Distribution of Fatal Vibrio Vulnificus Necrotizing Skin and Soft-Tissue Infections: A Systematic Review and Meta-Analysis

Travel-related sepsis with colitis and necrotizing skin and soft tissue infection after oysters consumption

We describe in this article a case of a 55-year-old woman admitted to our hospital in France, for oedema and paraesthesia of the lower limbs after returning from a trip to Florida. In only four hours, the patient's condition evolved into a multiple organs failure, leading the physicians to carry out a TAP scan and a CT angiogram of the lower limb, which showed acute pan-colitis and diffuse infiltration of the skin and soft legs tissues. Leg fasciotomy was performed and revealed necrotizing fasciitis and myonecrosis. The evolution was unfavorable, leading to shock and death 12 h after hospital admission. Culture revealed Vibrio vulnificus and rapid genome sequencing led to identification of MO6-24/O genotype. V. vulnificus is a bacterium commonly found in warm coastal water and responsible for necrosis SSTI after exposure to seawater through skin lesions and gastroenteritis after ingestion of contaminated seafood. Strain MO6-24/O found in our patient is associated with very poor prognosis. This case is uncommon in Europe but the modification of geographic distribution due to warming coastal waters in Pacific and Atlantic coastal regions of the northern hemisphere lead to consider V. vulnificus in travellers from coastal and estuarine regions, with history of exposure to water or seafood consumption, especially during the summer.

Early diagnosis and application of hemopurification combined with antibiotic therapy and surgical debridement for successful treatment of a child with Vibrio vulnificus necrotizing fasciitis and septic shock: a case report

BACKGROUND

Vibrio vulnificus (V. vulnificus) is a halophilic marine Gram-negative bacterium. Necrotizing fasciitis caused by V. vulnificus is a rapidly progressing clinical emergency often accompanied by septic shock. Despite advances in antibiotics and infection control measures, it remains a highly fatal and disabling infection. The incidence of V. vulnificus infection has increased due to climate warming and expanded global seafood trade in recent years. However, pediatric cases of V. vulnificus infection remain rare, leading to limited clinical experience in their management.

METHODS

This report analyzes the clinical data of a pediatric case of V. vulnificus necrotizing fasciitis with septic shock, treated at Zhuhai Center for Maternal and Child Health Care in April 2024. The report also reviews the literature on pediatric V. vulnificus infection.

RESULTS

A 26-month-old boy developed a V. vulnificus infection after being scratched by a sea bass. The patient experienced an acute onset of illness that quickly worsened, presenting with a fever, mental fatigue, soft tissue edema, and pain, necrosis of the fascia and foot, coagulation dysfunction, and even shock. Laboratory results revealed white blood cell count(5.0 × 109/L), neutrophilia %(65%), thrombocytopenia (56 × 109/L), elevated CRP (200 mg/L), PCT (67.4 ng/mL), and IL-6 (> 4000 pg/mL), hypoalbuminemia (17.4 g/L), prolonged PT (17.5 s), reduced total T and NK cell counts, and a significantly reduced proportion of Treg cells. Initial treatment included surgical debridement and drainage, empirical antibiotic therapy, and rapid diagnosis of V. vulnificus via bacterial wound culture. Next-generation sequencing (NGS) of the blood microbial macrogenome and high-throughput sequencing of wound microbial pathogens (MetCap) were performed. Antibiotics were selected based on drug sensitivity testing, accompanied by hemopurification and measures to prevent disseminated intravascular coagulation. The patient's condition stabilized gradually post-treatment, and he was discharged.

CONCLUSION

Prompt diagnosis is important for children with seafood exposure. Early hemopurification, surgical intervention, effective antibiotic therapy, and DIC prevention significantly improve prognosis and survival rates. These findings provide a practical reference for managing pediatric V. vulnificus infections.

