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Medical Consequences in Malnourished HIV-Infected Drug Abusers


Michael S. Hickey, M.D.
University of California at San Francisco


Outline

  1. Introduction
    1. Level I Trauma Center
    2. County facility
    3. High-volume HIV/malnourished patients
  2. San Francisco General Hospital Nutrition Support Service
    1. Daily census: 15-20
    2. 20-25% patients are HIV positive
    3. Average admission albumin less than 2.5 gm
    4. Average weight loss of HIV-positive patients treated by the Trauma Surgical Service is greater than 14 kg
  3. SFGH Trauma Surgical admissions
    1. Soft tissue infections (STI) admitted to SFGH Trauma Surgical Service in:
      1996 = 1,131
      1997 = 1,299
    2. Total admissions to SFGH Trauma Surgical Service in:
      1996 = 19,992
      1997 = 20,622
    3. % STI vs. total admissions in:
      1996 = 5.6
      1997 = 6.3
  4. Clinical examples of soft tissue infections/necrotizing infections secondary to intravenous drug abuse
  5. Operative analysis
    1. STI requiring operative procedures:
      1996 = 841
      1997 = 858
    2. Total trauma surgical operatives procedures:
      1996 = 3,094
      1997 = 3,008
    3. % STI vs. total operative procedures:
      1996 = 27.18
      1997 = 28.50
  6. Cost per 4 day STI operative admission
    1. Hospital and miscellaneous fees: $8,000.00
    2. Professional fees: 500.00
    3. Medication costs: 100.00
      Total: $8,600.00
  7. Cost analysis
    1. Average length of stay (days) of STI patients requiring operative procedures:
      1996 = 4.3
      1997 = 3.9
    2. Average cost per STI operative admission:
      1996 = $8,600
      1997 = $9,000
    3. Total cost for STI operative admissions:
      1996 = $7,232,600.00
      1997 = $7,722,000.00
  8. Potential risk factors for recurrent STI
    1. Malnutrition:
      Depleted body cell mass
      Depleted fat mass
      Malabsorption
    2. HIV status:
      Malabsorption
      Change in body composition
    3. Social factors:
      Access to clean needles
      Access to food
  9. Factors to evaluate in the STI study
    1. HIV status
    2. Nutritional status
    3. Degree of malabsorption
    4. Impact of social/nutritional support
  10. Intervention strategies
    1. Nutrition:
      Acute
      Chronic
    2. Social support
    3. Oral antibiotics for patients with gut dysfunction (malabsorption)
  11. Questions

Abstract

Soft tissue infections (STI) in malnourished, HIV-positive intravenous drug abusers are a challenging problem. San Francisco General Hospital (SFGH) is a county facility designated as a Level I Trauma Center. Twenty to twenty-five percent of the patients treated by the SFGH Trauma Surgical Service are HIV positive. The average albumin of these patients is 2.5 gm; the average weight loss is greater than 14 kg.

The Trauma Surgical Service admitted 1,131 patients with STI in 1996; 1,299 in 1997. These admissions represented 5.6 and 6.3 percent of all hospital admissions respectively. Soft tissue infections requiring operative procedures numbered 841 in 1996; 858 in 1997 or 27.18 and 28.50 percent of all operations performed in the respective years.

The management of these infections is both time consuming and costly. The length of hospitalization ranges from overnight to frequently several months duration. The average length of stay, however, was 4.3 days in 1996; 3.9 days in 1997. Hospital and miscellaneous fees average $2,000.00 per day in 1996. Professional and medication fees per admission averaged $500.00 and $100.00 respectively in 1996. The average cost per STI admission was $8,600.00 in 1996, but increased to $9,000.00 in 1997. The total cost for STI admissions was $7,232,600.00 in 1996; $7,722,000.00 in 1997.

Recurrent STI is a major problem. Ten to twenty percent of the STI treated by the Trauma Surgical Service fall into this category. Many of the patients treated at SFGH are admitted 5-10 times per year for incision and drainage of abscesses and expensive antibiotic therapy. The potential risks for recurrent STI include malnutrition (depleted body cell and fat mass, malabsorption), HIV status (malabsorption, change in body composition), and social factors (access to clean needles and food).

Potential factors to evaluate in an STI study would include HIV and nutritional status, degree of malabsorption and the impact of both social and nutritional support. Intervention strategies to consider would include aggressive nutritional therapy, both acute and chronic, social programs, and specific oral antibiotics modified for patients with gut dysfunction.

Suggested References

Santolaria-Fernandez, F.J. Nutritional assessment of drug addicts. Drug Alcohol Depend 38:11-18, 1995.

McCombie, L. Letters to the editor. Addiction 90:1117-1121, 1995.

Kotler, D.P.; Wang, J.; and Pierson, R.N. Body composition studies in patients with AIDS. Am J Clin Nutr 42:1255-1265, 1985.

Altes, J. Prevalence of protein-energy malnutrition in heroin addicts hospitalized for detoxication. J Clin Nutr Gastroenterol 3:55-58, 1988.

Aylett, P. Some aspects of nutritional state in "hard" drug addicts. Br J Addict 73:77-81, 1978.

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