eMedicine Specialties > Infectious Diseases > Bacterial Infections

Vibrio Infections

Hoi Ho, MD, Associate Dean for Faculty Affairs and Development, Professor, Department of Internal Medicine, Director, Clinical Skills and Clinical Simulation Center, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center; Consulting Staff, Thomason Hospital
Thong Huy Do, MD, Staff Physician, Department of Internal Medicine, Thomason Hospital, Texas Tech University; Tony Tran Ho, MS, Texas Tech University School of Medicine

Updated: Mar 30, 2009

Introduction

Background

Vibrio infections are largely classified into two distinct groups: Vibrio cholera infections and noncholera Vibrio infections. Historically, the noncholera Vibrio species are classified as halophilic or nonhalophilic, depending on their requirement of sodium chloride for growth.

Because most Vibrio infections are associated with the consumption of contaminated food, these infections are often considered a foodborne disease. The prevalence of noncholera Vibrio infections in the United States appears to have increased in recent years. The combination of increased water temperature and salinity where shellfish are harvested may contribute to increased contamination rates of shellfish. Although many foodborne diseases are not reportable in the United States, the Centers for Disease Control and Prevention (CDC) estimates that approximately 76 million cases of foodborne illnesses occur annually, with 5200 deaths.^1,2

Since 1988, the CDC has maintained a voluntary surveillance system for culture-confirmed Vibrio infections in Alabama, Florida, Louisiana, Mississippi, and Texas. Cases of culture-confirmed noncholera Vibrio infections from these states accounted for 39% of the 462 cases reported to the CDC in 2003. Noncholera Vibrio species in the United States cause an estimated 8000 illnesses yearly.³

While the estimated incidence of infection with Shiga toxin–producing Escherichia coli O157:H7 (STEC O157) and species of Campylobacter, Cryptosporidium, Listeria, Salmonella, and Yersinia significantly decreased from 1996-1998 to 2004, the incidence of Vibrio infections during this period increased 47% (95% CI, 7%-102%).^3,4

Although Vibrio parahaemolyticus is the most common noncholera Vibrio species reported to cause infection, Vibrio vulnificus is associated with 94% of reported deaths. Because clinical laboratories do not routinely use the selective medium thiosulfate-citrate-bile salts-sucrose (TCBS) for stool culture, many cases of Vibrio gastroenteritis are not identified.^5,6

In the event of a natural disaster, the disturbance to the environment may increase the risk of infectious diseases such as Vibrio infections. During the 2 weeks following Hurricane Katrina in August 2005, the CDC reported 22 new cases of Vibrio infections in Louisiana and Mississippi. V vulnificus accounted for most (82%) of these wound-associated infections. The increased incidence of Vibrio wound infections in the residents of Gulf Coast states was most likely associated with the exposure of skin and soft-tissue injuries to the contaminated floodwaters.⁷

Pathophysiology

The Vibrionaceae family includes the genera Vibrio, Plesiomonas, and Aeromonas. Members of the family Vibrionaceae are natural inhabitants of sea water but can also be found in fresh water. Vibrio species are oxidase-positive, gram-negative bacilli. With the exception of nonhalophilic Vibrio species, such as Vibrio cholerae and Vibrio mimicus, all Vibrio species require saline for growth.

Vibrio species can produce multiple extracellular cytotoxins and enzymes that are associated with extensive tissue damage and that may play a major role in the development of sepsis (see Table 1).

Table 1. Noncholera Vibrio Species and Associated Clinical Presentations

V vulnificus lives in areas where the temperature exceeds 18°C. In the United States, it is found in the coastal waters of the Gulf of Mexico, New England, and the northern Pacific. Low-to-moderate salinity (15-25 parts per thousand) provides the most favorable growing condition for V vulnificus, and, conversely, high salinity (>25 parts per thousand) adversely affects its survival. Similar to the effect of high salinity, low seawater temperature (<10°C) significantly inhibits the growth of V vulnificus. V vulnificus is ingested by filter-feeding mollusks such as oysters, mussels, clams, and scallops. During the warmer months, the concentration of bacteria can be as high as 1 X 10⁶ bacteria per gram of oyster.⁸

