[Vibrio vulnificus, an increasing threat of sepsis in Germany?]

First Steps towards a near Real-Time Modelling System of Vibrio vulnificus in the Baltic Sea

Over the last two decades, Vibrio vulnificus infections have emerged as an increasingly serious public health threat along the German Baltic coast. To manage related risks, near real-time (NRT) modelling of V. vulnificus quantities has often been proposed. Such models require spatially explicit input data, for example, from remote sensing or numerical model products. We tested if data from a hydrodynamic, a meteorological, and a biogeochemical model are suitable as input for an NRT model system by coupling it with field samples and assessing the models' ability to capture known ecological parameters of V. vulnificus. We also identify the most important predictors for V. vulnificus in the Baltic Sea by leveraging the St. Nicolas House Analysis. Using a 27-year time series of sea surface temperature, we have investigated trends of V. vulnificus season length, which pinpoint hotspots mainly in the east of our study region. Our results underline the importance of water temperature and salinity on V. vulnificus abundance but also highlight the potential of air temperature, oxygen, and precipitation to serve as predictors in a statistical model, albeit their relationship with V. vulnificus may not be causal. The evaluated models cannot be used in an NRT model system due to data availability constraints, but promising alternatives are presented. The results provide a valuable basis for a future NRT model for V. vulnificus in the Baltic Sea.

[Climate change and (surgical) health in context]

BACKGROUND

The impacts of the climate crisis will result in a health crisis in addition to loss of habitats and increasing supply uncertainty. In this context, the health sector and especially surgery are relevant emitters of greenhouse gases, thus contributing to the magnitude of the climate crisis. Many reviews regarding the impacts on human health are available; however, a view from the surgical perspective has so far been underrepresented.

MATERIAL AND METHODS

This narrative review summarizes the relevance of climate-related changes for the surgical disciplines based on a literature search.

RESULTS

Immediate impacts are expected by the increasing number of extreme weather events, e.g., floods, droughts and wildfires. In these settings, surgery is a part of the disaster medicine chain but simultaneously the functionality of surgical departments can be impaired or even break down when they are themselves affected by extreme weather events. Heat waves cause an increase in surgical site infections, which may lead to postponement of elective surgery for patients at high risk. Collateral impacts are mirrored by an increase in the incidence of lung and skin cancers, which often need surgical treatment within a multidisciplinary setting. Additionally, there are indirect impacts that are of a very different nature, e.g., inadequate diet which leads to further deterioration of the greenhouse gas footprint of the health sector due to the necessity of bariatric surgical capacities.

CONCLUSION

The climate crisis represents a major challenge in surgery and all other medical disciplines. At the same time is it indispensable that the health sector and therefore surgery, take steps towards a zero emission pathway.

Prevalence and Distribution of Potentially Human Pathogenic Vibrio spp. on German North and Baltic Sea Coasts

Global ocean warming results in an increase of infectious diseases including an elevated emergence of Vibrio spp. in Northern Europe. The European Centre for Disease Prevention and Control reported annual periods of high to very high risks of infection with Vibrio spp. during summer months along the North Sea and Baltic Sea coasts. Based on those facts, the risk of Vibrio infections associated with recreational bathing in European coastal waters increases. To obtain an overview of the seasonal and spatial distribution of potentially human pathogenic Vibrio spp. at German coasts, this study monitored V. cholerae, V. parahaemolyticus, and V. vulnificus at seven recreational bathing areas from 2017 to 2018, including the heat wave event in summer 2018. The study shows that all three Vibrio species occurred in water and sediment samples at all sampling sites. Temperature was shown to be the main driving factor of Vibrio abundance, whereas Vibrio community composition was mainly modulated by salinity. A species-specific rapid increase was observed at water temperatures above 10°C, reaching the highest detection numbers during the heat wave event with abundances of 4.5 log10 CFU+1/100 ml of seawater and 6.5 log10 CFU+1/100 g of sediment. Due to salinity, the dominant Vibrio species found in North Sea samples was V. parahaemolyticus, whereas V. vulnificus was predominantly detected in Baltic Sea samples. Most detections of V. cholerae were associated with estuarine samples from both seas. Vibrio spp. concentrations in sediments were up to three log higher compared to water samples, indicating that sediments are an important habitat for Vibrio spp. to persist in the environment. Antibiotic resistances were found against beta-lactam antibiotics (ampicillin 31%, cefazolin 36%, and oxacillin and penicillin 100%) and trimethoprim-sulfamethoxazole (45%). Moreover, isolates harboring pathogenicity-associated genes such as trh for V. parahaemolyticus as well as vcg, cap/wcv, and the 16S rRNA-type B variant for V. vulnificus were detected. All sampled V. cholerae isolates were identified as non-toxigenic non-O1/non-O139 serotypes. To sum up, increasing water temperatures at German North Sea and Baltic Sea coasts provoke elevated Vibrio numbers and encourage human recreational water activities, resulting in increased exposure rates. Owing to a moderate Baltic Sea salinity, the risk of V. vulnificus infections is of particular concern.