Emerging Vibrio vulnificus-Associated Infections After Seawater Exposure-Cases from the Bulgarian Black Sea Coast

Objectives: The aim of the current report is to present three cases of necrotizing fasciitis and sepsis caused by Vibrio vulnificus on the Bulgarian Black Sea coast. Materials and Methods: Two of the patients are males, 70 and 86 years of age, respectively, and one is an 86-year-old female. Data were collected from the patients' examination records. V. vulnificus was isolated on 5% sheep blood agar from wound and blood samples and identified by the automated system Phoenix M50 (BD, Franklin Lakes, NJ, USA). Antimicrobial susceptibility was tested with two well-known methods (disk diffusion and broth microdilution). Results: All of the patients were admitted to our hospital due to pain, swelling, ulceration, and bullae on the legs and were febrile. They underwent surgery and received intensive care support. One of the patients developed septicemia and septic shock; one of his legs was amputated, but the outcome was fatal. The other patient received immediate approptiate antibiotic and surgical treatment, and the outcome was favorable. The third patient underwent emergency fasciotomy but died a few hours after admission. Conclusions: Global climate change is affecting the distribution of Vibrio spp., and their incidence is expected to increase. It is important to highlight the need for awareness among immunocompromised and elderly patients of the potential threat posed by V. vulnificus infections.

Association between time to surgery and hospital mortality in patients with community-acquired limb necrotizing fasciitis: an 11-year multicenter retrospective cohort analysis

BACKGROUND

Necrotizing fasciitis (NF) is a rare but potentially life-threatening soft tissue infection. The objective of this study was to assess the association between timely surgery within 6 h and hospital mortality in patients with limb NF, and to describe the trends in patients with NF, time to surgery and standardized mortality ratio (SMR) over 11 years.

METHODS

This was a multicenter, retrospective cohort study of all intensive care unit patients who had emergency surgery within 24 h of hospitalization for limb NF between April 1, 2008 and March 31, 2019 in Hong Kong. Timely surgery was defined as the first surgical treatment within 6 h of initial hospitalization. Appropriate antibiotics were achieved if the patient was given antibiotic(s) for all documented pathogens prior to or on day of culture results. The primary outcome was hospital mortality.

RESULTS

There were 495 patients (median age 62 years, 349 (70.5%) males) with limb NF treated by surgery within 24 h of hospitalization over the 11 years. Appropriate antibiotic(s) were used in 392 (79.2%) patients. There were 181 (36.5%) deaths. Timely surgery was not associated with hospital mortality (Relative Risk 0.89, 95% CI: 0.73 to 1.07) but admission year, advanced age, higher severity of illness, comorbidities, renal replacement therapy, vasopressor use, and type of surgery were significant predictors in the multivariable model. There was an upward trend in NF diagnosis (1.9 cases/year, 95% CI: 0.7 to 3.1; P < 0.01; R2 = 0.60) but there was no downward trend in median time to surgery (-0.2 h/year, 95% CI: -0.4 to 0.1; P = 0.16) or SMR (-0.02/year, 95% CI: -0.06 to 0.01; P = 0.22; R2 = 0.16).

CONCLUSIONS

Among patients operated within 24 h, very early surgery within 6-12 h was not associated with survival. Increasing limb NF cases were reported each year but mortality remained high despite a high rate of appropriate antibiotic use and timely surgical intervention.

Genome analysis of clinical genotype Vibrio vulnificus isolated from seafood in Mangaluru Coast, India provides insights into its pathogenicity

