Sepsis in a person who injects drugs

Antimicrobial prescribing: NHS Lothian
NHS Lothian

Patients with dependent (daily) or erratic and hazardous drug use who are not already engaged with community treatment services can be referred to the drug liaison service by:

For STJs

Further guidelines for opioid substitution and management can be found here: Guidelines on the management of people who inject drugs in Lothian hospitals

Required investigations

Suggested Investigations:

  • Blood cultures x2, PRIOR to antibiotic administration
  • Imaging of injection sites, looking for abscesses, DVT etc.
  • Consider disseminated infection such as septic pulmonary emboli based on symptoms and signs. Consider further chest imaging (CXR or CT) if suspicious.
  • Consider endocarditis in patients with confirmed blood stream infection or where there are clinic signs.
  • Review Staph. aureus blood stream infection if SAB is confirmed.
  • Recommend: HIV test, Hepatitis C antibody test, and Hepatitis B surface antigen test. If patient has previously tested positive for Hepatitis C antibodies and is not known to have chronic infection then send Hepatitis C PCR or antigen - discuss with Virology.

Antimicrobial recommendations

 

Antibiotic recommendation

Flucloxacillin 2g every 6 hours IV

PLUS

Gentamicin IV (use NHS Lothian Calculator located AMT intranet page)

PLUS

Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable)

Where patient has sepsis with refractory hypotension

ADD

Clindamycin 1200mg every 6 hours IV
Penicillin-allergy/Previous MRSA

Vancomycin (use NHS Lothian Calculator located AMT intranet page) - target trough level 10-15mg/L

PLUS

Gentamicin IV (use NHS Lothian Calculator located AMT intranet page)

PLUS

Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable)

Where patient has sepsis with refractory hypotension

ADD

Clindamycin 1200mg every 6 hours IV

REVIEW RESPONSE AT @24-48h: if not improving ask for advice.

Notes

Likely organisms: S.aureus. Other organisms can include Clostridium spp, and other anaerobes.

  • There have been outbreaks of anthrax, tetanus and botulism in people who inject drugs both intravenously and subcutaneously (skin popping): discuss potential cases early with microbiology.