Diagnostic and treatment options for skin and soft tissue abscesses in injecting drug users with consideration of the natural history and concomitant risk factors.

OBJECTIVE: Skin and soft tissue abscesses are common findings in injecting drug users (IDUs) who present to the surgical emergency department for evaluation and treatment. Although most cases can be managed by incision and drainage, they do require special considerations as compared to abscesses which are not caused by intravenous drug abuse.

METHODS: Skin and soft tissue abscesses treated in the emergency department between 2005 and 2007 were reviewed and a systematic literature search of skin and soft tissue abscesses in IDUs was conducted, including the etiology, occurrence, risk factors, and treatment options, thus providing the rationale for the treatment algorithm presented herein.

RESULTS: The drugs injected, the technique by which they were injected, the attendant circumstances, as well as the immunological status of the IDUs were major factors for the development of abscesses. Skin and soft tissue abscesses in IDUs should be incised and drained under local or general anesthesia depending on the size, location, and association with neurovascular structures. Different factors have been taken into account when treating soft tissue abscesses in this population which predict their specific risks and therefore further therapy needs. The incidence of tetanus is high among IDUs compared to the general population, giving rise to the recommendation for a strict booster policy if the vaccination status is unclear when the patient presents to the emergency department. The presence of fever requires hospitalisation and evaluation for the presence of endocarditis. Foreign bodies, such as broken needles, should be ruled out by radiography, and duplex sonography should be performed to identify the presence of vascular complications. Prior to incision and drainage, prophylactic antimicrobial agents should be administered to every patient and as therapy for high-risk patients, such as immunocompromised patients and patients with fevers and chills.

CONCLUSIONS: IDUs presenting with skin and soft tissue abscesses can be managed safely if some special issues are taken in account. The presented algorithm may help facilitate the decision-making in this context.