Vibrio vulnificus an opportunistic human pathogen native to marine/estuarine environment, is one of the leading causes of death due to seafood consumption and exposure of wounds to seawater worldwide. The present study involves the whole genome sequence analysis of an environmental strain of V. vulnificus (clinical genotype) isolated from seafood along the Mangaluru coast of India. The sequenced genome data was subjected to in-silico analysis of phylogeny, virulence genes, antimicrobial resistance determinants, and secretary proteins using suitable bioinformatics tools. The sequenced isolate had an overall genome length of 4.8 Mb and GC content of 46% with 4400 coding DNA sequences. The sequenced strain belongs to a new sequence type (Multilocus sequence typing) and was also found to branch with a phylogenetic lineage that groups the most infectious strains of V. vulnificus. The seafood isolate had complete genes involved in conferring serum resistance yet showed limited serum resistance. The study identified several genes against the antibiotics that are commonly used in their treatment, highlighting the need for alternative treatments. Also, the secretory protein analysis revealed genes associated with major pathways like ABC transporters, two-component systems, quorum sensing, biofilm formation, cationic antimicrobial peptide (CAMP) resistance, and others that play a critical role in the pathogenesis of the V. vulnificus. To the best of our knowledge, this is the first report of a detailed analysis of the genomic information of a V. vulnificus isolated from the Indian subcontinent and provides evidence that raises public health concerns about the safety of seafood.

A case report of Vibrio vulnificus sepsis in a diabetic patient

Vibrio vulnificus is a facultative anaerobic, alkalophilic, halophilic, mesophilic, Gram-negative bacterium that can cause severe wound infection, sepsis and diarrhea. This paper reported a case of 85-year-old male patient infected with Vibrio vulnificus due to being stabbed by a sea shrimp. This patient also had diabetes with a long history of alcoholism. Due to bacterial pathogenicity and the patient's underlying diseases, his condition deteriorated rapidly. Based on the rapid diagnosis of Vibrio vulnificus using the next-generation sequencing（NGS）technology and blood culture method, as well as the selection of the most effective antibiotics via drug sensitivity test, this patient underwent precise antimicrobial treatment, thorough debridement and drainage within the shortest possible time, and thus the prognosis of this patient was greatly improved. In this paper, we have systematically explored the epidemiology, clinical features, diagnosis and treatment of Vibrio vulnificus infection, thus providing a practical reference for the clinicians to quickly identify and treat possible Vibrio vulnificus infection in diabetic patients after contacting with sea water or seafood.

Detection of V. vulnificus septic shock with ARDS using mNGS

The latest surveillance from the Centers for Disease Control and Prevention shows that the annual incidence of V. vulnificus infection is increasing. Unfortunately, in less well-known high-risk groups, this infection is usually excluded from differential diagnosis. Transmitted through wound exposure or ingestion, the mortality rate of foodborne diseases of V. vulnificus is the highest of all V. vulnificus. V. vulnificus is as lethal early diagnosis as Ebola and bubonic plague, so timely treatment is imperative. Sepsis caused by V. vulnificus infection mainly exists in the United States and is rarely reported in Southeast Asia. We report a 78-year-old man who went to the local hospital and complained of swelling in his right hand with severe pain. He ate raw salmon 2 days ago and denied other recognized seafood stab or trauma history and other seafood contact history. He was in septic shock at the time of treatment, so we immediately transferred to the emergency intensive care unit and tested for metagenomic next-generation sequencing (mNGS). The diagnosis was confirmed the second day after admission, and eventually he was cured and discharged from the hospital only after medical treatment, thus avoiding the risk of surgical debridement or even amputation. mNGS is helpful for early clinical diagnosis and effective early intervention for etiology, so that patients can get a good prognosis.

Climate warming and increasing Vibrio vulnificus infections in North America

Vibrio vulnificus is an opportunistic bacterial pathogen, occurring in warm low-salinity waters. V. vulnificus wound infections due to seawater exposure are infrequent but mortality rates are high (~ 18%). Seawater bacterial concentrations are increasing but changing disease pattern assessments or climate change projections are rare. Here, using a 30-year database of V. vulnificus cases for the Eastern USA, changing disease distribution was assessed. An ecological niche model was developed, trained and validated to identify links to oceanographic and climate data. This model was used to predict future disease distribution using data simulated by seven Global Climate Models (GCMs) which belong to the newest Coupled Model Intercomparison Project (CMIP6). Risk was estimated by calculating the total population within 200 km of the disease distribution. Predictions were generated for different "pathways" of global socioeconomic development which incorporate projections of greenhouse gas emissions and demographic change. In Eastern USA between 1988 and 2018, V. vulnificus wound infections increased eightfold (10-80 cases p.a.) and the northern case limit shifted northwards 48 km p.a. By 2041-2060, V. vulnificus infections may expand their current range to encompass major population centres around New York (40.7°N). Combined with a growing and increasingly elderly population, annual case numbers may double. By 2081-2100 V. vulnificus infections may be present in every Eastern USA State under medium-to-high future emissions and warming. The projected expansion of V. vulnificus wound infections stresses the need for increased individual and public health awareness in these areas.

