Primary Septicemia Research Articles

Wound infections caused by Vibrio vulnificus and other marine bacteria

Infections caused by Vibrio vulnificus were first reported in 1979 by Blake et al. of the US Centers for Disease Control. At that time described as a 'rare, unnamed halophilic lactose-fermenting Vibrio species', V. vulnificus has emerged as the most virulent foodborne pathogen in the United States with a hospitalization rate of 0.910 and a case-fatality rate of 0.390. It is in addition a significant cause of potentially life-threatening wound infections. Infections following ingestion of raw or undercooked seafood, commonly raw oysters, can lead to a primary septicaemia with a fatality rate of 50-60%. An unusual symptom, occurring in 69% of 274 cases reviewed by Oliver, is the development of secondary lesions, typically on the extremities, which are generally severe (often a necrotizing fasciitis) and require tissue debridement or amputation. These cases occur almost exclusively in males over the age of 50 years. Interestingly, this gender specificity has been found to be due to the female hormone oestrogen, which in some manner provides protection against the lethal V. vulnificus endotoxin. Further, most cases occur in persons with certain underlying diseases which are either immunocompromising or which lead to elevated serum iron levels (e.g. liver cirrhosis, chronic hepatitis, haemochromatosis). V. vulnificus infections resulting in primary septicaemia have been extensively studied, and the subject of several reviews. This review concentrates on the wound infections caused by this marine bacterial pathogen, including the more recently described biotypes 2 and 3, with brief discussions of those caused by other marine vibrios, and the increasingly reported wound/skin infections caused by Mycobacterium marinum, Erysipelothrix rhusiopathiae, and Aeromnonas hydrophila.

Systemic Vibrio Infection Presenting as Necrotizing Fasciitis and Sepsis: A Series of Thirteen Cases

Vibrio species are an uncommon cause of necrotizing fasciitis and primary septicemia, which are likely to occur in patients with hepatic disease, diabetes mellitus, adrenal insufficiency, and immunocompromised conditions. These organisms are found in warm sea waters and are often present in raw oysters, shellfish, and other seafood. The purposes of the present report were to describe a series of patients who had this potentially lethal infection and to identify clinical features associated with a poor prognosis. We retrospectively reviewed the records of thirteen patients (ten men and three women) who had necrotizing fasciitis and sepsis caused by Vibrio species. All patients had a history of contact with seawater or raw seafood. Eight patients had a hepatic disease such as hepatitis or cirrhosis of the liver, three had diabetes mellitus (without hepatic disease), and two had chronic renal or adrenal insufficiency (without hepatic disease). Twelve patients underwent fasciotomy or limb amputation. Five patients (38%) died within two to six days after admission, and eight patients survived. Patients with a systolic blood pressure of < or =90 mm Hg and leukopenia in the emergency room had a significantly higher mortality rate (p < 0.05). The diagnosis of Vibrio necrotizing fasciitis should be suspected when a patient has the appropriate clinical findings and a history of contact with seawater or raw seafood. The treatment should begin as early as possible, essentially when the patient has symptoms of sepsis. Although emergency fasciotomy or limb amputation did not reduce the mortality rate in this series, we consider such operations to be an important aspect of treatment.

Inflammatory cytokine response to Vibrio vulnificus elicited by peripheral blood mononuclear cells from chronic alcohol users is associated with biomarkers of cellular oxidative stress.

Vibrio vulnificus is the leading cause of death in the United States associated with the consumption of raw seafood, particularly oysters. In epidemiological studies, primary septicemia and inflammation-mediated septic shock caused by V. vulnificus is strongly associated with liver disease, often in the context of chronic alcohol abuse. The present study was undertaken to determine whether clinical biomarkers of liver function or cellular oxidative stress are associated with peripheral blood mononuclear cell inflammatory cytokine responses to V. vulnificus. Levels of interleukin-1 beta (IL-1 beta), IL-6, IL-8, and tumor necrosis factor alpha elicited in response to V. vulnificus and measured in cell supernatants were not associated with the liver biomarkers aspartate aminotransferase (AST) or alanine aminotransferase (ALT) or the AST/ALT ratio. In contrast, reduced glutathione (GSH) levels were associated with the release of all four cytokines (IL-1 beta [R(2) = 0.382; P = 0.006], IL-6 [R(2) = 0.393; P = 0.005], IL-8 [R(2) = 0.487; P = 0.001], and TNF-alpha [R(2) = 0.292; P = 0.021]). Those individuals with below-normal GSH levels produced significantly less proinflammatory cytokines in response to V. vulnificus. We hypothesize that persons with markers for cellular oxidative stress have increased susceptibility to V. vulnificus septicemia.

