Finger Necrotizing Fasciitis and Septicemia Caused by Vibrio vulnificus.

Background: Vibrio vulnificus infections develop rapidly and have high mortality and disability rates. Vibrio vulnificus can cause local wound infection, gastroenteritis, or septicemia. Case Presentation: In this case, an 86-year-old male was accidentally stabbed in the middle of his right thumb while cleaning whitewater fish and came to the emergency department with high fever and painful swelling of the right hand. Physical examination revealed hemorrhagic bullae in the right hand. Emergency surgery and bacterial culture were performed. Because of timely antibiotic use and surgical treatment, the patient eventually recovered and was discharged from the hospital. Conclusions: This case suggests that the possibility of Vibrio vulnificus should be considered in cases of severe infection of the extremities, even without a history of seafood consumption or seawater exposure. Early recognition, rational choice of antibiotic agents, and timely wound debridement can substantially improve the prognosis of patients and reduce mortality.

Early clinical manifestations of vibrio necrotising fasciitis.

We present five patients with vibrio necrotising fasciitis, a lethal and disabling disease. Two of these patients had a history of exposure to either warm seawater or raw/live seafood, three had underlying chronic liver disease, and four presented with hypotension and fever. There were three deaths and four patients required intensive care unit stays. Among the two survivors, one had high morbidity. Only one patient met the criteria of Laboratory Risk Indicator for Necrotising Fasciitis score > 6. A clinician should suspect possible vibrio necrotising fasciitis if the following are present: contact with fresh seafood/warm seawater, a known history of chronic liver disease and pain that is out of proportion to cutaneous signs. All patients must be managed via intensive care in high dependency units. We recommend a two-step surgical protocol for patient management involving an initial local debridement, followed by a second-stage radical debridement and skin grafting.

Vibrio vulnificus infection and liver cirrhosis: a potentially lethal combination.

We present a case of a 40-year-old man with decompensated alcoholic liver cirrhosis presenting with atraumatic cellulitis of one extremity and severe sepsis that rapidly progressed to compartment syndrome despite broad-spectrum antibiotics. Local cultures following debridement revealed Vibrio vulnificus, and subsequent history revealed consumption of raw oysters 48 h before presentation. Our case points out the unique susceptibility of those with cirrhosis and elevated iron saturation to Vibrio septicaemia, as well as the rapidity and severity of the disease progression.

Tigecycline salvage therapy for necrotizing fasciitis caused by Vibrio vulnificus: Case report in a child.

Necrotizing fasciitis caused by Vibrio vulnificus is rarely reported in children. We describe a 12-year-old immunocompetent boy with necrotizing fasciitis caused by V. vulnificus. He was cured by radical and serial debridement and salvage therapy with intravenous cefpirome plus tigecycline. The in vitro antibacterial activity of combination regimens and a literature review of pediatric V. vulnificus infection are described.

Temporizing surgical management improves outcome in patients with Vibrio necrotizing fasciitis complicated with septic shock on admission.

BACKGROUND: Necrotizing fasciitis (NF) caused by Vibrio infection is one of the most fatal diseases, resulting in high morbidity and mortality. Early diagnosis and effective surgical intervention are the mainstays for better outcomes for affected patients. Currently, standard surgical management calls for prompt and aggressive debridement and amputation. However, due to its rapid progression and deterioration, 50-60% of Vibrio NF cases present with septic shock and multiple organ dysfunction on admission. These patients, who usually have many surgical contraindications, are unable to tolerate a prolonged aggressive surgical debridement. Therefore, determining the optimal surgical intervention for these particularly severe patients remains a formidable problem in emergency medicine. METHODS: A retrospective study was conducted on patients who underwent surgery for Vibrio NF and septic shock on admission to the emergency room from April 2001 to October 2012. These patients received the same treatment protocol, with the exception of the initial surgical intervention strategy. Nineteen patients were treated with a temporizing strategy, which called for simple incisions and drainage under regional anesthesia, followed by complete debridement 24h later. Another fifteen patients underwent aggressive surgical debridement during the first operative procedure. Basic demographics, laboratory results on admission, clinical course and outcomes were compared to assess the efficacy and safety of two initial surgical treatment methods: the temporizing strategy and the aggressive strategy. RESULTS: Thirty-four patients were included in this study, and the average age was 51.65 years. Chronic liver disease was the most prevalent preexisting condition (50.00%) and the lower limbs were most commonly involved in infection (76.47%). In this patient population, 19 cases underwent surgery with a temporizing therapeutic strategy, while the remaining 15 cases were treated with an aggressive surgical strategy. There were no differences between the two groups with respect to demographics, severity of illness and laboratory data. Compared with those treated with the aggressive strategy, patients treated with the temporizing strategy had shorter operation time (40.79 ± 16.61 vs. 102.00 ± 18.97 min, p<0.001), less bleeding (120.53 ± 67.20 vs. 417.33 ± 134.72 mL, p<0.001), a reduced amount of intraoperatively administrated fluid (3144.70 ± 554.71 vs. 1637.40 ± 302.11 mL, p<0.001), decreased maximum dose of dopamine (15.73 ± 5.64 vs. 10.47 ± 5.61 µg/kg/min, p=0.011) and noradrenaline (20.13 ± 7.50 vs. 13.37 ± 6.18 µg/kg/min, p=0.007), lower arterial lactate values at the end of surgery (5.56±1.99 vs. 8.66 ± 3.25 mmol/L, p=0.004), and, most importantly, lower mortality (26.32% vs. 60.00%, p=0.048). All other treatment conditions, such as duration of vasopressor therapy, number of debridement procedures, rate of amputation, ICU length of stay and hospital length of stay, were the same for both groups. CONCLUSION: The temporizing strategy, with early initiation of simple incisions and drainage under regional anesthesia followed by complete debridement 24h later, is more feasible and effective for patients with Vibrio NF complicated with septic shock, as compared with the aggressive surgical debridement strategy.

