Bacteria

Vibrio Cellulitis

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Vibrio Cellulitis, Vibrio vulnificus, Vibrio alginolyticus, Vibrio damsela

  • Epidemiology
  1. Most common cause of shellfish related deaths in U.S.
  • Causes
  1. Vibrio vulnificus (most common)
  2. Vibrio alginolyticus
  3. Vibrio damsela
  • Pathophysiology
  1. Vibrio vulnificus is halophilic (high salt concentration), brackish, warm water (esp. Gulf Coast states in U.S.)
  2. Laceration in salt water or brackish fresh water
    1. See Marine Trauma
    2. Warm water Temperature (>68 degrees F)
    3. Not associated with pollution or fecal waste
  3. Wound exposure (most common)
    1. Drippings from raw seafood
    2. Fish fin punctures
  4. Ingestion of contaminated seafood (raw oysters)
    1. Especially oysters harvested in Gulf of Mexico
    2. Infection does not alter food taste, odor, appearance
    3. Highest risk with immunocompromised state (e.g. Diabetes Mellitus, Cirrhosis)
  • Risk Factors
  1. Immunocompromising conditions
    1. Diabetes Mellitus
    2. Lymphoma
    3. Cirrhosis
  2. Enhanced iron storage (high Transferrin Saturation)
    1. Alcoholic Cirrhosis
    2. Hemochromatosis
    3. Thalassemia major
  • Symptoms and Signs
  • Ingestion
  1. Onset: 1-5 days
  2. Duration: 2-8 days
  3. Fever
  4. Diarrhea
  5. Nausea and Vomiting
  6. Mental status changes (50%)
  7. Septic Shock (33%)
  8. Abdominal Pain
  9. Skin lesions with Ecchymoses, ulcers and bullae
    1. See Cellulitis below
    2. Skin lesions develop within first 24 hours
  1. Fever and chills (Bacteremia in 50%)
  2. Mental status changes (33%)
  3. Hypotension (10%)
  4. Painful Cellulitis onset at open wound sites
    1. Rapidly progressive infection
    2. Hemorrhagic bullous lesions (75% of cases)
    3. Marked local edema
    4. Necrotic ulcers
    5. Necrotizing Fasciitis
  • Labs
  1. Complete Blood Count with differential
  2. Blood Culture
  3. Gram Stain and Culture of skin lesions
  • Course
  1. Cellulitis
    1. See Cellulitis or Marine Trauma
    2. Rapidly progressive Necrotizing Fasciitis and Septicemia
  2. Ingestion raw oysters
    1. Acute Gastroenteritis 24 hours after intake
    2. Hemorrhagic skin bullae
    3. See Foodborne Illness
  • Management
  1. Hospitalization
    1. Progresses rapidly with high mortality and morbidity
    2. Mortality rate rises with delayed treatment
  2. Surgical debridement indications (Limb Amputation may be required)
    1. Embedded debris
    2. Necrotizing Fasciitis
  3. Antibiotics
    1. Recommended Protocol
      1. Doxycycline or Minocycline 100 mg PO or IV q12 hours AND
      2. Ceftazidime (Fortaz) 2 grams IV q8 hours or Ceftriaxone 2 g IV q24 hours
    2. Alternative protocol
      1. Ciprofloxacin 750 mg PO or 400 mg IV every 12 hours OR
      2. Levofloxacin 750 mg PO or IV every 24 hours
  • Prognosis
  1. Very high case fatality rate: 30-40%
  2. Comorbid liver disease or immunocompromised confers higher mortality
  3. Mortality increases with delay in treatment
    1. Prompt diagnosis: 33% mortality
    2. Delayed 24 hours: 53% mortality
    3. Delayed 72 hours: 100% mortality
    4. Klontz (1988) Ann Intern Med 109:318-23 [PubMed]
  • Prevention
  1. See Prevention of Foodborne Illness
  2. Avoid seawater contact with open wounds
    1. Highest risk when water Temperature >68 F degrees
    2. Wash exposed wounds with soap and water immediately
    3. Seak immediate attention for signs of Cellulitis