Characteristic Metabolic Changes in Skeletal Muscle Due to Vibrio vulnificus Infection in a Wound Infection Model

Vibrio vulnificus is a bacterium that inhabits warm seawater or brackish water environments and causes foodborne diseases and wound infections. In severe cases, V. vulnificus invades the skeletal muscle tissue, where bacterial proliferation leads to septicemia and necrotizing fasciitis with high mortality. Despite this characteristic, information on metabolic changes in tissue infected with V. vulnificus is not available. Here, we elucidated the metabolic changes in V. vulnificus-infected mouse skeletal muscle using capillary electrophoresis time-of-flight mass spectrometry (CE-TOFMS). Metabolome analysis revealed changes in muscle catabolites and energy metabolites during V. vulnificus infection. In particular, succinic acid accumulated but fumaric acid decreased in the infected muscle. However, the virulence factor deletion mutant revealed that changes in metabolites and bacterial proliferation were abolished in skeletal muscle infected with a multifunctional-autoprocessing repeats-in-toxin (MARTX) mutant. On the other hand, mice that were immunosuppressed via cyclophosphamide (CPA) treatment exhibited a similar level of bacterial counts and metabolites between the wild type and MARTX mutant. Therefore, our data indicate that V. vulnificus induces metabolic changes in mouse skeletal muscle and proliferates by using the MARTX toxin to evade the host immune system. This study indicates a new correlation between V. vulnificus infections and metabolic changes that lead to severe reactions or damage to host skeletal muscle. IMPORTANCE V. vulnificus causes necrotizing skin and soft tissue infections (NSSTIs) in severe cases, with high mortality and sign of rapid deterioration. Despite the severity of the infection, the dysfunction of the host metabolism in skeletal muscle triggered by V. vulnificus is poorly understood. In this study, by using a mouse wound infection model, we revealed characteristic changes in muscle catabolism and energy metabolism in skeletal muscle associated with bacterial proliferation in the infected tissues. Understanding such metabolic changes in V. vulnificus-infected tissue may provide crucial information to identify the mechanism via which V. vulnificus induces severe infections. Moreover, our metabolite data may be useful for the recognition, identification, or detection of V. vulnificus infections in clinical studies.

[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.

Successful surgical treatment of polybacterial gas gangrene confirmed by metagenomic next-generation sequencing detection: A case report

BACKGROUND

We report on a case of Vibrio vulnificus (V. vulnificus) detected by metagenomics next-generation sequencing (mNGS) in a 53-year-old male patient with polymicrobial gas gangrene and successful treatment by surgery. This report raises awareness among dermatologists that when a patient is clinically suspected of a special type of pathogenic infection, the mNGS method should be preferred to identify the patient’s pathogen infection as soon as possible and then take effective treatment in time to save patients’ lives.