"The Baltic Sea Germ": A Case Report of Necrotizing Fasciitis following Vibrio vulnificus Infection

Reported is an 80-year-old patient with septic shock from necrotizing fasciitis secondary to a Vibrio vulnificus (Vv) infection. The patient reports having been swimming in the Baltic Sea after a minor trauma to the left leg. Emergency superficial necrosectomy followed by intensive medical therapy was performed. Antibiotic therapy was initiated with a third-generation cephalosporin and a tetracycline. Vv was detected in the intraoperative microbiological smears. Instead of a leg amputation and a flap, due to the patient's age, a split skin covering to consolidate the wound was performed. Vv is a gram-negative rod bacterium of the genus Vibrio. Vv occurs in warm, low-salinity seawater (brackish water). In Germany, Vv occurs primarily in river mouths of the low-salinity Baltic Sea. Infections by Vv can occur through open wounds or by eating raw infected seafood, especially oysters. Infection via wounds often take a fulminant lethal course. Patients with chronic diseases, weakened immune system, and open wounds are particularly at risk. Infections with Vv are rare, but occur worldwide. Global warming is expected to spread Vv as water temperature increases and the dilution effect of sea level rise further decreases ocean salinity, and natural disasters promote the spread of Vv.

Case Report: Vibrio fluvialis isolated from a wound infection after a piercing trauma in the Baltic Sea

Vibrio spp. are Gram-negative bacteria found in marine ecosystems. Non-cholera Vibrio spp. can cause gastrointestinal infections and can also lead to wound infections through exposure to contaminated seawater. Vibrio infections are increasingly documented from the Baltic Sea due to extended warm weather periods. We describe the first isolation of Vibrio fluvialis from a wound infection acquired by an impalement injury in the shallow waters of the Baltic Sea. The severe infection required amputation of the third toe. Whole genome sequencing of the isolate was performed and revealed a genome consisting of two circular chromosomes with a size of 1.57 and 3.24 Mb.

Septic Shock Induced by Vibrio Vulnificus in Northern Poland, a Case Report

INTRODUCTION

Vibrio vulnificus infections are a growing problem worldwide. In recent years, infections with this bacteria have been reported in Central Europe, especially in the German Baltic coast but also in France and Italy. Climate warming causes the sea temperature to increase every year, which translates to an increased risk of infections from the Vibrio group. Most of these are mild and present as wound infections, but some patients develop life-threatening sepsis from either ingestion of infected mollusks or wound lesions that develop into generalized infections. Illness may be associated with necrotizing fasciitis and may require several weeks of therapy, often based on a surgical operation, demarcation of necrosis or limb amputation. A case such as the one described in this manuscript has not been previously described in Poland and demonstrates the need for a multidisciplinary approach to infection with Vibrio vulnificus.

CASE PRESENTATION

A 68-year-old patient was pricked with an unknown object in the side of a lower limb during his stay at the Polish seaside. He developed a life-threatening infection in the form of severe sepsis with multiple organ failure. He required broad-spectrum antibiotic therapy, and after obtaining results for Vibrio vulnificus targeted therapy, a surgical operation with skin lesion decompression and fasciotomy was performed. Finally, hyperbaric chamber therapy was given. The patient's general condition improved, and local changes and his vital parameters stabilized.

