Medication Summary
In adults with noncholera Vibrio infections other than gastroenteritis, the combination of a third-generation cephalosporin (eg, ceftazidime, cefotaxime, ceftriaxone) and tetracycline or one of its analogues (eg, doxycycline) or a single-agent regimen with a fluoroquinolone (eg, levofloxacin, ciprofloxacin) is the therapy of choice. [53, 54]
Among children with serious noncholera Vibrio infections in whom tetracycline and fluoroquinolone are contraindicated, trimethoprim-sulfamethoxazole plus an aminoglycoside (eg, gentamicin) is recommended. [53]
Analyzing the efficacy of 3 antibiotic regimens (group 1, a third-generation cephalosporin; group 2, a third-generation cephalosporin plus minocycline; group 3, a fluoroquinolone with or without minocycline) in terms of patient outcomes in the treatment of 89 cases of V vulnificus necrotizing fasciitis, authors reported that a fluoroquinolone or the combination of a third-generation cephalosporin plus minocycline are antibiotics of choice in lowering mortality rates (61% in group 1 vs 14% in group 2; P = 0.0003; 61% in group 1 vs 14% in group 3; P = 0.00027). [55]
Another alternative regimen with documented synergism in an in vivo study on mice is cefotaxime and minocycline. [56]
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 (odds ratio, 0.037; P< .001). [37]
A recent study done in Republic of Korea on 218 subjects with V. vulnificus septicemia showed the 30-day survival rate of the third-generation cephalosporin (TGC) plus doxycycline group was not statistically different from that of the TGC plus ciprofloxacin group (38% vs.54%, P = 0.18). There was no significant difference in survival rate between the TGC monotherapy and TGC plus doxycycline groups (P = 0.76). [57]
Tigecycline, a novel glycylcycline, has a potent in vitro antimicrobial effect against Vibrio species. The efficacy of tigecycline in combination with cefpirome has been highlighted as "salvage" therapy in a child with V. vulnificus necrotizing fasciitis who was not clinically responding to ceftazidime and minocycline. [58] The survival rate in mice treated with the combination of tigecycline and ciprofloxacin was significantly higher than those treated with the combination of cefotaxime and minocycline (71% vs 42%; log-rank test, P = 0.04). [59]
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 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. [60]
Antibiotics
Class Summary
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.
Piperacillin and tazobactam (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
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.
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.
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.
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Vibrio infections. Early bullous lesions appear over the dorsum of the foot of a patient with cirrhosis.
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Vibrio infections. In a patient with cirrhosis, skin lesion rapidly becomes necrotic.
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Vibrio infections. Bullous lesions in a patient with cirrhosis continue to progress, and the patient rapidly develops hypotension and shock despite aggressive medical therapy.
Tables
Infection Type |
Noncholera Vibrio Species |
Cytotoxins/Enzymes |
Gastroenteritis |
V parahaemolyticus Non-01 V cholerae Vibrio fluvialis V mimicus Vibrio furnissii Vibrio hollisae Vibrio alginolyticus V vulnificus |
Cytotoxin Hemolysin |
Wound infection |
V alginolyticus V vulnificus Non-01 V cholerae Vibrio damsela Vibrio carchariae V fluvialis V parahaemolyticus V mimicus |
Protease Hemolysin Lipase DNAase Cytolysin |
Septicemia |
V vulnificus V fluvialis V damsela Non-01 V cholerae Vibrio cincinnatiensis |
Proteases Endotoxic lipopolysaccharide |
Vibrio Species |
Gastroenteritis (%) |
Wound Infection (%) |
Septicemia (%) |
Miscellaneous (%) |
V parahaemolyticus |
59 |
34 |
5 |
2 |
V vulnificus |
5 |
45 |
43 |
7 |
Non-01 V cholerae |
67 |
9 |
15 |
… |
V alginolyticus |
5-12 |
71 |
1 |
10-15 |
V mimicus |
85 |
3 |
3 |
… |
V fluvialis |
73 |
10 |
6 |
… |
V damsela |
Rare |
>95 |
Rare |
… |
V furnissii |
>90 |
Rare |
Rare |
… |
Vibrio metschnikovii |
Common |
Rare |
Rare |
… |
V hollisae |
85 |
7 |
5 |
… |
V cincinnatiensis |
Rare |
Rare |
Rare |
Meningitis |
Clinical Presentation |
Symptoms (Frequency) |
Gastroenteritis |
Diarrhea (100%) Abdominal cramps (89%) Nausea (76%) Vomiting (55%) Fever (47%) Bloody stools (29%) Headache (24%) Myalgia (24%) |
Wound infection |
Swelling (100%) Pain (100%) Erythema (100%) Bullae (30-50%) Necrosis (30-50%) Gangrene (< 10%) |
Septicemia |
Fever (>90%) Hypothermia (< 10%) Hypotension (100%) Tachycardia (80-90%) Shock (50-70%) Bullae (80-100%) Acute respiratory distress syndrome (< 5%) Multiple organ dysfunction (30-50%) |