Several mechanisms contribute to the virulence of V vulnificus. Iron is an important growth factor. However, because free iron is virtually absent in humans, the organism produces siderophores that acquire iron from transferrin or lactoferrin and deliver it to the bacteria. Conversely, the inability to produce siderophores leads to reduction of virulence. Hepcidin, a natural cysteine-rich peptide, has recently been suggested to possess important antibacterial activity. It is possible that inadequate expression of hepcidin in patients with liver disease predisposes them to serious infections, including those caused by Vibrio species.^9,10

Clinical conditions associated with increased free iron, such as hemochromatosis or hemolytic anemia, represent a major risk factor for disseminated Vibrio infections. In addition, V vulnificus produces several other virulence factors, including proteases, hemolysins, and cytolysins. One in particular, a thermolysin-like metalloprotease, activates the bradykinin pathway, causing an increase in vascular permeability. This metalloprotease is far more efficient at activating human enzymes than those of other Vibrio species, possibly explaining why V vulnificus causes severe skin damage and necrotizing fasciitis.¹¹

Recently, the gene pyrH has been demonstrated as essential for in vivo survival and growth of V vulnificus in infected mice and is likely associated with its virulence. Clinical isolates of V vulnificus, but not environmental isolates , caused extensive damage to macrophages in animal models, possibly explaining the lethal effects of this infection. One of the major virulence factors in pathogenic V haemolyticus strains is a thermostable direct hemolysin (TDH). This beta-hemolysin has both enterotoxic and cytotoxic effects; it is detoxified at 60-70°C but reactivated at 80°C (Arrhenius effect).

For additional information on cutaneous V vulnificus infections, see the article Vibrio Vulnificus in eMedicine’s Dermatology volume.

Frequency

United States

Between 1996 and 2001, the incidence of Vibrio infections increased by more than 80%. More importantly, despite a significant decline (30-45%) in the incidence of most bacterial foodborne infections in the United States in 2004, the incidence of Vibrio infections increased by 47% over the baseline period of 2001-2002.¹² The CDC estimates that 8000 Vibrio infections and approximately 60 deaths related to Vibrio infections may occur annually in the United States. Vibrio infections are acquired through consumption of contaminated raw or undercooked shellfish such as oysters, clams, mussels, or crabs. Exposure of wounds to contaminated sea water, injury caused by contaminated seashells, and shark and alligator bites are potential alternative sources of infection (see Table 2).

International

Noncholera Vibrio infections are commonly reported in areas such as Japan, Taiwan, China, Hong Kong, Korea, Italy, and Israel. The high prevalence of hepatitis B infections in areas such as China and Taiwan may also contribute to the high incidence of severe noncholera Vibrio infections.

Contrary to epidemiologic patterns of Vibrio infections, only sporadic cases were reported among survivors and injured individuals following the tsunami that devastated Thailand, Indonesia, and India in December 2004.

Despite a high annual estimated incidence of V vulnificus septicemia in Japan (425 cases; 95% CI, 238-752), a survey of registered emergency physicians in Japan surprisingly revealed that only 15.7% (95% CI, 11.3-21.0) of responding physicians had a basic knowledge of this frequently fatal infection.¹⁴

Mortality/Morbidity

According to CDC estimates, foodborne diseases cause approximately 76 million illnesses, 325,000 hospitalizations, and 5200 deaths annually in the United States.¹⁴

• Foodborne noncholera Vibrio infections may occur at rate of 0.2-0.3 per 100,000 population. Three thousand cases of V parahaemolyticus infection are estimated to occur annually, resulting in 40 hospitalizations and 7 deaths. Ninety-five cases of V vulnificus infection are estimated to occur annually, resulting in 85 hospitalizations and 35 deaths.
• Although Vibrio infections are not as common as Campylobacter, Salmonella, or Listeria infections, more patients with Vibrio infections die because of the high mortality rate associated with V vulnificus septicemia.
• Among all foodborne diseases, V vulnificus infection is associated with the highest case fatality rate (39%).
• Patients with cirrhosis who consumed raw oysters were 80 times more likely to develop V vulnificus infection and 200 times more likely to die of the infection than those without liver disease who consumed raw oysters.¹⁵
• Regardless of pre-existing conditions, the mortality risk increases in patients with V vulnificus infection who are hospitalized more than two days after symptoms develop (OR, 2.9; 95% CI, 1.8-4.8).¹⁶
• A delay in performing the first fasciotomy (>24 h) after development of clinical symptoms in patients with V vulnificus necrotizing fasciitis was associated with 5-fold increase in the mortality risk.

