FLESH-EATING BACTERIA: VIBRIO VULNIFICUS & NECROTIZING FASCIITIS

Recently we have been hearing news about the “flesh eating bacteria”, creating a panic in our community. While the existence of this bacterium is real, it would be important to know more details about the bacteria that are affecting the Florida coastal area of the Gulf of Mexico and the bacteria commonly known as "flesh-eating bacteria" which produce what is medically known as "necrotizing fasciitis".

VIBRIO VULNIFICUS:

The first documented case of a disease caused by the Vibrio Vulnificus was in 1979, it is a gram-negative bacillus that only affects humans and other primates, and is usually found in warm, shallow, coastal salt water in temperate climates throughout most of the world (Schwartz, 2012).

Vibrio Vulnificus is a bacterium in the same family as those that cause cholera, the Vibrionaceae family that includes the genera Vibrio, Plesiomonas, and Aeromonas. As we mentioned before, they are natural inhabitants of sea water but they can also be found in fresh water, and they are part of the group of vibrios that known as halophilic because they require salt for growth (Ho, 2011).

These bacteria can cause disease in those who eat contaminated seafood or have an open wound that is exposed to seawater. Among healthy people, ingestion of Vibrio Vulnificus can cause vomiting, diarrhea, and abdominal pain. In immuno-compromised persons, particularly those with chronic liver disease, it can infect the bloodstream, causing a severe and life-threatening illness characterized by fever and chills, decreased blood pressure, and blistering skin lesions. 50 % of the time the bloodstream infection of Vibrio Vulnificus can be fatal (CDC, 2013).

Vibrio Vulnificus, according to Centers for Disease Control and Prevention (2013), can cause an infection of the skin when open wounds are exposed to warm seawater; these infections may lead to skin breakdown and ulceration. Persons who are immuno-compromised are at higher risk for invasion of the organism into the bloodstream and potentially fatal complications.

Antibiotics are necessary to eradicate the infection because it improves survival. In case of wound infection, aggressive debridement is useful to remove necrotic tissue, amputation of the infected limb is sometimes necessary. Also in patients with shock, resuscitate interventions should be performed (Schwartz, 2012).

The CDC recommends:

ü Culture of wound or hemorrhagic bullae, all V. Vulnificus isolates should be forwarded to a public health laboratory.

ü Blood cultures are recommended if the patient is febrile, has hemorrhagic bullae, or has any signs of sepsis.

ü Antibiotic therapy:

·        Doxycycline (100 mg PO/IV twice a day for 7-14 days) and a third-generation cephalosporin (e.g. ceftazidime 1-2 g IV/IM every eight hours) are generally recommended.

·        A single agent regimen with a fluoroquinolone such as Levofloxacin, Ciprofloxacin or Gatifloxacin, has been reported to be at least as effective in animal model as combination drug regimens with Doxycycline and a Cephalosporin.

·        Children, in whom Doxycycline and Fluoroquinolones are contraindicated, can be treated with Trimethoprim-Sulfamethoxazole plus an Aminoglycoside.

·        Necrotic tissue should be debrided; severe cases may require fasciotomy or limb amputation.

 

V. Vulnificus septicemia is the most common cause of death from seafood consumption in the United Stated (Haq & Dayal, 2005).

Choi, et al., reported in 2005 that the first evidence of V. Vulnificus septicemia was in the skin as purpura fulminans, which can take a catastrophic course without inmediate and intensive empirical antibiotic treatment. Furthermore V. Vulnificus infection may be a rare cause of necrotizing fasciitis, but it can be fatal (Tajiri, et al., 2008).

NECROTIZING FASCIITIS:

Necrotizing Fasciitis, first discribed by Joseph Jones, a Conferate Army surgeon, during the US Civil War, is a serious bacterial infection that spreads rapidly and destroys the body’s soft tissue (Quirk & Sternbach, 1996). It is considered a life-threatening disease that is often difficult but crucial to diagnose as soon as possible in order to save a life (Swain, Hatcher, Azadian, Soni, & De Souza, 2013).

Commonly called a “flesh-eating infection”, Necrotizing Fasciitis is a rare disease with a rapidly progressive inflammatory infection of the facia and a secondary necrosis of the subcutaneous tissue.

