High prevalence of iliofemoral venous thrombosis with severe groin infection among injecting drug users in North East Scotland: successful use of low molecular weight heparin with antibiotics

Abstract

Injecting drug use, mainly of heroin, currently represents a major public health issue in the North East of Scotland. The recent tendency of the committed injecting drug user to inject into the groin has created novel problems for the Infection Unit.Data are presented on 20 consecutive patients admitted between 1994 and 1999 with iliofemoral venous thromboses, often complicated by severe soft tissue infections and bacteraemia as a result of heroin injection into the femoral vein. Nine had coexistent groin abscesses, four had severe streptococcal soft tissue infection of the right thigh, groin and lower abdomen, and two had coincidental soft tissue infections of the upper limb. Nine were bacteraemic on admission. All of the patients were chronic injecting drug users with a median injection duration of 6.5 years. The 18 patients tested for hepatitis C virus were all seropositive. None of the 14 patients tested was positive for HIV.Seventeen patients were treated with subcutaneous low molecular weight heparin (tinzaparin), three having received intravenous unfractionated heparin initially. The tinzaparin was self administered and given for a median duration of seven weeks. One patient declined to have any treatment. Three months after presentation eight patients were asymptomatic, seven had a persistently swollen leg, and five were lost to follow up. None developed clinically apparent pulmonary embolism after institution of anticoagulant therapy.The management of iliofemoral venous thrombosis in injection drug users is problematic because of poor venous access, non-compliance with prescribed treatment, ongoing injecting behaviour, and coexistent sepsis. It is unlikely that a randomised trial of standard treatment with heparin and warfarin versus low molecular weight heparin alone would be practical in this patient group. These retrospective data indicate that the use of tinzaparin in injecting drug users is feasible and appears to result in satisfactory clinical responses.The possibility of concomitant infection in injecting drug users with venous thrombosis should always be addressed, as it appears to be a common phenomenon. Early drainage of abscesses and antimicrobial chemotherapy, often administered intramuscularly or orally because of lack of peripheral venous access, is central to the appropriate care of these patients.

Is opium addiction a risk factor for deep vein thrombosis? A case–control study

“…The committed IV drug abusers ultimately attempt to inject drugs into a deep vein, usually in the groin, with the potential for both vascular injury and deep abscess formation. Both infection and IV injection are confirmed risk factors for DVT [23][24][25]. The repeated vascular injury and superficial thrombophlebitis with coincidental infection increase the risk of DVT in lower limbs.…”

Prevalence and Characteristics of Femoral Injection among Seattle-Area Injection Drug Users

“…9 Femoral injection may be preferred over peripheral injection not only due to difficulty finding other veins, but also due to access that is quick (to avoid detection), easy (due to large size of femoral vein and development of a sinus tract) and reliable (less likely to miss the vein altogether or have to repeat injection), a possibly superior "rush," and the lack of visible track marks when clothed. 9 On the other hand, femoral injection has been associated with a number of deleterious medical consequences, including deep vein thrombosis, 10 septic thrombophlebitis, 11 abscesses, 12 damage of the femoral nerve, 13 femoral artery necrosis, 14 and arteriovenous fistula 5 or pseudoaneurysm. 15 It is not known whether the increase in femoral injection observed in the UK is an isolated phenomenon or more widespread.…”

Deep vein thromboses in users of opioid drugs: incidence, prevalence, and risk factors

“…5 However, the aetiological factors in users of intravenous drugs are likely to be different; possible causes include reduced blood flow from inactive muscle pumps during periods of intoxication, endothelial damage from injections, and elevated coagulation factors from infection introduced via injections. 1,6 Although 3 months' anticoagulation is now established as the optimum treatment for patients with DVT who have an 8% chance of developing further DVT or pulmonary emboli over 1 year, 7,8 there is a lack of evidence about the risk of long-term complications and the optimum treatment approach for DVT resulting from intravenous drug use: for instance, taking anticoagulants may be more risky if intravenous drug use is continuing. 1 There…”