Race

Vibrio infections have no racial predilection.

• Because Vibrio species are natural inhabitants of sea water, Vibrio infections are more commonly reported in states or countries bordered by large bodies of sea water.
• Persons with underlying medical conditions, such as alcoholism, cirrhosis, or malignancy, and recipients of organ transplants are at increased risk of Vibrio infections and serious complications.
• Patients with end-stage renal failure who are on continuous ambulatory peritoneal dialysis (CAPD) may develop peritonitis after eating or handling raw sea fish.

Sex

Vibrio infections can occur in all persons, regardless of sex. V vulnificus infections were reported in women who engaged in sexual intercourse in brackish water of the Gulf of Mexico. In general, V vulnificus infections are more common in males (82%), according to most reports.

Age

• Persons of any age who consume or are exposed to Vibrio- contaminated food or water are at risk of developing Vibrio infection, especially if they have underlying medical conditions such as advanced liver disease.
• Most patients with Vibrio wound infections and septicemia are aged 50-60 years.

Clinical

History

Most patients with noncholera Vibrio infections report having recently consumed raw seafood such as oysters, clams, crabs, or mussels. With the exception of a dramatic clinical progression in wound infection and septicemia, no characteristic signs and symptoms of early-stage noncholera Vibrio infections exist (see Table 3).

Table 3. Clinical Signs and Symptoms of Vibrio Infections

• Vibrio gastroenteritis: After an average incubation period of 19 hours (12-52 h), patients with Vibrio gastroenteritis report diarrhea, abdominal cramps, nausea, and vomiting.^17,5
  • Patients frequently pass several watery stools (10-15/d).
  • The occurrence of bloody diarrhea varies. It is reported in 25% of patients with V parahaemolyticus infection but may develop in up to 75% of patients with V fluvialis infection.
  • Low-grade fever may be observed in patients with Vibrio gastroenteritis.
  • Most patients remain alert upon admission. However, elderly patients may have decreased mental status due to dehydration or sepsis.
• Noncholera Vibrio wound infection: Patients frequently report injury caused by fish hooks; preparation of St Peter's fish (Tilapia zillii); preparation of crabs, lobsters, or mussels; or stepping on seashells.¹⁸
  • Initially, patients with such infections almost always report severe pain of the involved limb or body part.
  • Numbness of the wound and the surrounding area may predominate if the patient has delayed seeking medical attention.
• Noncholera Vibrio septicemia: Patients frequently exhibit a dramatic clinical presentation characterized by the following:
  • High fever
  • Shaking chills
  • Generalized myalgia
  • Exquisite pain in the lower extremities (most characteristic) or, rarely, pain in the lower trunk¹⁹

Physical

The physical findings of Vibrio infections vary according to clinical presentations.

• Acute gastroenteritis
  • Patients with acute Vibrio gastroenteritis are typically acutely ill with diarrhea, nausea, vomiting, abdominal pain, and fever (50%).
  • The vital signs, such as blood pressure and heart rate, vary depending on the level of dehydration.
  • Unless the patient has underlying disease, no physical findings are specific for acute Vibrio gastroenteritis.⁵
• Wound infection
  • After a short incubation period (3-24 h), patients with Vibrio wound infections frequently present with rapidly progressing wound swelling and severe pain.
  • The majority of such wounds involve the fingers, palms, or soles of the feet.
  • In milder cases, erythema, edema, and pain are localized to the initial wound, without signs of compartment syndrome, necrosis, gangrene, or necrotizing fasciitis.
  • In patients with medical conditions such as cirrhosis or malignancies, the wound infection may progress very rapidly, with formation of hemorrhagic bullae and extensive soft-tissue necrosis.¹⁸
• Septicemia
  • After a short incubation period (12-48 h) following the consumption of raw seafood or exposure of broken skin to warm seawater, patients with Vibrio septicemia frequently develop fever, shaking chills, generalized myalgia, edema, and severe pain in the lower extremities.¹⁹
  • Within 3-24 hours, edema of the lower extremities worsens.
  • Multiple hemorrhagic bullae and extensive ecchymoses distributed predominantly over the lower extremities form rapidly (see Images 1-3).
    
    

    

    Vibrio infections. Early bullous lesions appear over the dorsum of the foot of a patient with cirrhosis.

    
    
    

    

    Vibrio infections. In a patient with cirrhosis, skin lesion rapidly becomes necrotic.