CASE SUMMARY

A 53-year-old male who worked in the aquatic market complained of redness and swelling of the lower limbs, blisters and ulcers with fever for 3 d. We used mNGS to test the pathogens in ulcer secretions. The results were returned in 24 h and indicated: V. vulnificus, Fusobacterium necrophorum, Staphylococcus haemolyticus, Staphylococcus aureus, Streptococcus dysgalactiae and Klebsiella aerogenes. This patient was diagnosed with V. vulnificus infection. The emergency operation was performed immediately under combined lumbar and epidural anesthesia: Left leg expansion and exploration (August 10, 2021). After surgery, we continued to use piperacillin sodium tazobactam sodium 4.5 g every 8 h and levofloxacin 0.5 g for anti-infection treatment. The patient underwent further surgery under lumbar anesthesia on August 17, 2021 and August 31, 2021: Left leg deactivation and skin grafting, negative pressure closed drainage and right thigh skin removal. After treatment, the transplanted flap survived.

CONCLUSION

We could confirm the diagnosis of Vibrio vulnificus infection within 24 h through mNGS detection and then immediately performed emergency surgery.

Secondary craniofacial necrotizing fasciitis from a distant septic emboli: A case report

BACKGROUND

Craniofacial necrotizing fasciitis (CNF) is an uncommon but fatal infection that can spread rapidly through the subfascial planes in the head and neck region. Symptoms usually progress rapidly, and early management is necessary to optimize outcomes.

CASE SUMMARY

A 43-year-old man visited our hospital with left hemifacial swelling involving the buccal and submandibular areas. The patient had fever for approximately 10 d before visiting the hospital, but did not report any other systemic symptoms. Computed tomography scan demonstrated an abscess with gas formation. After surgical drainage of the facial abscess, the patient’s systemic condition worsened and progressed to septic shock. Further examination revealed pulmonary and renal abscesses. Renal percutaneous catheter drainage was performed at the renal abscess site, which caused improvement of symptoms. The patient showed no evidence of systemic complications during the 4-mo post-operative follow-up period.

CONCLUSION

As the patient did not improve with conventional CNF treatment and symptoms only resolved after controlling the infection, the final diagnosis was secondary CNF with septic emboli. Aggressive surgical decompression is important for CNF management. However, if symptoms worsen despite early diagnosis and management, such as pus drainage and surgical intervention, clinicians should consider the possibility of a secondary abscess from internal organs.

Genetic Divergence of Vibrio vulnificus Clinical Isolates with Mild to Severe Outcomes

The marine bacterium Vibrio vulnificus infects humans via food or water contamination, leading to serious manifestations, including gastroenteritis, wound infections, and septic shock. Previous studies suggest phylogenetic Lineage 1 isolates with the vcgC allele of the vcg gene cause human infections, whereas Lineage 2 isolates with the vcgE allele are less pathogenic. Mouse studies suggest that some variants of the primary toxin could drive more serious infections. A collection of 109 V. vulnificus United States human clinical isolates from 2001 to 2019 with paired clinical outcome data were assembled. The isolates underwent whole-genome sequencing, multilocus-sequence phylogenetic analysis, and toxinotype analysis of the multifunctional autoprocessing repeats-in-toxin (MARTX) toxin. In contrast to prior reports, clinical isolates were equally distributed between lineages. We found no correlation between phylogenetic lineage or MARTX toxinotype and disease severity. Infections caused by isolates in Lineage 1 demonstrated a borderline statistically significant higher mortality. Lineage 1 isolates had a trend toward a higher proportion of M-type MARTX toxins compared with Lineage 2, although this was not statistically significant. IMPORTANCE Vibrio vulnificus is an aquatic pathogen that is capable of causing severe disease in humans. Previous studies have suggested that pathogenic isolates were restricted to certain phylogenetic lineages and possibly toxinotype. Our study demonstrated that phylogenetic lineage and multifunctional autoprocessing repeats-in-toxin (MARTX) toxinotype do not predict severity of infection. V. vulnificus strains capable of causing severe human disease are not concentrated in Lineage 1 but are genetically diverse. Thus, food surveillance based on lineage type or toxinotype may not be an appropriate intervention measure to control this rare but serious infection.

