Wound Botulism, Tetanus, and Necrotizing Fasciitis among Injecting Drug Users in California: the Clostridial Connection

Abstract

Diseases caused by clostridia are often mediated via toxins. For botulism and tetanus, specific neurotoxins produced by Clostridium botulinum and Clostridium tetani affect different areas in the nervous system to cause weakness or spasticity. In 1995, the California Department of Health Services (CDHS) documented an increase in the reported number of cases of wound botulism (WB) that started in 1994. A total of 96 cases of tetanus were reported to occur in California between 1988 and 2000. Necrotizing soft tissue infections (NSTIs) and necrotizing fasciitis are not reportable conditions in California. The proportion of cases with necrotizing fasciitis was over 80% at two of the three hospitals, and the mortality rate ranged from 10 to 27%. The recent epidemic of wound botulism (WB), tetanus, and NSTIs among injecting drug users (IDUs) in California is likely due, in great part, to skin popping of black tar heroin (BTH) contaminated with Clostridium species. Injection drug use is a complicated issue, and IDUs are a difficult population to reach with prevention messages. These messages will have to address drug rehabilitation to decrease the risk of infection with blood-borne pathogens along with the risk for WB, tetanus, and NSTIs. In recent years, California clinicians have seen increasing numbers of serious Clostridium infections among IDUs, including WB, tetanus, and necrotizing fasciitis. The recent epidemics of WB, tetanus, and NSTIs among IDUs in California are likely due, in great part, to skin popping of BTH contaminated with Clostridium species.