Medical Care
Medical care depends on the clinical presentation and the presence of underlying medical conditions.
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:
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Prompt initiation of effective antibiotic therapy
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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
Antimicrobial resistance
Up to 90% of seafood consumed in the United States is imported, of which 50% is wild-caught. The United States imports seafood mainly from China, Thailand, Canada, Indonesia, Vietnam, and Ecuador. The top imports include shrimp, freshwater fish, tuna, salmon, groundfish, crab, and squid. [43]
V vulnificus and V parahaemolyticus have shown resistance to multiple antibiotics owing to overuse and misuse of prophylactic antibiotics in aquaculture. In contrast with the extensive investigation of antibiotic resistance in Vibrio cholera and Salmonella species, few studies of this type in noncholera Vibrio species have been conducted in the United States. [44, 45] A study on antimicrobial susceptibilities of 168 V parahaemolyticus isolates and 151 V vulnificus isolates from Louisiana Gulf and retail raw oysters was conducted in 2005 and revealed ampicillin resistance in 57% of V parahaemolyticus strains and intermediate ampicillin resistance in 24% of V parahaemolyticus strains. [46]
Another study on 296 V parahaemolyticus isolates and 94 V vulnificus isolates from oysters (during an oyster relay study), published in 2018 and identified more than three quarters of the V. vulnificus and about a third of the V. parahaemolyticus isolates resistant to at least one antimicrobial. Furthermore, 48% of V. vulnificus and 8% of V parahaemolyticus isolates showed resistance to more than one antimicrobial. For V. vulnificus isolates, resistances to cephalothin were 67%, tetracycline 29%, amoxicillin-clavulanic acid and ampicillin 26%, doxycycline 21%, ceftriaxone and ceftazidime 12%, and cefotaxime 7%. [47]
The antimicrobial resistance pattern of V parahaemolyticus is an important factor to consider for successful treatment. However, such data in Vietnam are limited. A study was conducted in 2010 to investigate the antimicrobial susceptibilities of 130 isolated samples of V parahaemolyticus from various sources (acute diarrheal patients, food, environment). Overall, most strains were susceptible to the majority of antimicrobials tested, including tetracycline (90%), chloramphenicol (97%), ciprofloxacin (100%), sulfamethoxazole/trimethoprim (Bactrim), and doxycycline (93%). About a third (34%) of tested strains were resistant to ampicillin. [48]
A recent study has found Extended Spectrum Beta-Lactamase (ESBL) activity in more than a quarter of V. parahaemolyticus isolated from shrimps purchased from 40 different markets in Ho Chi Minh City, Vietnam. [49]
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.
Expeditious and serial surgical evaluation and intervention are required because patients may deteriorate rapidly, especially those with necrotizing fasciitis or compartment syndrome.
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.
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. [50]
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Fry, bake, steam, or boil oysters, clams, and mussels 4-9 minutes or until plump.
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Boil shrimp or crab until shells turn pink and the meat is cooked in the middle.
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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.
Studies of V vulnificus bacteriophage SSP002 have demonstrated its protective efficacy in infected mouse models and its potential use as a biocontrol agent against V vulnificus in the food industry. [51]
High hydrostatic pressure (HPP), a nonthermal process, has been shown to be effective in inactivating V vulnificus and V parahaemolyticus in oysters without changes in original nutrient, flavor, or appearance. However, because of the high cost of HPP, this process may not be affordable by most oyster producers. [52]
Long-Term Monitoring
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.
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.
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.
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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%) |
