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David J. Miller, George C. Candida species uncommonly cause vertebral osteomyelitis. We present a case of lumbar vertebral osteomyelitis caused by Candida albicans and review 59 cases of candidal vertebral osteomyelitis reported in the literature. Risk factors for candidal vertebral osteomyelitis were the presence of a central venous catheter, antibiotic use, immunosuppression, and injection drug use. Medical and surgical therapies were both used, and amphotericin B was the primary antifungal agent. Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:. Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account. 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In the United States, more than 6. Cocaine and ketamine are also injected but less often. PWID have higher morbidity and mortality from numerous causes, including infections predominantly human immunodeficiency virus \[HIV\] infection; hepatitis; endocarditis; and pulmonary, bone, and skin infections , psychiatric disorders e. PWID are less likely to receive primary care than the general population. Although the U. Preventive Services Task Force found in that the evidence was insufficient to merit a recommendation on illicit drug screening, it is currently reevaluating the evidence. Some PWID may be ready to seek additional medical services for opioid use disorder, whereas others may be precontemplative. Physical signs of active injection drug use include recent injection sites, bruising, and patches of hyperpigmentation. These are most common in the antecubital fossa but can also be found elsewhere e. Family physicians have multiple office-based options for patients with opioid use disorder who want treatment, including sublingual buprenorphine, oral naltrexone Revia , and depot naltrexone Vivitrol. Patients with opioid use disorder who request medically supervised withdrawal, or detoxification, can be treated with antiemetics prochlorperazine, ondansetron \[Zofran\] , antidiarrheals loperamide \[Imodium\] , and sedatives trazodone, doxepin to alleviate the specific symptoms of opioid withdrawal. Alpha-2 agonists such as lofexidine Lucemyra and clonidine off-label use can also be used. Buprenorphine tapers are significantly more effective than nonopioid therapy in decreasing the discomfort of opioid withdrawal and keeping patients in treatment. Preventive care such as infectious disease screening and treatment, vaccinations, and harm reduction interventions can reduce morbidity and mortality in PWID Table 1. The U. Active injection drug use is not a contraindication for HIV or hepatitis C treatment because successful treatment greatly reduces the risk of viral transmission, limiting spread in the community at large. All PWID should receive hepatitis A and B vaccinations if there is no evidence of immunity from vaccine titers 30 and be up to date on tetanus vaccinations. Patients are eligible for pre-exposure prophylaxis if they have negative HIV test results, no signs of HIV infection within the previous four weeks, normal creatinine clearance, and laboratory evidence of immunity to hepatitis B virus or absence of infection without immunity in which case they should be vaccinated against hepatitis B. Clinicians should monitor for symptoms suggestive of acute HIV infection i. For patients on a pre-exposure prophylaxis regimen, repeat HIV and pregnancy testing if applicable is indicated every three months, and creatinine clearance testing and sexually transmitted infection screening are recommended every six months. Naloxone is a synthetic opioid antagonist with high opioid receptor affinity that reverses potentially fatal respiratory depression through competitive inhibition. It is available in several forms and strengths, including an intramuscular form, a preassembled intranasal kit Narcan , and an autoinjector Evzio. Naloxone can lead to unpleasant but nonfatal acute withdrawal symptoms in chronic opioid users, including agitation, anxiety, lacrimation, rhinorrhea, diarrhea, nausea, and vomiting. All patients should be instructed to seek medical attention after administration of naloxone given its shorter half-life compared with most opioids. Close observation is needed because readministration may be required. The American Academy of Family Physicians recommends providing access to appropriate overdose antidotes, such as naloxone prescriptions, for individuals at high risk of opioid overdose. Needle-syringe exchange programs reduce rates of HIV, hepatitis C, and high-risk injecting behavior without increasing drug use, number of PWID, or needles discarded in an unsafe manner. Physicians should counsel PWID about safer injection practices such as never reuse or share syringes; only use new or sterile syringes from reliable sources; use clean water, a new or disinfected container cooker , and a new filter cotton to prepare drugs; use an alcohol swab to clean the injection site; and dispose of syringes after a single use. Injection drug use can result in harmful infectious and noninfectious effects to almost every organ system Table 2. All PWID exhibiting signs of systemic infection, including fever, tachycardia, tachypnea, hypotension, and leukocytosis, should be referred to an emergency department or admitted to an acute care hospital for blood cultures and a full history and physical examination to determine the source of potential infections. Skin and soft tissue infections are the most common medical complication affecting PWID and the top reason for hospitalization in these patients. Although Staphylococcus and group A streptococci are most commonly associated with superficial skin infections, abscesses are usually polymicrobial and can contain oral flora and anaerobes. Patients with signs of systemic infection should be hospitalized with appropriate sepsis management and evaluation for other sources of infection. Delayed complications from injecting include