    
    
    

    

    Vibrio infections. Bullous lesions in a patient with cirrhosis continue to progress, and the patient rapidly develops hypotension and shock despite aggressive medical therapy.

    
    
  • Patients frequently become hypotensive despite aggressive intravenous fluid therapy.
  • Patients become lethargic, obtunded, and, finally, unconscious as the disease progresses.
  • Oliguria may develop.
  • Noncardiogenic pulmonary edema may develop.
• Ocular infection -Conjunctivitis, keratitis, endophthalmitis
• Peritonitis - Abdominal pain and cloudy peritoneal fluid in patients receiving CAPD

Causes

• Noncholera Vibrio infections are foodborne diseases that are largely associated with the following:
  • Consumption of raw or undercooked seafood such as oysters, clams, crabs, or mussels
  • Exposure of wound to contaminated water
• Acute gastroenteritis associated with noncholera Vibrio infection is frequently self-limited, although persons with certain underlying medical conditions may develop fulminant infections. These underlying medical conditions include the following:
  • Advanced liver diseases, such as cirrhosis, hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, alcoholism, hemochromatosis, and liver transplantation
  • Hematologic diseases, such as acute leukemia, aplastic anemia, hemolytic anemia, and thalassemia
  • Immunosuppressive therapy, including cytotoxic chemotherapy, corticosteroids, and tacrolimus
  • Kidney disease involving kidney transplantation or hemodialysis
  • Miscellaneous procedures and conditions, including splenectomy and diabetes mellitus

Differential Diagnoses

Other Problems to Be Considered

Clostridial necrotizing fasciitis
Aeromonas necrotizing fasciitis

Workup

Laboratory Studies

• CBC count with differential and platelet count
  • Findings on blood count are initially nondiagnostic in patients with Vibrio infection.
  • In patients with underlying medical conditions, such as cirrhosis, the presence of thrombocytopenia and/or schistocytes is an early indicator of disseminated intravascular coagulation (DIC).
• Serum chemistries (comprehensive metabolic panel)
  • Serum electrolytes, BUN, and creatinine levels may become abnormal in patients with dehydration, hypotension, and severe sepsis.
  • Monitoring serum electrolytes is essential in the treatment of severe gastroenteritis.
• Stool examination for occult blood and fecal leukocytes: The presence of either fecal occult blood or fecal leukocytes is a reliable marker for invasive infectious diarrhea.
• Stool examination for ova and parasites and stool cultures for Salmonella, Shigella, Campylobacter, Yersinia, and Vibrio species
  • Stool examination for parasites and stool culture are indicated in patients who present with diarrhea and who have a history of recent travel and/or consumption of contaminated food or water.
  • Perform these tests in patients with gastroenteritis, especially upon suspicion of foodborne illness.
  • The physician may alert the public health department if a specific pathogen is identified in a group of people.
• Prothrombin time and activated partial thromboplastin time
  • Prothrombin time (PT) and activated partial thromboplastin time (aPTT) may be prolonged in patients with DIC.
  • Coagulation tests are indicated in patients who require extensive surgical debridement.
• Gram stain and culture of the bulla aspirate
  • Gram stain and culture are indicated in patients with wound infections.
  • Gram stain may reveal gram-negative rods, or studies may be used to isolate a specific pathogen for antibiotic sensitivity testing.
• Gram stain and culture of other body fluids and/or exudates such as peritoneal fluid or ocular exudates
• Blood cultures
  • Patients with certain medical conditions, such as advanced liver disease, may develop bacteremia and serious complications.
  • Blood culture findings are frequently positive in patients with V vulnificus infections.
• Arterial blood gas
  • Arterial blood gas (ABG) is indicated in patients with severe sepsis, septic shock, multiple organ dysfunction, DIC, or acute respiratory distress syndrome (ARDS).
  • ABG may show severe metabolic acidosis due to tissue hypoperfusion and/or hypoxia.

Imaging Studies

• Chest radiography in patients with Vibrio infections may show fluffy bilateral pulmonary infiltrates compatible with ARDS. Radiographic examination of the injured anatomical parts, such as fingers, hand, foot, or trunk may reveal foreign objects, such as fragments of fishhooks or seashells. The presence of gas feathering in the soft tissue may help to identify other potential diagnoses, such as gas gangrene.
• CT scanning of the injured body parts may be indicated if the patient develops signs and symptoms of compartment syndrome or necrotizing fasciitis.

