Sepsis requiring intensive care following intramuscular injections: two case reports
© licensee BioMed Central Ltd. 2009
Received: 20 April 2009
Accepted: 27 July 2009
Published: 18 August 2009
Intramuscular injections can rarely result in serious infectious complications such as abscesses which may progress to bacteraemia and generalized sepsis. These complications are rare, but can be life threatening, as they can lead to multi-organ failure associated with high morbidity and mortality.
In this report we present two patients who developed life-threatening infections after intramuscular injections. They were admitted to the hospital, had prompt surgical drainage, required ICU admission for severe sepsis, were treated with an early goal-directed therapy protocol and had a good outcome.
Sepsis is a rare, potentially life-threatening complication after intramuscular injections. Timely surgical drainage followed by appropriate ICU care and early goal directed therapy is crucial and may contribute to a good outcome in these rare cases.
Intramuscular injections (IM) can lead to local infectious complications, such as abscesses [1, 2] skin necrosis  or intra-articular infections, and can rarely progress to generalized sepsis and multi-organ failure . Such serious infections are more likely to occur in immuno-compromised patients but have also been described in immune-competent persons. They are usually caused by Staphylococcus aureus and require timely medical and surgical treatment. Life-threatening generalized sepsis is rare but has been reported [4, 5], and aggressive care in an ICU is required for optimal results in these cases. We describe two patients with multiple abscesses and generalized sepsis caused by Staphylococcus aureus after intramuscular injections. Both patients were treated with early surgical drainage, were supported in the ICU with a goal-directed protocol  and had a good outcome.
Case report 1
Case report 2
Demographics, medical history and ICU data
Age / Sex
Drug injected IM
Admission SOFA score
Renal Failure/ Dialysis
54 / Male
Alcohol abuse, diabetes
Dopamine 7 days
73 / Female
Dopamine 5 days
An intramuscular (IM) injection is a minor procedure whereby a drug is deposited into a muscle via a sterile needle. Most IM injections should be performed into the deltoid muscle in the arm, or into the gluteus maximus muscle in the buttocks. Recent studies [2, 3] have highlighted the importance of correct IM drug administration, in order to minimize the risk of potentially serious complications. Appropriate clinical practice needs to reflect considerations about appropriate needle length and gauge, to ensure that patients get the benefit of drug administration without adverse effects. Muscle tissue is usually spared the harmful effects of substances injected into it, probably because of its abundant blood supply. However, deep IM injections can cause abscesses and granulomas, whereas more superficial IM injections may result in increased incidence of local reactions, such as irritation, inflammation and necrosis [1, 2, 9].
In this report we present two patients who developed sepsis and multiple organ failure after IM injections. Injection safety is a complex problem, and unsafe practices can place patients at increased risk of infection [3, 6]. However, even when properly administered, IM injections can result in severe tissue trauma, by creating a local entry point for bacteria. Although aminoglycosides are often administered as IM injections, we could not find any published reports of necrotizing fasciitis or other serious local infection after aminoglycoside injections. In contrast, several reports of serious or fatal complications from NSAID injections have been published [3, 10]-.
Sepsis and multi-organ failure are the leading causes of death in critically ill patients . Much of modern critical care practice is based, in principle, on restoring aberrant respiratory, cardiovascular and other functions to physiologic levels in an attempt to maintain or restore adequate organ perfusion. Goal-directed therapy has been used for severe sepsis and multiple organ dysfunction in the Intensive Care Unit , and consists of maintaining CVP > 8-12 mmHg, MAP > 65 mmHg, urine output > 0.5 ml/kg/h, SvO2 > 70%, SaO2 > 93% and hematocrit > 30%. Both patients required mechanical ventilation and received broad-spectrum antibiotics, IV fluids and pharmaceutical agents (dopamine) to achieve and maintain the aforementioned physiologic goals.
These two cases highlight the potential for severe tissue necrosis following IM injections. The pathogenesis explaining skin necrosis is uncertain, but damage to an end-artery is a plausible hypothesis. Other causes to consider, especially when deep tissue necrosis is also present, are the cytotoxic effect of the drug or additives in the injectate. Both our patients had skin necrosis that progressed to bacteremia and sepsis from multi-resistant Staphylococcus aureus, a finding consistent with previously published cases [1, 2].
Serious complications, including limb amputation and life-threatening sepsis related to IM injections have been reported in the past -. However, we believe this report is an important addition to previously reported cases of sepsis and multi-organ failure following IM injections, because both patients became severely ill (SOFA  score 10 on ICU admission) and were treated with early surgical intervention , followed by prolonged ICU care with a goal-directed therapy protocol . We believe that timely radical surgical intervention followed by goal-directed ICU care probably contributed to the good outcome in both cases.
Minor medical interventions, such as intramuscular injections, can rarely result in life-threatening infections. If a serious infection occurs, isolation of the offending pathogen is helpful in ensuring that appropriate antibiotic therapy is given. Timely radical surgical intervention with abscess drainage is crucial and may help improve outcome. Goal directed therapy in the ICU may contribute to a good outcome in patients who develop sepsis and multi-organ failure.
Written informed consent was obtained from patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief.
intensive care unit
non-steroidal anti-inflammatory drug.
This research project was financially supported in its entirety by Department Funds.
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