Multidisciplinary Guidance to Care for Persons With Xylazine-Associated Wounds

Abstract

Xylazine, an adulterant of unregulated opioid supplies, is increasingly prevalent in the United States and associated with distinctive wounds. Xylazine-associated wounds (XAWs) are primarily noted in the extremities and are not always associated with injection drug use. XAWs are often chronic and can become superinfected, posing a great challenge to clinical care. We share multidisciplinary guidance to care for persons with XAWs: (1) substance use disorder treatment and longitudinal multidisciplinary care including addiction medicine, wound care, infectious diseases, and surgery are imperative; (2) avoid aggressive debridement; (3) administer empirical antibiotics for methicillin-resistant Staphylococcus aureus (MRSA)- and group A Streptococcus (GAS)-infected wounds, specifically oral trimethoprim-sulfamethoxazole for MRSA and oral β-lactams for GAS; (4) administer intravenous daptomycin to reduce the discomfort and challenges associated with frequent phlebotomy for vancomycin therapeutic drug monitoring; and (5) create explicit contingency antibiotic plans with potential use of linezolid, tedizolid, or dalbavancin for patient-directed hospital discharge.

Keywords: illicitly manufactured fentanyl; multidisciplinary care; opioid use disorder; persons who use drugs; xylazine-associated wounds.

Figure 1.

Xylazine-associated wounds (XAWs). Center: a schema of different stages of XAWs. Courtesy of Dr Margaret Shang [25, 28]. Upper left: a coin-sized painful blister with a central eschar. Upper right: painful dark necrotic areas with intact skin, resembling unstageable deep tissue pressure injury. Lower left: angulated open wounds with small areas of eschars and islands of healthy tissue. Lower right: a wound with extensive eschar. Wound pictures from Lutz et al [6] and McFadden et al [7] with permission to reuse.

Figure 2.

A multidisciplinary framework to care for persons with xylazine-associated wounds. Abbreviations: CT, computed tomography; GAS, group A Streptococcus; ID, infectious diseases; IV, intravenous; MRI, magnetic resonance imaging; MRSA, methicillin-resistant Staphylococcus aureus; NSTI, necrotizing soft tissue infection; PDD, patient-directed discharge; SA, Staphylococcus aureus; SSTI, skin and soft tissue infection.