Inability to Predict Diagnosis in Febrile Intravenous Drug Abusers

Abstract

Although hospitalization is recommended for all febrile intravenous drug abusers, this practice has not been tested and validated. To determine the distribution of disease and the predictive value of clinical information available in the emergency room for diagnosis in these patients, we prospectively evaluated the clinical and laboratory data for 87 consecutive admissions involving 75 intravenous drug abusers with temperature of 38.1 degrees C or more, emergency room physicians' diagnostic predictions, and final diagnosis. Final diagnoses were pneumonia in 38% of the patients, trivial illness (viral syndrome, pharyngitis, or pyrogen reaction) in 26%, infective endocarditis in 13%, and other conditions in 23%. Neither emergency room physicians' diagnostic predictions nor clinical data correlated with a final diagnosis of endocarditis. Although physicians' prediction of trivial illness was associated with a final diagnosis of trivial illness (p less than 0.05), 29% of these patients had a more serious final diagnosis. These data confirm the need to hospitalize all intravenous drug abusers presenting with fever at an emergency room.

Infectious Complications in Drug Addicts: Seven-Year Review of 269 Hospitalized Narcotics Abusers in Switzerland

“…In cases with positive blood cultures, the question arises of whether endocarditis is present; it cannot be proved by history or by clinical signs [6][7][8]10]. In the present study the rate of occurrence of endocarditis was 0.7070 of all admissions.…”

“…In the present study the rate of occurrence of endocarditis was 0.7070 of all admissions. Others have reported higher rates in unselected hospitalized (3.9070-8.3070) [6,8,9] and febrile (13070) [10] drug addicts.…”

“…Bronchopulmonary infections were the main infectious complication in our study. Similarly, Marantz et al [10] diagnosed pneumonia in 38070 of 87 febrile episodes in 75 drug addicts. In contrast, others reported many fewerpulmonary infections [9,23,29].…”

“…Such individuals should be hospitalized since a major infection cannot be ruled out by history or by clinical examination [10]. The following differential diagnosis should be considered: pyrogenic reaction, fever as a symptom of drug withdrawal, occult focal infection, HIV infection group IVA, and bacteremia or fungemia with or without endocarditis.…”

Cotton Fever: Does the Patient Know Best?

“…Despite numerous unsuccessful attempts to develop discriminating decision rules to guide ambulatory triage in these cases, clinicians are still unable to reliably exclude occult infections such as endocarditis and osteomyelitis. 2,3 This often results in short-term hospitalization of these patients, with accrual of health care expenditures. 4 An infrequently recognized cause of fever in injection drug users is cotton fever, a poorly characterized systemic febrile inflammatory syndrome seen in this population.…”