Impact of timing of surgery on outcome of Vibrio vulnificus-related necrotizing fasciitis.

BACKGROUND: The aim of this study was to evaluate the impact of timing of surgery on mortality risk in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus infection. METHODS: Medical records of 121 patients (mean age, 65.2 ± 11.6 years) with V vulnificus-related NF who underwent surgical intervention between July 1998 and June 2011 were collected and reviewed retrospectively. These patients were divided into 3 groups according to the time between admission and surgical treatment as follows: those who received surgical treatment less than 12 hours after admission, those who received treatment 12 to 24 hours after admission, and those who received treatment more than 24 hours after admission. Cox regression analysis was performed to assess the effect of the timing of surgery after admission on mortality risk across the 3 groups by adjusting for potential confounding covariates. RESULTS: During their hospitalization, 35 patients died, yielding a case-fatality rate of 29%. After adjustment for potential confounding covariates (age, sex, duration of prodrome before admission, severity of illness on admission, the presence of primary septicemia, hepatic disorders, chronic renal insufficiency, blood pressure less than 90/60 mm Hg on admission, surgical and antibiotic modalities, and intensive care needed), patients who underwent surgery less than 12 hours after admission had a significantly lower mortality risk compared with those who had surgery either 12 to 24 hours after admission (adjusted hazard ratio [HR], .064; 95% confidence interval [CI], 1.6 × 10⁻7 to .25; P = .037) or more than 24 hours after admission (adjusted HR, .0043; 95% CI, 2.1 × 10⁻5 to .0085; P = .002). There was no difference in mortality risk between patients who underwent surgery 12 to 24 hours after admission and those who had surgery more than 24 hours after admission (P = .849). CONCLUSIONS: Our data provide important clinically based evidence for the beneficial effects of surgical treatment within 12 hours of admission for V vulnificus-related NF.

Antibiotic therapy for necrotizing fasciitis caused by Vibrio vulnificus: retrospective analysis of an 8 year period.

OBJECTIVES: To compare the effectiveness of a third-generation cephalosporin alone, a third-generation cephalosporin plus minocycline, and a fluoroquinolone in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus. METHODS: A retrospective review of case notes was performed for 89 patients who presented with NF caused by V. vulnificus and underwent surgical intervention within 24 h of admission between 2003 and 2010. Data on comorbidities, clinical manifestations, laboratory studies, treatments and outcomes were extracted for analysis. These patients were grouped according to the antimicrobials prescribed: those who received only a third-generation cephalosporin (Group 1; n = 18); a third-generation cephalosporin plus minocycline (Group 2; n = 49); or a fluoroquinolone with/without minocycline (Group 3; n = 22). RESULTS: The mean age of the 89 patients included in the study was 64.0 ± 12.0 years (range 33-89 years); 55% of the patients were male. There were no differences in age, sex or clinical characteristics among the three groups except that patients in Group 3 had a higher frequency of underlying chronic renal insufficiency than those in Groups 1 and 2 (P = 0.009). Groups 2 and 3 each had a significantly lower case fatality rate than Group 1 (61% in Group 1 versus 14% in Group 2, P = 0.0003; 61% in Group 1 versus 14% in Group 3, P = 0.0027), while no difference in case fatality rate was noted between Groups 2 and 3. CONCLUSIONS: Our data suggested that, in addition to primary surgery, fluoroquinolones or third-generation cephalosporins plus minocycline are the best option for antibiotic treatment of NF caused by V. vulnificus.

Surgical treatment of 19 cases with vibrio necrotising fasciitis.