Other Tests

• Other tests may be unnecessary upon admission but may help identify the underlying medical conditions that predispose the patient to serious Vibrio infection and/or complications.
• Serology for HBV and HCV and serum iron studies are used to identify the etiology of advanced liver disease.

Procedures

• Wound debridement
  • Early wound debridement is indicated in patients with Vibrio wound infection or septicemia. A delay of wound debridement may lead to amputation.
  • Debridement must be performed urgently if the patient develops compartment syndrome.

Histologic Findings

Findings on histologic examination of the skin and/or soft tissue in patients with noncholera Vibrio wound infection frequently demonstrate gram-negative bacilli, acute inflammatory reaction with extensive tissue necrosis, and fat infarction. In patients with rapidly progressing illness, examination of biopsy specimens of the skin may demonstrate an absence of cellular response.

Treatment

Medical Care

Medical care depends on the clinical presentation and the presence of underlying medical conditions.

• Gastroenteritis
  • Because Vibrio gastroenteritis is self-limited in most patients, no specific medical therapy is required. Patients who cannot tolerate oral fluid replacement may require intravenous fluid therapy.
  • Although most Vibrio species are sensitive to antibiotics such as doxycycline or quinolones, antibiotic therapy does not shorten the course of the illness or the duration of pathogen excretion. However, if the patient is ill and has a high fever or an underlying medical condition, oral antibiotic therapy with doxycycline or quinolone can be initiated.
• Patients with noncholera Vibrio wound infection or septicemia are much more ill and frequently have other medical conditions. Medical therapy consists of the following:
  • Prompt initiation of effective antibiotic therapy
  • Intensive medical therapy with aggressive fluid replacement and vasopressors for hypotension and septic shock to correct acid-base and electrolytes abnormalities that may be associated with severe sepsis

Surgical Care

• Early fasciotomy within 24 hours after development of clinical symptoms can be life saving in patients with necrotizing fasciitis.
• Early debridement of the infected wound has an important role in successful therapy and is especially indicated to avoid amputation of fingers, toes, or limbs.
• Because patients with Vibrio wound infections or septicemia may deteriorate rapidly, with development of necrotizing fasciitis or compartment syndrome, expeditious and serial surgical evaluation and intervention are required.
• Reconstructive surgery, such as skin graft, is indicated in the recovery phase.

Consultations

A team effort is required to ensure successful therapy in patients with noncholera Vibrio wound infection or septicemia.

• Urgent consultation with an infectious diseases specialist for diagnosis and possible investigation of foodborne illness
• Urgent consultation with a general surgeon or orthopedist for debridement
• Consultation with a critical care specialist to manage possible developments such as severe sepsis, septic shock, and multiple organ dysfunction (eg, ARDS, renal failure)
• Consultation with a gastroenterologist since many patients with Vibrio infections have advanced liver disease and may develop serious complications such as gastrointestinal bleeding

Diet

• Patients with Vibrio gastroenteritis are permitted oral intake as tolerated.
• Patients with Vibrio wound infection and septicemia are frequently too ill to tolerate oral intake during the acute phase.
• Some patients with advanced liver disease develop hepatic encephalopathy and may require oral or parenteral hepatic nutrition.

Medication

For noncholera Vibrio infections other than gastroenteritis, the combination of ceftazidime and doxycycline or an antipseudomonal penicillin (eg, ticarcillin and clavulanate, piperacillin and tazobactam) is the therapy of choice. Alternative antibiotics include cefotaxime or fluoroquinolones. Although in vitro testing demonstrates that Vibrio species are sensitive to aminoglycosides, the use of aminoglycosides may be associated with toxicities above those observed with other agents.

In a retrospective chart review of 93 patients hospitalized with serious Vibrio infections, the combination of a third-generation cephalosporin and tetracycline or its analogue was an independent factor for lower mortality (OR, 0.337; 95% CI, 0.007-0.192; P <0.001).

Tigecycline, a novel glycylcycline, has a potent in vitro antimicrobial effect against Vibrio species. Other newer antibiotics such as daptomycin and linezolid that were approved for the treatment of serious skin and soft-tissue infections have not been studied in serious Vibrio infections. Therefore, the authors do not currently recommend the use of these antibiotics in the treatment of serious Vibrio infections.