CONCLUSION

Vibrio vulnificus infection may be confused with other causes of skin and subcutaneous tissue infection, although it requires a different approach and different targeted antibiotic therapies. This infection may take the form of a life-threatening disease requiring a multidisciplinary approach.

[Non-cholera Vibrio species - currently still rare but growing danger of infection in the North Sea and the Baltic Sea]

BACKGROUND

The abundance of non-cholera Vibrio spp. in the aquatic environment shows a positive correlation with water temperatures. Therefore, climate change has an important impact on the epidemiology of human infections with these pathogens. In recent years large outbreaks have been repeatedly observed during the summer months in temperate climate zones.

OBJECTIVE

To inform medical professionals about the potentially life-threatening diseases caused by non-cholera Vibrio spp.

MATERIAL AND METHODS

Review of the current literature on infections with non-cholera Vibrio spp. in general and on the epidemiological situation in Germany in particular.

RESULTS

Non-cholera Vibrio spp. predominantly cause wound and ear infections after contact with contaminated seawater and gastroenteritis after consumption of undercooked seafood. As there have not been mandatory notification systems for these pathogens in Germany up to March 2020, a high number of unreported cases must be assumed. Immunosuppressed and chronically ill patients have a much higher risk for severe courses of diseases. If an infection with non-cholera Vibrio spp. is suspected anti-infective treatment should be promptly initiated and surgical cleansing is often necessary for wound and soft tissue infections.

CONCLUSION

Due to the ongoing global warming an increased incidence of human infections with non-cholera Vibrio spp. must be expected in the future. Medical professionals should be aware of these bacterial pathogens and the potentially life-threatening infections in order to enable timely diagnostics and treatment.

-Blue mussel (Mytilus spp.) cultivation in mesohaline eutrophied inner coastal waters: mitigation potential, threats and cost effectiveness

The EU-water framework directive (WFD) focuses on nutrient reductions to return coastal waters to the good ecological status. As of today, many coastal waters have reached a steady state of insufficient water quality due to continuous external nutrient inputs and internal loadings. This study focuses first on the current environmental status of mesohaline inner coastal waters to illustrate their needs of internal measures to reach demanded nutrient reductions and secondly, if mussel cultivation can be a suitable strategy to improve water quality. Therefore, nitrogen, phosphorus, chlorophyll a, and Secchi depth of nine mesohaline inner coastal waters in north east Germany were analyzed from 1990 to 2018. Two pilot mussel farms were used to evaluate their effectiveness as a mitigation measure and to estimate potential environmental risks, including the interactions with pathogenic vibrio bacteria. Further, estimated production and mitigation potential were used to assess economic profitability based on the sale of small sized mussels for animal feed and a compensation for nutrient mitigation. The compensation costs were derived from nutrient removal costs of a waste water treatment plant (WWTP). Results show that currently all nine water bodies do not reach the nutrient thresholds demanded by the WFD. However, coastal waters differ in nutrient pollution, indicating that some can reach the desired threshold values if internal measures are applied. The mitigation potential of mussel cultivation depends on the amount of biomass that is cultivated and harvested. However, since mussel growth is closely coupled to the salinity level, mussel cultivation in low saline environments leads to lower biomass production and inevitably to larger cultivation areas. If 50% of the case study area Greifswald Bay was covered with mussel farms the resulting nitrogen reduction would increase Secchi depth by 7.8 cm. However, high chlorophyll a values can hamper clearance rates (<20 mg m⁻³ = 0.43 l h⁻¹ dry weight g⁻¹) and therefore the mitigation potential. Also, the risk of mussel stock loss due to high summer water temperatures might affect the mitigation potential. The pilot farms had no significant effect on the total organic content of sediments beneath. However, increased values of Vibrio spp. in bio deposits within the pilot farm (1.43 10⁶ ± 1.10 10⁶CFU 100 ml⁻¹ (reference site: 1.04 10⁶ ± 1.45 10⁶ CFU 100 ml⁻¹) were measured with sediment traps. Hence, mussel farms might act as a sink for Vibrio spp. in systems with already high vibrio concentrations. However, more research is required to investigate the risks of Vibrio occurrence coupled to mussel farming. The economic model showed that mussel cultivation in environments below 12 PSU cannot be economic at current market prices for small size mussels and compensations based on nutrient removal cost of WWTPs.