The causative bacteria, as mentioned by Richard E Edlich (2013), may be aerobic, anaerobic, or mixed flora (Kihiczak, Schwartz, & Kapila, 2006). There are a few recognized distinct syndromes of this entity where the most important are:

·        Type I, or polymicrobial

·        Type II, or group A streptococcal

·        Type III gas gangrene, or Clostridial Myonecrosis

There are a variety of organisms capable to causing Necrotizing Fasciitis; these include group A Streptococcus, Klebsiella, Clostridium, E. Coli, Staphylococcus aureus, and Aeromonas hydrophila, among others (CDC, 2013). A variant of Necrotizing Fasciitis type I is a saltwater necrotizing fasciitis, in which an apparently minor skin wound is contaminated with saltwater containing a Vibrio species (Edlich, 2013).

In many cases of Necrotizing Fasciitis, antecedent trauma or surgery can be identified; the initial lesion is often trivial, such as an insect bite, minor abrasion, boil, or injection site. The hallmark symptom is intense pain and tenderness over the involved skin and underlying muscle (Olafsson, Zeni, & Wilkes, 2005). But also the symptoms may begin at a site distant from the initial traumatic insult.

Most people who get Necrotizing Fasciitis have other health problems that may lower their body’s ability to fight infection such as diabetes, kidney disease, cancer, or other chronic health conditions that weaken the immune system.

Beginning an immediate treatment is essential in Necrotizing Fasciitis once the diagnose is confirmed. Antibiotic therapy is a key consideration, including a combination of penicillin G and an Aminoglycoside, as well as Clindamycin. Keep in mind that Necrotizing fasciitis is a surgical emergency and the patient should be admitted immediately to a surgical intensive care unit, where the surgical staff is skilled in performing extensive debridement and reconstructive surgery (Edlich, 2013).

If you are healthy, have a strong immune system, and practice good hygiene and proper wound care, your chances of getting Necrotizing Fasciitis are extremely low, explains m the CDC.

 

Bibliography

 

CDC. (2013, Jun 28). cdc.gov. Retrieved from Necrotizing Fasciitis: A rare disease, especially for the healthy: http://www.cdc.gov/features/NecrotizingFasciitis/

CDC. (2013, Oct 21). Centers for Disease Control and Prevention. Retrieved from Vibrio Illness: http://www.cdc.gov/vibrio/vibriov.html

Choi, H., Lee, D., Lee, M., Choi, M., Moon, K., & Koh, J. (2005). Vibrio Vulnificus septicemia presenting as purpura fulminans. J Dermatol, ;32(1):48-51.

Edlich, R. F. (2013, Apr 29). medscape.com. Retrieved from Necrotizing Fasciitis: http://emedicine.medscape.com/article/2051157-overview#a0101

Haq, S., & Dayal, H. (2005). Chronic Liver diseaseand consumtion of raw oysters: a potentially lethal combination--a review of Vibrio vulnificus septicemia. Am J Gastroenterol, ;100(5):1195-9.

Ho, H. (2011, Aug 15). medscape.com. Retrieved from Vibrio Infection: http://emedicine.medscape.com/article/232038-overview#a0104

Kihiczak, G., Schwartz, R., & Kapila, R. (2006). Necrotizing Fasciitis: a deadly infection. J Eur Acad Dermatol Venereol, ;20(4):365-9.

Olafsson, E., Zeni, T., & Wilkes, D. (2005). A 46 year old man with excruciating shoulder pain. Chest, ;127(3):1039-44.

Quirk, W., & Sternbach, G. (1996). Joseph Jones: infection with flesh eating bacteria. J Emerg Med, ;14(6):747-53.

Schwartz, R. A. (2012, Sep 17). medscape.com. Retrieved from Vibrio Vulnificus Infection: http://emedicine.medscape.com/article/1055523-overview

Swain, R., Hatcher, J., Azadian, B., Soni, N., & De Souza, B. (2013). A five-year review of necrotizing fasciitis in a tertiary referral unit. Ann R Coll Surg Engl, ;95(1):57-60.

Tajiri, T., Tate, G., Akita, H., Ohike, N., Masunaga, A., Kunimura, T., . . . Morohoshi, T. (2008). Autopsy cases of fulminant-type bacterial infection with necrotizing fasciitis: group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection. Pathol Int, ;58(3):196-202.