Adjuvant therapy: Recombinant human activated protein C (drotrecogin alfa activated) has been used as an adjuvant therapy in patients with severe sepsis who scored 25 or more on the Acute Physiology and Chronic Health Evaluation (APACHE II). A few patients with V vulnificus sepsis who were successfully treated with antibiotics, surgical debridement, and recombinant human activated protein C were reported. In view of serious bleeding associated with the continuous infusion of recombinant human activated protein C and the potential requirement for repeated surgical debridement in patients with V vulnificus sepsis, routine use of this adjuvant therapy is not recommended.²⁰

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic combinations are usually recommended for serious gram-negative bacillary infections. This approach ensures coverage for a broad range of organisms and polymicrobial infections. In addition, resistance from bacterial subpopulations is prevented, and additive or synergistic effects are provided. Once organisms and sensitivities are known, the use of antibiotic monotherapy is recommended.

Doxycycline (Bio-Tab, Doryx, Vibramycin, Doxy)

Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Dosing

Adult

200 mg PO/IV q12h for 3 d, then 100-200 mg PO q12h for 14 d

Pediatric

<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO/IV qd or divided bid; not to exceed 200 mg/d

Interactions

Bioavailability decreases minimally with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may rarely occur; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth

Piperacillin and tazobactam (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Dosing

Adult

4.5 g IV q8h

Pediatric

<6 months: Not established
>6 months: 75 mg/kg IV q6h

Interactions

Tetracyclines may decrease effects of piperacillin; high concentrations in vivo or in vitro of piperacillin may chemically inactivate aminoglycosides; synergistic effect occurs when administered concurrently with aminoglycosides; probenecid may increase penicillin levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBC prior to initiation of therapy and at least weekly during therapy; adjust dose in renal dysfunction; monitor for liver and renal function abnormalities

Ticarcillin and clavulanate (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor provides coverage against most gram-positive, gram-negative, and anaerobic bacteria.

Dosing

Adult

3.1 g IV q4-6h

Pediatric

75 mg/kg IV q6h

Interactions

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin in vivo or in vitro may chemically inactivate aminoglycosides; synergistic effect occurs when administered concurrently with aminoglycosides; probenecid may increase penicillin levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBC prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, BUN, and creatinine determinations during therapy and adjust dose if values become elevated

Ciprofloxacin (Cipro, Ciloxan)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Dosing

Adult

400 mg IV bid for 7-14 d, may switch to 500 mg PO to complete therapy when oral intake is normalized

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; CNS and GI disturbances have been observed

Cefotaxime (Claforan)

For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.

Dosing

Adult

2 g IV q6h

Pediatric

Infants to <12 years: 50-180 mg/kg/d IV divided q4-6h
>12 years: Administer as in adults

Interactions

Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal impairment; has been associated with severe colitis

Follow-up

Further Inpatient Care

• Daily or repeated surgical debridement may be necessary.
• Continue intensive medical care for fluid, electrolytes, and acid-base abnormalities.
• Blood transfusion or infusion of platelet or clotting factors is necessary for the treatment of DIC.
• Perform hemodialysis for renal failure, if indicated.
• Medically monitor and treat other underlying medical conditions such as advanced liver disease, diabetes mellitus, or leukemia.

Further Outpatient Care

• Noncholera Vibrio gastroenteritis is self-limited and does not require further outpatient care.
• Patients who survive devastating halophilic Vibrio infections may sustain finger, toe, or limb amputation and massive destruction of skin and soft tissue. These patients require extensive reconstructive surgery and physical rehabilitation.

Transfer

• Patients with serious noncholera Vibrio infections may require transfer to a facility where intensive monitoring and surgical expertise is available.
• In contrast to the treatment of gas gangrene, hyperbaric oxygen therapy (HBO) has not been studied or proven effective in the treatment of serious halophilic Vibrio infections. Therefore, transfer to an HBO facility is not recommended.

Deterrence/Prevention

• Avoid eating raw or undercooked seafood. Contaminated seafood cannot be distinguished by smell or taste. This is especially important for individuals with conditions that predispose to invasive Vibrio infections.²¹
  • Fry, bake, steam, or boil oysters, clams, and mussels 4-9 minutes or until plump.
  • Boil shrimp or crab until shells turn pink and the meat is cooked in the middle.
  • Fish is cooked until the thickest part is opaque.
• Avoid exposure to seawater in summer months or along the coastal regions in the southeastern United States.
• Promptly seek medical attention if fever, nausea, abdominal cramps, diarrhea, myalgia, or severe pain in the lower extremities develops.