A fatal case of Vibrio vulnificus meningoencephalitis

The objective of this paper is to report a rare case of Vibrio vulnificus presenting as meningoencephalitis without a wound infection. Vibrio vulnificus is capable of causing severe and often fatal infections in susceptible individuals. It commonly causes necrotizing wound infections, primary septicemia, and gastroenteritis. A 69-year-old man had meningoencephalitis with lesion on the red nucleus, substantia nigra, basal ganglia, and dentate nucleus as the initial clinical manifestation of a V. vulnificus infection. This is the first case of V. vulnificus infection in which MRI demonstrated the involvement of deep nuclei of the brain.

Vibrio vulnificus infection in patients with liver disease: report of five autopsy cases.

Five autopsy cases of Vibrio vulnificus infection with liver disease are reported. All five patients ate raw seafood 24 h before the onset of illness. The clinical presentation was of primary septicemia, with positive cultures in both the blood and cutaneous lesions. Stool cultures were positive for the organism in one patient with gastrointestinal symptoms. Autopsy examination revealed liver cirrhosis in three cases and alcoholic liver disease in two; all showed portal hypertension. Gastrointestinal mucosal changes were seen in four patients: edema, hemorrhagic necrosis, and lymphocyte infiltration. One case was of an human immunodeficiency virus infected patient in which histology showed a rare intestinal disease, phlegmonous colitis. We believe this is the first description of a case of concomitant phlegmonous enterocolitis and V. vulnificus infection. Patients with liver disease should be warned about the possibility of life-threatening infections and complications associated with the consumption of raw seafood.

Vibrio vulnificus as a health hazard for shrimp consumers.

Over the last 30 years, a number of Vibrio species found in the aquatic environment have been indicated as cause of disease in human beings. Vibrio vulnificus is an emergent pathogen, an invasive and lethal marine bacterium related to wound infection and held accountable for gastroenteritis and primary septicemia. It occurs quite frequently in marine organisms, mainly in mollusks. This study aimed at isolating and identifying strains of V. vulnificus based upon the analysis of twenty samples of seabob shrimp, Xiphopenaeus kroyeri (Heller), purchased at the Mucuripe fish market (Fortaleza, Brazil). TCBS agar was used to isolate suspect strains. Seven of twenty-nine strains isolated from six different samples were confirmed as such by means of biochemical evidence and thus submitted to biological assays to determine their virulence. The susceptibility of the V. vulnificus strains to a number of antibiotics was tested. None of the V. vulnificus strains showed signs of virulence during a 24-hour observation period, possibly due to the shedding of the capsules by the cells. As to the results of the antimicrobial susceptibility tests, the seven above-mentioned V. vulnificus strains were found to be sensitive to nitrofurantoin (NT), ciprofloxacin (CIP), gentamicin (GN) and chloramphenicol (CO) and resistant to clindamycin (CI), penicillin (PN) and ampicillin (AP).

Role of antibiotic prophylaxis for the prevention of intravascular catheter-related infection

Intravascular catheters have become essential tools for the management of patients in modern medical practice, but there are complications. In particular, catheter-related infection remains a major cause of nosocomial infection and primary septicemia. The development of preventive strategies to reduce the incidence of catheter-related infection is an important goal for all health providers. Over recent years, significant advances in prophylactic measures for the prevention of catheter-related infection have been made. This paper reviews strategies based on antibiotic prophylaxis such as systemic administration of antibiotics, application of antibiotic ointments to the skin insertion site as well as catheter flushing with antibiotics, the antibiotic-lock technique and the use of antimicrobial impregnated catheters.

Vibrio Species

Vibrios are an important cause of human food-borne illness associated with the consumption of seafood worldwide, and contaminated food and drinking water in developing countries. Clinical syndromes induced by vibrios such as Vibrio cholerae, V parahaemolyticus, V. vulnificus, and others range from mild, self-limiting gastroenteritis to life-threatening primary septicemia. As natural inhabitants of the aquatic environment, these bacteria pose a continual threat to food safety.

