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The use of parenterally administered recreational drugs has increased enormously in recent years There are now an estimated 300,000 or more injection drug users in the United States

set aList to {n, x, aBool, msgStr, date} set aNewList to {aList, {1, 2, 3, 4}}

The source code for this example is presented in Example A-54.

Skin infections are associated with poor hygiene and use of nonsterile technique when injecting drugs S aureus (including methicillin-resistant strains) and oral flora (streptococci, Eikenella, Fusobacterium, Peptostreptococcus) are the most common organisms, with enteric gram-negatives less common and seen in those who inject into the groin Cellulitis and subcutaneous abscesses occur most commonly, particularly in association with subcutaneous ( skin-popping ) or intramuscular injections and the use of cocaine and heroin mixtures

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(probably due to ischemia) Myositis, clostridial myonecrosis, and necrotizing fasciitis occur infrequently but are life-threatening Wound botulism in association with black tar heroin occurs sporadically but often in clusters Hepatitis is very common among habitual drug users and is transmissible both by the parenteral (hepatitis B, C, and D) and by the fecal-oral route (hepatitis A) Multiple episodes of hepatitis with different agents can occur Aspiration pneumonia and its complications (lung abscess, empyema, brain abscess) result from altered consciousness associated with drug use Mixed aerobic and anaerobic mouth flora are usually involved Tuberculosis also occurs in drug users, and infection with HIV has fostered the spread of tuberculosis in this population Morbidity and mortality rates are increased in HIV-infected individuals with tuberculosis Classic radiographic findings are often absent; tuberculosis is suspected in any patient with infiltrates who does not respond to antibiotics Pulmonary septic emboli may originate from venous thrombi or right-sided endocarditis STDs are not directly related to drug use, but the practice of exchanging sex for drugs has resulted in an increased frequency of STDs Syphilis, gonorrhea, and chancroid are the most common AIDS has a high incidence among injection drug users and their sexual contacts and among the offspring of infected women (see 31) Infective endocarditis The organisms that cause infective endocarditis in those who use drugs intravenously are most commonly S aureus, Candida (usually C albicans or C parapsilosis), Enterococcus faecalis, other streptococci, and gram-negative bacteria (especially Pseudomonas and Serratia marcescens) A number of complications of endocarditis can occur, including splenic abscesses, central nervous system infections (meningitis, brain abscess, subdural empyema, epidural abscess), and endophthalmitis Involvement of the right side of the heart is common, and infection of more than one valve is not infrequent Right-sided involvement, especially in the absence of murmurs, is often suggested by the presence of septic pulmonary emboli The diagnosis must be established by blood culture Therapy, including empiric treatment, is discussed in 33 Other vascular infections include septic thrombophlebitis and mycotic aneurysms Mycotic aneurysms resulting from direct trauma to a vessel with secondary infection most commonly occur in femoral arteries and less commonly in arteries of the neck Aneurysms resulting from hematogenous spread of organisms frequently involve intracerebral vessels and thus are seen in association with endocarditis Osteomyelitis and septic arthritis Osteomyelitis involving vertebral bodies, sternoclavicular joints, the pubic symphysis, the sacroiliac joints, and other sites usually results from hematogenous distribution of injected organisms or septic venous thrombi Pain and fever precede radiographic changes, sometimes by several weeks While staphylococci often methicillin-resistant are common organisms, Serratia, Pseudomonas, Candida (often not C albicans), and other pathogens rarely encountered in spontaneous bone or joint disease are found in injection drug users.

In the 1950s and 1960s, tetanus was commonly seen in drug users, especially in unimmunized women who injected drugs subcutaneously ( skin-popping ) Increased tetanus immunization among drug users has resulted in a decline in this disease, although cases are still reported

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