BACKGROUND: Necrotising fasciitis and sepsis caused by the infection of vibrio is a rare but dangerous clinical emergency, with a mortality of 50-100%. Early diagnosis and surgical treatment may improve the prognosis significantly. However, valid emergency operation indications are scarce and need to be explored, which will be helpful for the early recognition and selection of operational procedures in patients with vibrio necrotising fasciitis. METHODS: We retrospectively analysed the patients with vibrio necrotising fasciitis admitted to the emergency department of our hospital from July 2000 to June 2009. The surgical treatment strategy was summarised in order to provide clinical evidence for surgical treatment of vibrio necrotising fasciitis. RESULTS: A total of 19 cases of vibrio necrotising fasciitis were selected in our study. All the patients were living along the coast, and 68.4% had a history of chronic liver disease, 78.9% had a history of ethanol abuse, 52.6% had fever, 89.5% were complicated with septic shock and 31.6% progressed to multiple-organ dysfunction syndrome. Rapidly progressive local swelling and pain as well as skin superficial venous stasis were the early presentations of vibrio necrotising fasciitis, while skin ecchymosis, blisters or blood blisters, necrosis and subcutaneous crepitation were the presentations of the advanced stage. Seventeen patients received emergency incision and drainage, subcutaneous vein thrombosis, subcutaneous tissue necrosis, muscle and full-thickness necrosis observed in the operation, and necrotising fasciitis was confirmed by exploration or pathologic examination. Selective debridement and skin graft was performed to repair the wound after operation, and amputation was performed on two patients to close the wound. The average length of stay was 21.3 days (1-82 days), and eight patients died, with mortality being 42.1%. CONCLUSION: Rapidly progressive local damage and acute deterioration of the patients are the most distinctive clinical manifestations of vibrio necrotising fasciitis. Recognition of the signs of local skin and tissue damage in early stage is crucial for early diagnosis and surgical intervention. Emergency incision and drainage, combined with selective debridement and skin graft, could improve the prognosis of the patients, and preserve the integrity of the patient's limbs as much as possible.

Laboratory indicators for early detection and surgical treatment of vibrio necrotizing fasciitis.

BACKGROUND: Vibrio necrotizing fasciitis is a rare and life-threatening soft tissue infection, with fulminant clinical courses and high mortality rates. However, the lack of specific disease characteristics and diagnostic tools during the initial examination may delay diagnosis. QUESTIONS/PURPOSES: We (1) asked whether the clinical indicators could predict laboratory findings during the initial stage of Vibrio necrotizing fasciitis and (2) determined the relationships between the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and the diagnosis of Vibrio infection. METHODS: We retrospectively reviewed 70 patients with 71 episodes of Vibrio necrotizing fasciitis and sepsis. Of the 70 patients, 68 had a history of contact with seawater or raw seafood; 66 had underlying chronic diseases. RESULTS: Eighteen patients (25.7%) died a mean 18.7 days after admission, and 52 patients survived. A systolic blood pressure of 90 mm Hg or less at the time of admission to the emergency room was associated with mortality. Patients who died had lower leukocyte counts, segmented leukocyte counts, platelet counts, and serum albumin levels compared with the patients who survived and higher counts of band forms of leukocytes. Only eight patients (11%) who survived had a LRINEC score of 6 or greater. CONCLUSIONS: The LRINEC scoring system is not applicable when treating such a highly lethal disease. We propose that severe hypoalbuminemia, severe thrombocytopenia, and increased banded forms of leukocytes are laboratory risk indicators of necrotizing fasciitis that aid in pointing toward initiation of early surgery and predict a higher risk of death. LEVEL OF EVIDENCE: Level III Prognostic study. See the Guidelines for Authors for complete descriptions of levels of evidence.

Necrotizing soft-tissue infections and primary sepsis caused by Vibrio vulnificus and Vibrio cholerae non-O1.

BACKGROUND: Vibrio species are a rare cause of necrotizing soft-tissue infections and primary septicemia, which are likely to occur in patients with hepatic disease, diabetes, adrenal insufficiency, and immunocompromised conditions. These organisms thrive in warm seawater and are often present in raw oysters, shellfish, and other seafood. This study examined fulminating clinical characteristics of Vibrio vulnificus and Vibrio cholerae non-O1 soft-tissue infections and identified outcome predictors. MATERIALS: Thirty patients with necrotizing fasciitis and sepsis caused by Vibrio species were retrospectively reviewed. Twenty-eight patients had a history of contact with seawater or raw seafood. Eight patients had hepatic disease such as hepatitis or liver cirrhosis, and seven patients had diabetes mellitus. Nine patients had hepatic dysfunction combined with diabetes mellitus. Microbiology laboratory culture studies confirmed V. vulnificus in 23 patients and V. cholerae non-O1 in seven patients. RESULTS: Surgical debridement or immediate limb amputation was initially performed in all patients with necrotizing soft-tissue infections. Eleven patients (37%) died within several days of admission and 19 survived. The mortality of V. cholerae non-O1 group (57%) is higher than that of the V. vulnificus group (30%). A significantly higher mortality rate was noted in patients with initial presentations of a systolic blood pressure of < or =90 mm Hg, leukopenia, decreased platelet counts, and a combination of hepatic dysfunction and diabetes mellitus. CONCLUSIONS: Vibrio necrotizing soft-tissue infections should be suspected in patients with appropriate clinical findings and history of contact with seawater or seafood. V. cholerae non-O1 may cause bacteremia more often than V. vulnificus in patients with liver cirrhosis. Early fasciotomy and culture-directed antimicrobial therapy are aggressively recommended in patients with hypotensive shock, leukopenia, high band forms of white blood cells, decreased platelet counts, severe hypoalbuminemia, and underlying chronic illness, such as hepatic dysfunction and diabetes mellitus.