Primary Shewanella alga Septicemia in a Patient on Hemodialysis

We report the first Japanese case of primary septicemia with Shewanella alga and also describe the bacteriological characteristics of and results of antibiotic susceptibility tests of the isolate. S. alga was repeatedly isolated, at times simultaneously with Escherichia coli, from the blood of a 64-year-old female undergoing hemodialysis. The isolated organism was determined to be S. alga based on recently published identification criteria, such as hemolysis on sheep blood agar, no acid production from carbohydrates, and growth on agar containing 6. 5% NaCl. Results of antibiotic susceptibility tests demonstrated that the isolate was sensitive to levofloxacin and cefpirome (MICs, </=0.063) but resistant to cefazolin, ceftizoxime, and imipenem (MICs, >128, 64, and 8 microg/ml, respectively). Although the role of S. alga as a human pathogen has not been fully determined, accumulating data suggest that this organism may be a potential pathogen, especially in compromised hosts.

Pathogenesis of Vibrio vulnificus.

This review describes the factors which are currently recognized as being central to the virulence of the human pathogen, Vibrio vulnificus. This estuarine/marine bacterium occurs in high numbers in molluscan shellfish, primarily oysters, and its ingestion in raw oysters results in a ca. 60% mortality in those persons who are susceptible to this bacterium. The organism is also able to produce life-threatening wound infections. We describe here the nature of both the wound and primary septicemia infections, the virulence factors known or believed to be involved in these infections, possible immunotherapy, and some thoughts on the possibility that not all strains of this pathogen are virulent.

The role of Gulf Coast oysters harvested in warmer months in Vibrio vulnificus infections in the United States, 1988-1996. Vibrio Working Group.

Vibrio vulnificus infections are highly lethal and associated with consumption of raw shellfish and exposure of wounds to seawater. V. vulnificus infections were reported to the Centers for Disease Control and Prevention from 23 states. For primary septicemia infections, oyster trace-backs were performed and water temperature data obtained at harvesting sites. Between 1988 and 1996, 422 infections were reported; 45% were wound infections, 43% primary septicemia, 5% gastroenteritis, and 7% from undetermined exposure. Eighty-six percent of patients were male, and 96% with primary septicemia consumed raw oysters. Sixty-one percent with primary septicemia died; underlying liver disease was associated with fatal outcome. All trace-backs with complete information implicated oysters harvested in the Gulf of Mexico; 89% were harvested in water >22 degrees C, the mean annual temperature at the harvesting sites (P < .0001). Control measures should focus on the increased risk from oysters harvested from the Gulf of Mexico during warm months as well as education about host susceptibility factors.

The occurrence of human pathogenic Vibrio spp. and Salmonella in aquaculture*

SummaryThis paper describes the occurrence of human pathogenic Vibrio spp. and Salmonella in aquaculture. Vibrio species are natural inhabitants of marine aquatic environments in both temperate and tropical regions, with most human infections acquired by exposure to such environments or to foods derived from them. There appears to be positive correlation between water temperature and the number of human pathogenic vibrios isolated as well as the number of reported infections. However, the occurrence of vibrios does not correlate with traditionally used bacterial indicator organisms of faecal pollution, and their presence in aquaculture is to be expected and cannot be controlled by water quality control measures such as wastewater treatment. Among more than 12 Vibrio spp. known to be associated with human disease, V. cholerae and V. parahaemolyticus are the most important causes of gastrointestinal diseases. Only V. cholerae serotypes O1 and O139, which are rarely found in the environment where aquaculture is practised, cause the disease cholera. Although fish and shellfish may be vehicles of cholera transmission, most episodes are identified as a single or a cluster of cases after consumption of raw seafood. Cholera cases caused by the consumption of commercial imported seafood products have to the author's knowledge not been reported. Seafood products should not contain strains of V. cholerae O1 and O139. However, non‐O1 non‐O139 strains, which are normally present in non‐faecal polluted aquaculture environments, have a low pathogenic potential, and their presence in fish products seems only to constitute a minor health hazard. Accordingly, fresh and frozen fish products containing V. cholerae non‐O1 non‐O139 should not be rejected for human consumption. V. parahaemolyticus is an important cause of gastrointestinal disease, most often after the consumption of seafood. Several haemolysins are important virulence factors, with environmental strains often showing a lower virulence than clinical strains. V. vulnificus may, mainly among immunocompromised individuals, cause serious would infections and primary septicaemia after ingestion of raw seafood, especially oysters, or contact with seawater. However, confirmed human cases of septicaemic or gastrointestinal disease caused by V. vulnificus after consumption of fish have not been reported, and evidence of V. vulnificus as a cause of gastroenteritis has not been provided. Based on data mainly from temperate regions, Salmonella is generally not recognized as being part of the normal microflora in aquaculture environments, and their presence in seafood is therefore seen as a sign of poor standards of process hygiene and sanitation. Accordingly, most countries will not accept Salmonella in any seafood product. Although some studies suggest that Salmonella may be ubiquitous in tropical aquaculture environments, further studies are needed to confirm this. Modern gene‐based typing techniques could provide important information about possible transmission of Salmonella strains from the aquaculture environment to processing facilities and the final products. Althhough Salmonella is one of the most important causes of human gastrointestinal disease world‐wide, surveillances of food‐borne outbreaks associated with the consumption of fish showed that Salmonella species are rarely implicated in gastrointestinal disease.

