 750,000 cases 40,000 new infections per year 26% due to IDU, 19% male, 6% female 25% of HIV-infected persons in the US are coinfected with HCV 50-93% of HIV-infected IDUs are coinfected

Slide 14:AIDS

Over the past few years, the numbers of newly reported cases of AIDS in IDUs has surpassed the numbers in MSM Women with AIDS: 42% from IDU Men with AIDS: 22% from IDU Most common reason for death: liver disease (HCV)

Slide 15:HIV in IDUs

Increasing reports of significant HIV infection rates in non-injection drug users Probably sexual transmission Disinhibiting effects of: Alcohol, amphetamines, cocaine, inhalants Substantially increased seroprevalence rates in crack users

Slide 16:HIV in IDUs

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

Slide 17:Preventing Transmission in IDUs

Needle exchange effective at reducing HIV transmission and does not increase use of injection drugs Counsel re: heterosexual transmission No breastfeeding

Slide 18:HIV Tests

HIV antibodies appear 2-12 weeks after infection HIV RNA: Determine prognosis (primary) �CD4+ T cell count is best indicator of the immediate state of immunologic competence in a patient with HIV

Slide 19:HAART

Highly-active anti-retroviral therapy Has resulted in marked declines in the majority of AIDS-defining conditions HAART involves the use of 3 or more antiviral medications, typically in 2 categories

Slide 20:Reverse Transcriptase Inhibitors

NRTI�s: nucleoside analogues AZT, ddI, ddC, d4T, 3TC, ABC Nonselective, serious side effects Methadone may reduce blood levels: ddI, stavudine NNRTI�s: non-nucleoside RTIs Nevirapine, delarvadine, efavirenz Very selective for HIV-1 RT Rash, neuropsychiatric toxicity Methadone level reduced: nevirapine, efavirenz Mitochondrial damage, hepatic steatosis, lactic acidosis, peripheral neuropathy, pancreatitisMitochondrial damage, hepatic steatosis, lactic acidosis, peripheral neuropathy, pancreatitis

Slide 21:Protease Inhibitors

Saquinavir, indinavir, ritonavir, nelfinavir, amprenavir Ritonavir �boosting� is common Lipodystrophy syndrome: Hyperlipidemia, insulin resistance Fat redistribution Methadone level reduced Ritonavir, nelfinavir, lopinavir

Slide 22:Hepatitis C

4 million cases in US, 170 million worldwide 60% of new and existing cases related to IDU Seroprevalence in IDU 65-96% Transmitted by blood: needles, syringes, cottons, cookers, rinsewater Sexual transmission rare, ~5% STD�s, multiple sexual partners Vertical transmission rare, ~5%

Slide 23:Hepatitis C

8-16% develop cirrhosis after 2 decades Accelerated disease with HIV Accelerated disease with EtOH Drug use not known to accelerate natural course

Slide 24:HCV Testing

LFT�s normal persistently in ~1/4 with active disease HCV antibody: EXPOSURE, NOT active infection ~25% spontaneously clear HCV viral load Indicates ACTIVE disease, not extent of disease HCV genotype By far the best predictor of response to therapy Determines length of therapy

Slide 25:HCV Treatment

Cornerstone of treatment is interferon/ribavirin combination therapy for 24-48 weeks Interferon administered by injection Ribavirin administered PO Outcome measure: Sustained virologic response (SVR) Lack of virus 6 months after completing therapy 54-56% with current therapy

Slide 26:Needlestick Injuries

Risk of transmission from needlestick injury is HIV<HCV<HBV: 0.3% with HIV 1.8% with HCV (6x higher) 6-30% with HBV (50x higher)

Slide 27:Vaccinations

dT every 10 years > 5 years if tetanus-prone wound HAV HBV Pneumovax: >50, HIV Flu