Mycotic abdominal aortic aneurysm infected by Vibrio mimicus: report of a case.

This report describes a case of a mycotic aneurysm of the infrarenal abdominal aorta infected by Vibrio mimicus, which is the only such case ever reported in the literature. The 80-year-old male patient was first treated for gastroenteritis for 7 days. Two months later, he was admitted to the hospital and the aneurysm was diagnosed by three-dimensional computed tomography. The aneurysm was excised and the restoration was done using a 16-mm Dacron straight graft. The cultivation of the excised aneurysm and the inflammatory fluid was positive for V. mimicus. The postoperative period was free of complications and the patient has remained asymptomatic during the 4-year follow-up.

Vibrio necrotizing soft-tissue infection of the upper extremity: factors predictive of amputation and death.

BACKGROUND: Vibrio necrotizing soft-tissue infection (VNSTI) is characterized by rapidly progressing soft-tissue necrosis and fulminant septicemia in the at-risk host. Despite advancing antibiotic and infection control practices, VNSTI is still a highly lethal and disabling disease. By evaluating prognostic factors for fatality and major amputation in VNSTI patients, this study was intended to improve treatment strategies, reduce mortality and minimize amputations. METHODS: We performed a cohort study of patients with VNSTI in the upper extremity at a trauma center which cares for residents in the costal southern Taiwan. Patients were considered for enrollment in this study if they met the following criteria: (1) histopathologically or surgically proven necrotizing soft-tissue infections of the upper extremities and (2) isolation of Vibrio species from soft-tissue lesions and/or blood collected immediately after arrival at emergency department. All patients were treated with a specified combination of parenteral antibiotic therapy (the combination of a third-generation cephalosporin and tetracycline), aggressive resuscitation and prompt débridement. The main outcome measures in this investigation included inpatient mortality and major amputation. RESULTS: Sixteen patients were enrolled in the 5-year study from July 2002 to June, 2007. The overall mortality rate in this case series was 18.6%. Another 25% of surviving patients required major amputations. These subjects were, then, divided into two groups based on treatment outcome: unsatisfactory (death and major amputation) and satisfactory (survival without major amputation). The two patient groups did not differ in demographic data, treatment protocol, bacteriological findings or APACHE II and LRINEC scores. Patients with unsatisfactory results had a higher incidence of septic shock requiring vasopressor/inotropic support (p=0.020), severe hypoalbuminemia with less than 2g/dL (p=0.001) and elevated AST (p=0.039) than those with satisfactory results. The former also had longer ICU stay (p=0.039) and a higher incidence of comorbidity during hospitalization (p=0.024). CONCLUSION: APACHE II or LRINEC scoring system cannot be used as a reliable tool for early detection of VNSTI. For treating such a highly lethal and disabling disease, clinical acumen remains of paramount importance regardless of the scores. Expanding purpura in these patients is considered an ominous sign and may indicate surgical intervention. A serial survey of ALT/AST or CPK levels can reflect the extent of muscle damage and help determine the optimal time of amputation. Severe hypoalbuminemia also serve as poor prognostic factors implicating a high probability of death or major amputation.

Lower extremity infections by vibrio vulnificus.

BACKGROUND: Vibrio vulnificus is a Gram-negative pathogen which is found in seawater and shellfish during warm months and can cause local infections in healthy individuals or septicemia in patients with chronic liver disease. MATERIALS-METHODS: Clinical and laboratory records of four complicated cases are presented, with a 4.2 mean year follow-up. RESULTS: Three patients underwent urgent leg amputation because of of irreversible necrotic changes with septic complications and failure of incisional drainage to control the infection. Another one patient underwent only excision of necrotic soft tissue but he developed calcaneus osteomyelitis after three years of the initial fish bone injury. DISCUSSION: Clinicians must maintain a high index of suspicion, especially in regions endemic for vibrio necrotising fasciitis and antibiotic prophylaxis must be given to swimmers before or during bathing.