The Hippo


May 25, 2020








Flesh-eating bacteria

While it’s generally considered to be more rare than endocarditis, the condition known by doctors as necrotizing fasciitis is being seen in a number of drug users.
“If you get the wrong strain introduced into your skin and soft tissues, it can advance really, really rapidly and that’s why they call it ... ‘flesh-eating bacteria,’” Andrew said. 
There were two cases where drug-needle-borne necrotizing fasciitis was the cause of death in recent years — one in 2012 and another in 2013. 
Kim Fallon at the ME’s office still remembers the most recent case. A young woman aged 20 to 29, addicted to heroin, had flesh-eating bacteria in her arm where she was injecting the drug. It had progressed too far before she sought treatment so doctors were prepared to amputate the arm, but by then it was too late.
“She ended up dying before they could get to that point,” Fallon said.   
Symptoms often begin like less-virulent infections or skin irritations that addicts may have experienced before and gotten over, according to Thomas Andrew, the chief medical examiner.
“It starts out as redness and swelling over the affected area. That soon becomes warm and itchy. Then there’s blister formation … at the center of the lesion and then the redness spreads out pretty rapidly up and down the particular extremity,” Andrew said.
As the extremity swells up, the skin begins to tear and ulcerate. Andrew says the open sores discharge fluid that some describe as looking like dirty dishwater.
It’s generally caused by an aggressive strain of strep.
Marsh says in his experience, amputations are often followed by several surgeries — seldom fewer than six — to cut off additional chunks of flesh.
According to the CDC about 700 to 1,100 cases of necrotizing fasciitis occur in the U.S. each year since 2010.

Worse ways to go
Overdose isn’t the only danger as infectious diseases surge among heroin addicts

By Ryan Lessard

 Intravenous drug users are dying from something other than overdoses. Every few weeks, the state Medical Examiner’s office releases an updated death toll from drug overdoses. As of Aug. 11, that number is 196 and is projected to reach as high as 482 by year end. But those numbers do not include the people who have died from serious infections delivered into their bodies through a needle containing heroin or fentanyl. Doctors working the front lines are seeing infection rates rising as addicts shun treatment or reinfect themselves; some of these cases, they say, are nothing short of nightmarish.