Clinical Infections of Vibrio vulnificus: A Case Report and Review of the Literature

Vibrio vulnificus is a marine Gram-negative bacillus that is recognized as a cause of fulminant primary septicemia and wound infections. One of the most common bacteria in seawater, V. vulnificus is concentrated in ocean filter feeders (e.g., oysters and clams). Primary septicemia can occur in patients, typically with underlying liver disease, who have acquired the organism through the gastrointestinal tract after recent consumption of raw shellfish. Characterized by fevers, chills, and bullous skin lesions, V. vulnificus septicemia is associated with a mortality greater than 50%. With septic shock, mortality approaches 100%. Wound infections are seen after injury to the skin in a marine environment or from exposure of preexisting wounds to seawater. Because of the high morbidity and mortality associated with V. vulnificus infections, effective treatment includes preventive measures to educate high-risk individuals, early search for and recognition of the disease, aggressive antibiotic therapy, supportive care, and, in the case of wound infections, aggressive debridement. Review of this subject was prompted by a case of V. vulnificus primary septicemia and fulminant septic shock in a patient with the unusual presentation of pain in the lower extremities.

Analysis of risk factors for nosocomial infections—results from the first national prevalence survey in Germany (NIDEP study, part 1)

An analysis of risk factors for nosocomial infections (NI) was carried out using data from the first national prevalence survey on NI in Germany. Fourteen thousand, nine hundred and sixty-six patients, with a total of 543 NI, were included. Urinary tract infections (UTI), lower respiratory tract infections (LRTI), surgical site infections (SSI) and primary septicaemia (PS) were analysed. UTI were significantly associated with unconsciousness, age, prior operation, hospital size and female sex ( P < 0.1). LRTI were significantly associated with chronic airway disease, intensive care units, unconsciousness, polytrauma, prior operation, cardiovascular disease, malignancy and absence of infection on admission. The department, age, diabetes mellitus, male sex and hospital size were risk factors for SSI. The department, prior operation and unconsciousness were significantly associated with PS. An investigator effect was observed for LRTI and PS. Although no final conclusions from a risk factor analysis based on prevalence data can be drawn the results support stratification of NI for routine surveillance.

Vibrio Infections Associated with Raw Oyster Consumption in Florida, 1981–1994

While the problem of raw-oyster-associated Vibrio vulnificus infection is well known, less is known about other Vibrio infections associated with raw oyster consumption. Case reports of 333 patients with raw-oyster-associated infections with V. vulnificus and other Vibrio species reported in Florida from 1981 through 1994 were reviewed to define the epidemiology of these infections. The average annual incidence of raw-oyster-associated Vibrio infection was 10.1 per 1,000,000 raw oyster-consuming adults (95% confidence interval: 8.3 to 11.9). Infection resulted in gastroenteritis for 231 (69%) patients, of whom 97 (42%) were hospitalized for a mean length of stay of 4.9 days, and 2 (1%) died. Vibrio species most often identified in patients with gastroenteritis included V. parahaemolyticus (29%), V. cholerae non-Ol (28%), V. hollisae (15%), and V.mimicus (12%). The remaining 102 (31 %) patients with raw-oyster-associated Vibrio infections developed primary septicemia and 50 (49%) died. Primary septicemia resulted from infection with V. vulnificus (80%), v. parahaemolyticus (9%), V. cholerae non-O1 (8%), and V. hollisae (3%). Non-V. vulnificus species accounted for 72% of all raw-oyster-associated Vibrio infections, and differed from infections with V. vulnificus in their lack of a seasonal distribution and the absence of underlying medical conditions in infected patients. These findings emphasize that Vibrio species other than V. vulnificus are more commonly associated with raw oyster consumption, are capable of producing significant morbidity, and may not be controlled by measures such as seasonal marketing restrictions and targeted education of high-risk? consumers that have been proposed to prevent infection with V. vulnificus.

Cellular fatty acid profiles of ninety-five strains of Vibrio vulnificus isolated from clinical specimens in Korea.