Complications

• Although reactive arthritis may occur, other complications are rare in immunocompetent patients who have noncholera Vibrio gastroenteritis.
• Patients with advanced liver disease or other underlying medical conditions are prone to developing serious complications of Vibrio infections, including the following:
  • Hypotension, shock
  • Compartment syndrome
  • Multiple organ dysfunction
  • DIC
  • ARDS
  • Hemolysis
• A delay in performing fasciotomy or debridement in a patient with a Vibrio wound infection may result in death or rapid disease progression, which may lead to amputation.
• Avoid admitting patients with noncholera Vibrio wound infection or septicemia to the regular ward. Hypotension or shock can develop very quickly.
• Frequent surgical evaluation is necessary to detect the rapid development of compartment syndrome.

Prognosis

• The prognosis is excellent in immunocompetent patients who have acute Vibrio gastroenteritis.
• In patients with Vibrio wound infection or septicemia, the prognosis is very grave (12), and depends on the following:
  • Underlying medical conditions such as cirrhosis or leukemia
  • Pathogen (V vulnificus infection is associated with a 50% mortality rate.)
  • Prompt initiation of effective antibiotic therapy
  • Early fasciotomy and debridement
  • Availability of intensive monitoring and medical care for serious complications
  • Availability of reconstructive surgery and physical rehabilitation

Patient Education

• Educate patients with appropriate underlying medical conditions about the serious medical illness that may be associated with the consumption of raw or undercooked seafood.
• Educate patients to seek medical attention promptly if fever, nausea, abdominal cramps, diarrhea, myalgia, or severe pain develops in the lower extremities.

Miscellaneous

Medicolegal Pitfalls

• Failure to suspect or to make an early diagnosis of noncholera Vibrio infection in a patient who has eaten raw seafood and who has advanced liver disease
• Delay in performing fasciotomy or debridement in patients with noncholera Vibrio wound infection, potentially leading to death or limb amputation
• Failure to warn a patient with advanced liver disease about the possibility of developing a life-threatening illness after eating raw or undercooked shellfish
• Failure to warn a patient with advanced liver disease about the possibility of developing a life-threatening illness after exposure to contaminated warm seawater
• Failure to educate a patient with advanced liver disease about properly cooking or preparing seafood
• Failure of the owner of a seafood restaurant to display a warning about the association between consumption of raw seafood and the development of life-threatening illness in patients with advanced liver disease

Special Concerns

• The public health department should be notified if V vulnificus or V parahaemolyticus infection is identified or suspected.

Multimedia

Media file 1: Vibrio infections. Early bullous lesions appear over the dorsum of the foot of a patient with cirrhosis.

Media file 2: Vibrio infections. In a patient with cirrhosis, skin lesion rapidly becomes necrotic.

Media file 3: Vibrio infections. Bullous lesions in a patient with cirrhosis continue to progress, and the patient rapidly develops hypotension and shock despite aggressive medical therapy.

References

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Keywords

Vibrio infections, Vibrio cholera infections, noncholera Vibrio infections, halophilic Vibrio species, nonhalophilic Vibrio species, Vibrio parahaemolyticus, Vibrio vulnificus, V parahaemolyticus, V vulnificus, Vibrionaceae family, vibriosis, vibrioses, Vibrio gastroenteritis, Vibrio wound infection, Vibrio septicemia, Vibrio sepsis, Vibrio cholerae, Vibrio mimicus, Vibrio fluvialis, Vibrio furnissii, Vibrio hollisae, Vibrio alginolyticus, Vibrio damsela, Vibrio carchariae, Vibrio cincinnatiensis, Vibrio metschnikovii, V cholerae, V mimicus, V fluvialis, V furnissii, V hollisae, V alginolyticus, V damsela, V carchariae, V cincinnatiensis, V metschnikovii

Contributor Information and Disclosures

Author

Hoi Ho, MD, Associate Dean for Faculty Affairs and Development, Professor, Department of Internal Medicine, Director, Clinical Skills and Clinical Simulation Center, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center; Consulting Staff, Thomason Hospital
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Thong Huy Do, MD, Staff Physician, Department of Internal Medicine, Thomason Hospital, Texas Tech University
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Tony Tran Ho, MS, Texas Tech University School of Medicine
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