Untold death toll
Getting a handle on how big this problem is can be difficult since regular tracking of these conditions is not commonplace and their links to drug use are not always evident. In the case of infectious diseases borne of intravenous drug use, the potential link may be found in death certificates. 
One condition that may serve as an early warning is infective endocarditis, an infection, usually bacterial, of the heart’s valves. Bacteria can enter the heart and blood stream a number of ways, but over the past century, studies have shown that increases in intravenous drug use correspond with increases in endocarditis diagnoses.
Jonathan Eddinger, a cardiologist with Catholic Medical Center’s New England Heart & Vascular Institute, said it’s a condition with a high mortality rate.
“For somebody with IV drug use who has a heart valve that’s infected that has to go to surgery, you’re probably looking at 20 to 30 percent mortality over the course of a year,” Eddinger said.
And it’s 100 percent fatal if it’s left untreated.
The Medical Examiner’s office checked its database for deaths caused by endocarditis due to intravenous drug use at the Hippo’s request and found that there have been four in the past three years, two of them from this year. Prior to that, there was a case in 2011 and another in 2006. 
The ME also found a number of other infections that caused death besides endocarditis that were linked to IV drug use. 
“We have a few every year who don’t overdose, but, because of their drug use, they develop some kind of infection like endocarditis or meningitis or fasciitis and die from that infection,” said Kim Fallon, the chief forensic investigator at the ME’s office.
These bacterial infections were recorded on death certificates with medical jargon describing how widespread, damaging and virulent they were, what strains of bacteria were detected and in what part of the body they took up residence. Meningitis, an infection of the brain’s outer membrane, and pneumonia, an infection of the lungs, are both examples of deadly diseases that residents have contracted from IV drug use. Infections like this happen because needles, narcotic substances or the injection points in the skin are not sterile.
Chief Medical Examiner Thomas Andrew said infections from needles can happen anywhere in the body. 
“These bacteria don’t read any textbooks, they don’t know what they’re supposed to do, they don’t know where we want them to go or expect them to go. They set up shop where they set up shop,” Andrew said. “If they find enough to eat and support themselves and their little families, they’re going to multiply right where they’re comfortable multiplying.”
Infection can occur virtually anywhere, from vital organs to joints and bones. Endocarditis is the most common and, along with brain abscesses and spinal abscesses, the most deadly.
Given the particular risks of injecting substances directly into the body, common strains of aggressive staph or strep are given an access point from which to invade and gain an upper hand over the body’s immune system. That’s why some infections from needles can manifest in nasty ways, such as when they necrotize tissue. That’s when bacteria leave parts of the body dead and scarred, like scorched earth.
Take necrotizing pneumonia for example.
“Lung tissue [is] destroyed and will never be replaced by normal lung tissue again. It’s going to be replaced by scarring, so it’s much more severe pneumonia,” Andrew said.
Death from endocarditis and related infections is most often caused by sepsis, a system-wide breakdown of vital functions, but they can also cause a stroke if a chunk of bacteria breaks loose from a heart valve and travels up to the brain.
Right now, the death toll from drug-related infections is still relatively small, but given the growing number of cases being seen in hospitals, that’s expected to change soon.
Dartmouth-Hitchcock’s chief of infectious diseases, Bryan Marsh, says this problem is going to get worse before it gets better.
“There’s no doubt in New Hampshire … we’re going to be seeing more people dying from bacterial infections from drug use,” Marsh said.
The walking dead
Clinicians in the field agree: bacterial infections from IV drug use have increased dramatically in the last few years. 
“The numbers have skyrocketed in the last few years,” Marsh said.
At the time of the interview there were five patients being treated for endocarditis from IV drug use at Dartmouth, mostly younger adults under the age of 50.
“It’s rare that a week goes by that we don’t have someone admitted with … infective endocarditis,” Marsh said.
At Elliot Hospital, there were around 40 endocarditis registrations each year between 2013 and 2015. This year, it’s doubled to more than 80. CMC found that endocarditis cases paired with chronic opioid use have grown exponentially in the past five years. In 2011, there were five cases, by 2014 there were 19. That doubled to 41 the year after and this year it’s up to 62 cases to date.
“Over the last three or five years, we’ve seen a real resurgence in the incidence of endocarditis,” Eddinger said.
Heart valve surgeries at CMC for endocarditis cases specifically identified as caused by IV drug use have gone from one or two a year five years ago to 10 in 2015. And there’ve been 10 heart valve surgeries so far this year. Eddinger said it’s now common to have about one or two surgeries each month.
Treatment for endocarditis begins with a four- to six-week regimen of intravenous antibiotics at a hospital. In cases where heart valves are badly damaged, valve surgery is called for.
Eddinger said the antibiotic treatment can cost more than $50,000 and the surgeries are more than $100,000, but since many of these drug addicts don’t have private insurance, these services go unpaid for, creating a mounting burden on our healthcare institutions. And Marsh said Medicaid reimbursement in New Hampshire is abysmal for these procedures.
To make matters worse, addicts may refuse to stay for the full six weeks of treatment, which may allow some bugs to survive in their system and rebound. 
Eddinger also said stigma and embarrassment are keeping people from seeking help sooner.
“People don’t want to come to the hospital and say they’re an IV drug user, so often times we get these folks late … when they’re real sick and the cat’s out of the bag,” Eddinger said.
Dr. Patrick Hickle, a cardiologist at Elliot Hospital, is seeing people who have previously undergone heart valve replacements at CMC only to reinfect themselves by continuing to use IV drugs.
This is not only a waste of expensive resources, but for many it’s a death sentence because in most cases a patient can’t safely undergo a second surgery.
In extreme cases, where abscesses have eaten away at parts of the heart, additional surgery is required to patch up and rebuild a patient’s heart. The bacteria have been treatable with antibiotics, but the more those are used, the greater the risk of creating superbugs that don’t respond to traditional treatments.
“As we see more cases and have to throw more antibiotics at them, [resistance] is going to be an issue,” Eddinger said.
Hep C
Beyond the increase in bacterial infections from drug use, doctors are also seeing a surge in cases of hepatitis C, a virus. Andrew said the ME’s office tests all known drug users for HIV, hepatitis C and hepatitis B.
“We’re not seeing a huge uptick in HIV or hepatitis B, but hepatitis C really seems to be prevalent among this population. And that, anecdotally speaking from my own experience, seems to be much increased,” he said.
Doctors in hospitals are seeing this too. Marsh said almost every patient diagnosed with endocarditis he sees also has hepatitis C, and clinicians at Dartmouth are encouraging endocarditis patients to be tested for hep C if they haven’t been diagnosed.
“The number of cases of hepatitis C is astounding,” Marsh said.
Right now, hep C is likely to stay contained within the heroin and fentanyl addict population since it is far easier to transmit via needle than sexually. But a repeat of the Exeter Hospital outbreak caused by a healthcare worker’s drug diversion four years ago is still a concern.
In an email, DHHS spokesperson Jake Leon said the department is aware of the problem from an uptick in reports, but the state still doesn’t have a full handle on the scope and scale of the infections since they are currently not formally tracked.
Tracking issues
DHHS is working to change the state reporting rules soon, however, to make hepatitis C a reportable disease. Leon said that would help identify outbreaks and implement steps to control them. The rule change requires legislative approval but is anticipated to be authorized in September. 
Unfortunately, there’s no system set up to track bacterial infections like endocarditis. 
Even tracking deaths caused by bacterial infections from IV drug use is imperfect as the ME’s office is understaffed and saddled with outdated information systems.
“We’ve been using this rather cumbersome, jury-rigged database system for quite a number of years now and I think we’re all frustrated by the lack of up-to-date technology,” Andrew said.
But healthcare specialists say a better tracking system for these infections would serve as important clues to broaden our knowledge of the drug epidemic and address important healthcare trends that may be economically costly.
“The bacterial infections … get a lot less press, but they are incredibly important,” Marsh said.
He also said that more cost-effective solutions to treating a high volume of endocarditis patients would be found if inpatient clinics were set up for the six-week antibiotic regimen since hospitals are set up for more acute care situations and beds are at a premium.
Individual hospitals like CMC are just starting to get a handle on the problem. 
Eddinger said the public’s understanding of how the drug crisis is affecting our community seldom touches on widespread healthcare side effects like these.
“People just don’t have a sense of the broad problem beyond the OD and the Narcan use. What happens after that?” he said. 

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