There have been many reports of primary Vibrio vulnificus septicemia in Korea since 1987. This study was undertaken to determine the cellular fatty acid (CFA) compositions of 95 clinical strains of V. vulnificus isolated in Korea during 1985-1995. We compared these results with the CFA profile of V. vulnificus in the Microbial Identification System (MIS) (CLIN library version 3.9; Microbial ID Inc., Newark, DE, U.S.A.), and the grouping of V. vulnificus by CFA analysis was also performed. The relationship between groups and serotypes of V. vulnificus was described. Although most of the CFAs in V. vulnificus strains were similar to the CFA profile of V. vulnificus in the MIS, some distinctive differences were observed between the results of this study and the MIS CFA profile of V. vulnificus. First, the means of 2 major CFAs, 16 : 0 and 16 : 1w7c, were 22.16 and 18.26% in this study but 23.52 and 25.44% in the MIS, respectively. Second, all isolates had 11 : 0iso3OH, which was not present in the MIS. Of 95 strains, 10 strains (10.5%) showed 'NO MATCH' results by the MIS identification. Eighty five strains (89.5%) were identified as V. vulnificus by the MIS (the first choice identification), but they disclosed low SI values of <0.6 (not 'EXCELLENT MATCH') except 2 strains (2.1%). This showed that V. vulnificus strains isolated in Korea had different characteristics in CFA composition in comparison with the MIS V. vulnificus library. Nine groups comprising all the strains were obtained by cluster analysis and were further characterized by principal-component analysis. There was heterogeneity between the groups by CFA and serotypes of V. vulnificus. The same serovars were distributed into diverse groups.

The epidemiology of Vibrio infections in Florida, 1981-1993.

The epidemiology of 690 Vibrio infections reported in Florida during 1981-1993 is described. Most infections resulted in one of three clinical syndromes: gastroenteritis (51%), wound infections (24%), or primary septicemia (17%). Case-fatality rates were 1% for gastroenteritis, 5% for wound infections, and 44% for primary septicemia. While gastroenteritis had little seasonal variation, 91% of primary septicemias and 86% of wound infections occurred from April through October, mostly due to the seasonality of Vibrio vulnificus and Vibrio parahaemolyticus infections. Infected wounds were largely a result of occupational activities around seawater. Some 68% of gastroenteritis cases and 83% of the primary septicemias were associated with raw oyster consumption. Preexisting liver disease was present in 48% of patients with primary septicemia and was associated with a fatal outcome in both wound infections (relative risk [RR], 28.3; 95% confidence interval [CI], 6.3-127.5; P < .0001) and primary septicemia (RR, 1.9; 95% CI, 1.2-3.1; P < .01).

Primary Vibrio damsela Septicemia

Vibrio damsela has been reported to cause integument infections and death in damselfish and captive eels as well as wound and soft-tissue infections in humans [1]. Although most patients who have had V. damsela infection have survived, four fatal infections due to this organism have been described [2-5]. All of the previously reported cases in humans have involved wound infections associated with exposure to seawater or handling fish. We report a fatal case of primary V. damsela septicemia associated with the consumption of raw eels in a patient with underlying alcoholic liver disease and diabetes mellitus.

Vibrio cholerae non-O1 primary septicaemia following a large thermal burn

A case of primary septicaemia with a Vibrio cholerae not agglutinable with O group 1 sera is reported in a burn patient. This appears to be the first reported case of this organism causing infection in a burn patient. The case is discussed, highlighting the difficulties encountered in treating this unexpected organism and the course of the infection in this patient. It is probable that the organism was obtained during first aid for the burn wound.

Primary Septicemia Caused by Vibrio cholerae Non-O1 Acquired on Cape Cod, Massachusetts

We describe a patient with non-O1, non-O139 Vibrio cholerae septicemia associated with hemorrhagic bullous skin lesions of the lower extremities. The patient had underlying liver disease, and he probably acquired the organism through ingestion of raw clams. Although his condition rapidly improved during appropriate therapy, the patient's cellulitis and skin lesions persisted and he developed a fluid collection of the lower extremity that required drainage. Molecular methods were used to examine the non-O1 V. cholerae isolate for several known virulence factors of V. cholerae O1. The isolate failed to express cholera toxin and toxin-coregulated pilus (Tcp) and was negative in Southern hybridizations for ctxB, tcpA, toxR, and toxT. The vast majority of vibrio infections in the United States are clustered in the Gulf Coast area. This patient acquired the infection on Cape Cod. To our knowledge, this is the first case of non-O1 V. cholerae septicemia reported to have occurred in Massachusetts. Given the high fatality rate of this infection, it is important for physicians to consider this diagnosis in patients who have underlying risk factors and appropriate epidemiologic exposures, even when they reside as far north as the New England states.