hyperpigmentation from postinflammatory changes, scarring along vascular distributions, and deposition of foreign materials in the dermis. Chronic venous insufficiency and impaired lymphatic drainage can predispose PWID to venous ulceration with impaired healing of upper and lower extremities. The annual incidence of community-acquired pneumonia is 1. Noninfectious pulmonary complications include pulmonary edema, foreign body deposition, emphysema, pulmonary embolism, and fatal asthma exacerbations. Noncardiogenic pulmonary edema can occur from opioid overdose within minutes to hours of opioid use, even if naloxone is given. Foreign body deposition within the pulmonary vasculature is common among PWID and is caused by injecting unfiltered substances or crushed pill preparations that include water-insoluble compounds such as talc, cornstarch, and cellulose that can result in granuloma formation. In patients with foreign body granulomatosis, pulmonary function testing can show restrictive or obstructive lung patterns with occasional pulmonary hypertension, often with decreased diffusing capacity. Infectious endocarditis is the most common cardiac complication associated with injection drug use. Transitioning from inpatient to outpatient treatment for infectious endocarditis may be complicated by concerns about discharging PWID with intravenous access for completion of parenteral antibiotic treatment. Patients with infectious endocarditis should initially be evaluated and stabilized in the hospital, and those with an adequate support system and home health care services and who will reliably follow up with medical visits can be discharged for completion of therapy. Short-course intravenous or oral antibiotic regimens may be considered in some uncomplicated cases. Noninfectious cardiovascular complications, such as myocarditis or myocardial ischemia, mycotic aneurysm rupture, cardiomyopathy, and dysrhythmias, may also occur in PWID, particularly with cocaine or amphetamine use. Bone and skeletal infections are more common in PWID, primarily from hematogenous spread of bacteria from other sites, such as infected heart valves or skin and soft tissues. A high index of suspicion is necessary in these patients because positive blood culture and radiology findings and systemic symptoms may not be present initially, and a delay in diagnosis may result in neurologic compromise. Most skeletal infections are caused by S. Multiple bony sites, including vertebrae, may be involved, leading to abscess formation in the subdural or epidural spaces. A PubMed search was completed using the following terms: primary care, injection drug, injection drug use, heroin injection, cocaine injection, ketamine injection, people who inject drugs. Search dates: October to March Estimating the number of persons who inject drugs in the United States by meta-analysis to calculate national rates of HIV and hepatitis C virus infections. PLoS One. Vital signs: demographic and substance use trends among heroin users - United States, — The first injection event: differences among heroin, methamphetamine, cocaine, and ketamine initiates. J Drug Issues. Degenhardt L, et al. Global burden of disease attributable to illicit drug use and dependence. Mackesy-Amiti ME, et al. Prevalence of psychiatric disorders among young injection drug users. Drug Alcohol Depend. Why the treatment of mental disorders is an important component of HIV prevention among people who inject drugs. Adv Prev Med. Mortality among people who inject drugs. Bull World Health Organ. Years of potential life lost among heroin addicts 33 years after treatment. Prev Med. The substance-abusing patient and primary care. Subst Abus. Drug use, illicit: screening. January Accessed August 30, Staley D, el-Guebaly N. Psychometric properties of the Drug Abuse Screening Test in a psychiatric patient population. Addict Behav. Drug Alcohol Rev. Connors GJ, et al. Substance Abuse Treatment and the Stages of Change. New York, NY: Guilford; Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Physical injecting sites among injecting drug users in Sydney, Australia. Buprenorphine therapy for opioid use disorder. Am Fam Physician. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database Syst Rev. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Mortality among regular or dependent users of heroin and other opioids. Buprenorphine for managing opioid withdrawal. LeFevre ML. Screening for hepatitis B virus infection in nonpregnant adolescents and adults: U. Preventive Services Task Force recommendation statement. Ann Intern Med. Moyer VA. Screening for hepatitis C virus infection in adults: U. American Association for the Study of Liver Diseases. Infectious Diseases Society of America. HCV guidance: recommendations for testing, managing, and treating hepatitis C. Accessed October 4, Screening for HIV: U. Primary care screening and treatment for latent tuberculosis infection in adults. Centers for Disease Control and Prevention. Latent tuberculosis infection: a guide for primary health care providers. Accessed January 29, Screening for chlamydia and gonorrhea: U. Behavioral counseling interventions to prevent sexually transmitted infections: U. Tetanus among injecting-drug users—California, Updated recommendations for prevention of invasive pneumococcal disease among adults using the valent pneumococcal polysaccharide vaccine PPSV Public Health Service. Chronic pain management and opioid misuse: a public health concern position paper. Accessed January 30, HIV treatment as prevention. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy \[published corrections appear in JAMA. Hind CR. Pulmonary complications of intravenous drug misuse. Infective and HIV related complications. HIV surveillance reports. November Epidemiology of HIV among injecting and non-injecting drug users. Effectiveness of needle and syringe programmes in people who inject drugs. MC Public Health. The cost-effectiveness of harm reduction. Int J Drug Policy. Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users. Subst Use Misuse. Substance abuse and addiction. Takahashi TA, et al. US hospitalizations and costs for illicit drug users with soft tissue infections. J Behav Health Serv Res. Factors associated with recent symptoms of an injection site infection or injury among people who inject drugs in three English cities. High prevalence of abscesses and cellulitis among community-recruited injection drug users in San Francisco. Clin Infect Dis. A systematic review of injecting-related injury and disease among people who inject drugs. Abscesses secondary to parenteral abuse of drugs. J Bone Joint Surg Am. Bacteriology of skin and soft-tissue infections. Skin and soft tissue infections. Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections. Pieper B, Templin T. Chronic venous insufficiency in persons with a history of injection drug use. Res Nurs Health. Lower extremity changes, pain, and function in injection drug users. J Subst Abuse Treat. Community-acquired pneumonia in a cohort of former injection drug users with and without human immunodeficiency virus infection. The health consequences of injecting tablet preparations. Alteration of pulmonary function in intravenous drug abusers. Am J Med. Bullous pulmonary damage in users of intravenous drugs. The effects of cocaine and heroin use on intubation rates and hospital utilization in patients with acute asthma exacerbations. Medical and legal consequences of ongoing drug use among young injection drug users infected with hepatitis C virus. April 24—27, Denver, Colorado, USA. J Gen Intern Med. Risk practices associated with bacterial infections among injection drug users in Denver, Colorado. Am J Drug Alcohol Abuse. Infective endocarditis in the injection drug user. Infect Dis Clin North Am. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century. Arch Intern Med. Current profile of infective endocarditis in intravenous drug users. Int J Cardiol. Surgical outcomes of infective endocarditis among intravenous drug users. J Thorac Cardiovasc Surg. Infective endocarditis in adults \[published corrections appear in Circulation. Cocaine and the heart. Clin Cardiol. Cardiac complications of adult methamphetamine exposures. J Emerg Med. Diagnosis and management of primary pyogenic spinal infections in intravenous recreational drug users. Neurosurg Focus. Spinal epidural abscesses. Spine J. Vertebral osteomyelitis due to Candida species. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Search search close. C 30 , 32 All eligible PWID should be offered pre-exposure prophylaxis for human immunodeficiency virus infection. Initial Evaluation. Preventive Care Recommendations. Medical Complications of Injection Drug Use. ADAM J. At the time this article was written, he was an assistant professor in the Department of Family and Community Medicine at the University of Maryland School of Medicine, Baltimore. Hershey Medical Center, Hershey, Pa. Capital St. Schuckit MA. Treatment of opioid-use disorders. Continue Reading. More in AFP. More in PubMed. All Rights Reserved. Buprenorphine or methadone should be offered to PWID for opioid detoxification and medication-assisted treatment. All eligible PWID should be offered pre-exposure prophylaxis for human immunodeficiency virus infection. Naloxone should be prescribed to PWID at high risk of opioid overdose. Hepatitis C 23 , Tuberculosis 26 , Sexually active females younger than 25 years, and females at high risk. Tetanus vaccine 31 , PWID who have concurrent heavy alcohol use, cigarette smoking, lung or liverdisease, or other qualifying conditions as defined by the Advisory Committee on Immunization Practices. Pre-exposure prophylaxis for HIV US or CT to evaluate underlying structures and retained products, with or without Gram stain or culture. Erythema, edema, pain out of proportion to examination findings, crepitus, rapid progression. Perinuclear antineutrophil cytoplasmic antibodies, antimyeloperoxidase. Chest radiography if indicated, sputum Gram stain and culture, urine Streptococcus pneumoniae antigen, legionella if admitted. Chest radiography, sputum for acid-fast bacilli, culture, nucleic acid amplification tests, interferon-gamma release assay, or tuberculin skin test. Fever, cough, and dyspnea, with or without murmur or peripheral stigmata of endocarditis. Acute shortness of breath, mental status change, respiratory depression, hypoxemia. Fever, malaise, flulike illness, pleuritic chest pain, back pain, palpitations, Osler nodes, Janeway lesions, Roth spots, splinter hemorrhages. Transesophageal echocardiography, serial blood cultures, complete blood count. Right-sided: see septic pulmonary embolism; left-sided: neurologic deficits, splinter hemorrhages, Roth spots, Janeway lesions. Left ventricular systolic dysfunction, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, edema. Electrocardiography changes, abnormal echocardiography findings, elevated serum troponin I, occasional coronary artery occlusion. Tender, enlarging, pulsatile mass; femoral vein most commonly affected. Heart failure, atrial fibrillation, pulmonary hypertension, dilated cardiomyopathy. Fever, fatigue, myalgias, skin rash, headache, pharyngitis, cervical adenopathy. Liver function tests, hepatitis serology or polymerase chain reaction test if acute ; liver ultrasonography. Symmetric neurologic deficits, responsiveness to stimuli, blurred vision, presence of a wound.
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Opioids and methamphetamines are the most commonly injected drugs. Cocaine and ketamine are also injected but less often. SORT: KEY.
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With the exception of patients who used injection drugs, the majority of patients with candidal vertebral osteomyelitis were 40–80 years old, and there was a.
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