Approach
Treatment of sepsis or severe systemic infection caused by non-cholera vibrios consists of intravenous antibiotics (i.e., a third-generation cephalosporin plus a tetracycline, or a third-generation cephalosporin plus ciprofloxacin). Sepsis has a high mortality, and therapy for Vibrio infection must be included in the empiric antibiotic regimen pending blood culture confirmation.[35] Patients with necrotizing skin/soft-tissue infection also require early aggressive debridement of devitalized tissue. In patients with necrotizing fasciitis, surgical intervention within the first 12 hours of admission has been shown to significantly reduce the risk of death.[45] Patients presenting with localized, non-necrotizing skin/soft-tissue wound infections alone can be managed in the outpatient setting with oral antibiotics. Gastroenteritis syndromes are treated with rehydration. Oral antibiotics are indicated if diarrhea persists >5 days.
Sepsis or severe systemic infection
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is defined as a subset of sepsis with circulatory and cellular or metabolic dysfunction associated with a higher risk of mortality.[35]
Vibrio vulnificus can rapidly produce fatal septic shock in immunocompromised patients or those with underlying liver disease. It is the organism most commonly associated with severe disease and/or death.[11][46] In patients with alcoholism or cirrhosis, Vibrio parahaemolyticus may cause sepsis with a mortality of 29%.[47] Patients with sepsis should be managed in an intensive care setting. Optimal patient survival depends on early goal-directed resuscitation and early institution of broad-spectrum antibiotic therapy.[35] For further information on the management of sepsis, please see Sepsis in adults.
One treatment option is combination intravenous antibiotic therapy with a third-generation cephalosporin (e.g., ceftazidime, ceftriaxone) plus a tetracycline (e.g., doxycycline, minocycline).[48] In a retrospective study over 8 years, which examined risk factors for fatality among patients with V vulnificus septicaemia, combination treatment with a third-generation cephalosporin plus a tetracycline was an independent predictor for lower mortality.[43]
Another option is combination intravenous antibiotic therapy with a third-generation cephalosporin plus ciprofloxacin.
A 2019 retrospective study of patients with V vulnificus septicemia supports combination therapy with a third-generation cephalosporin. This study of 218 patients with Vibrio vulnificus septicemia, over a 26 year period, reported an overall 30-day survival of 39%. Survival in the monotherapy group receiving a third-generation cephalosporin alone (35%) or ciprofloxacin alone (29%) was lower than in the groups receiving a third-generation cephalosporin plus doxycycline (38%) or a third-generation cephalosporin plus ciprofloxacin (54%). In a subgroup of 81 patients subject to a propensity score matched analysis, there was no statistically significant difference in 30-day survival between the groups receiving a third-generation cephalosporin plus doxycycline (50%) and those receiving a third-generation cephalosporin plus ciprofloxacin (67%).[49]
Therefore, treatment for V vulnificus septicemia is with a third-generation cephalosporin plus either a tetracycline or ciprofloxacin.[43][48][49] Antibiotic monotherapy is not recommended.
Fluoroquinolones are associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[50][51] The Food and Drug Administration (FDA) has also issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[52][53]
Duration of therapy should be individualized, but a minimum of 10-14 days would be expected. The onset of septic shock and delay in initiating antibiotic therapy with Vibrioactivity results in marked increases in fatality rates.[43] Antibiotic therapy should be reassessed with microbiology and clinical data to narrow coverage when appropriate.[35]
In patients with concurrent necrotizing skin/soft-tissue infection, surgical management is essential to improve survival outcomes and shorten intensive care unit and hospital stay. This is accomplished through early aggressive debridement of devitalized tissue.[45][54][55][56][57] In one study, initial temporizing surgery consisting of incision, drainage, and irrigation of infected sites under regional anesthesia with aggressive surgery 24 hours later had lower mortality (26%) versus initial aggressive surgery under general anesthesia (60%). This was felt to be explained by the temporized surgery group being physiologically stabilized prior to general anesthesia.[58]
Localized skin/soft-tissue infection
Mild cellulitis resulting from a local inoculation injury in an otherwise healthy host can be managed in the outpatient setting with oral doxycycline with or without an oral newer-generation fluoroquinolone.
Patients might present with necrotizing skin/soft-tissue infection alone. This should be managed in the hospital with intravenous antimicrobial therapy and surgical assistance (i.e., early aggressive debridement of devitalized tissue).
One retrospective study of antibiotic therapy for necrotizing fasciitis caused by V vulnificus reported that, in patients receiving prompt surgical intervention, ceftazidime plus minocycline, or ciprofloxacin alone, resulted in statistically better survival than ceftazidime alone.[59]
For wound infections, the US Centers for Disease Control and Prevention recommends antibiotic therapy with a third-generation cephalosporin plus doxycycline.[38] Alternative regimens are a third-generation cephalosporin plus a fluoroquinolone, or monotherapy with a fluoroquinolone.[38]
Gastroenteritis syndromes
V parahaemolyticus most commonly causes a self-limiting gastrointestinal illness, lasting 2-3 days. Therapy is limited to rehydration. There is no clear role for antibiotic treatment in mild to moderate diarrhea.[48] For more severe persistent diarrhea of >5 days, it is suggested without published clinical data that a course of oral doxycycline for 5-7 days or an oral fluoroquinolone for 3 days may be effective.[48]
Superficial inoculation infections
There are no standard recommendations for the management of otitis externa caused by Vibrio alginolyticus. Therapy should be based on the isolate's antimicrobial susceptibility. Data regarding the therapeutic management of Vibrio ocular infections are limited to remote anecdotal reports.[42] Referral to an ophthalmologist is recommended.
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