Refining real-time predictions of Vibrio vulnificus concentrations in a tropical urban estuary by incorporating dissolved organic matter dynamics

The south shore of O'ahu, Hawai'i is one of the most visited coastal tourism areas in the United States with some of the highest instances of recreational waterborne disease. A population of the pathogenic bacterium Vibrio vulnificus lives in the estuarine Ala Wai Canal in Honolulu which surrounds the heavily populated tourism center of Waikīkī. We developed a statistical model to predict V. vulnificus dynamics in this system using environmental measurements from moored oceanographic and atmospheric sensors in real time. During a year-long investigation, we analyzed water from 9 sampling events at 3 depths and 8 sites along the canal (n = 213) for 36 biogeochemical variables and V. vulnificus concentration using quantitative polymerase chain reaction (qPCR) of the hemolysin A gene (vvhA). The best multiple linear regression model of V. vulnificus concentration, explaining 80% of variation, included only six predictors: 5-day average rainfall preceding water sampling, daily maximum air temperature, water temperature, nitrate plus nitrite, and two metrics of humic dissolved organic matter (DOM). We show how real-time predictions of V. vulnificus concentration can be made using these models applied to the time series of water quality measurements from the Pacific Islands Ocean Observing System (PacIOOS) as well as the PacIOOS plume model based on the Waikīkī Regional Ocean Modeling System (ROMS) products. These applications highlight the importance of including DOM variables in predictive modeling of V. vulnificus and the influence of rain events in elevating nearshore concentrations of V. vulnificus. Long-term climate model projections of locally downscaled monthly rainfall and air temperature were used to predict an overall increase in V. vulnificus concentration of approximately 2- to 3-fold by 2100. Improving these predictive models of microbial populations is critical for management of waterborne pathogen risk exposure, particularly in the wake of a changing global climate.

Biomimetic Nanosponges Enable the Detoxification of Vibrio vulnificus Hemolysin

Vibrio vulnificus (V. vulnificus) infection-associated multiple antibiotic resistance has raised serious public health concerns. Recently, nanosponges (NSs) have been expected to provide innovative platforms for addressing antibacterial and drug-resistant challenges by targeting various pore-forming toxins (PFTs). In the present study, we constructed NSs to explore the effects and possible mechanism of recombinant V. vulnificus hemolysin (rVvhA)-induced injuries. In vitro, NSs significantly reversed rVvhA-induced apoptosis and necrosis, and improved toxin-induced intracellular reactive oxygen species (ROS) production, adenosine triphosphate (ATP) depletion, and apoptosis signaling pathway disruption. To explore the clinical translation potential of NSs, we established VvhA-induced septicemia and wound infection mouse models, respectively, and further found NSs could notably attenuate rVvhA-induced acute toxicity and septicemia-associated inflammation, as well as local tissue damage. In a conclusion, NSs showed excellent protective effects against rVvhA-induced toxicity, thus providing useful insights into addressing the rising threats of severe V. vulnificus infections.

Building sustainable and resilient surgical systems: A narrative review of opportunities to integrate climate change into national surgical planning in the Western Pacific region

Five billion people lack access to surgical care worldwide; climate change is the biggest threat to human health in the 21st century. This review studies how climate change could be integrated into national surgical planning in the Western Pacific region. We searched databases (PubMed, Web of Science, and Global Health) for articles on climate change and surgical care. Findings were categorised using the modified World Health Organisation Health System Building Blocks Framework. 220 out of 2577 records were included. Infrastructure: Operating theatres are highly resource-intensive. Their carbon footprint could be reduced by maximising equipment longevity, improving energy efficiency, and renewable energy use. Service delivery Tele-medicine, outreaches, and avoiding desflurane could reduce emissions. Robust surgical systems are required to adapt to the increasing burden of surgically treated diseases, such as injuries from natural disasters. Finance: Climate change adaptation funds could be mobilised for surgical system strengthening. Information systems: Sustainability should be a key performance indicator for surgical systems. Workforce: Surgical providers could change clinical, institutional, and societal practices. Governance: Planning in surgical care and climate change should be aligned. Climate change mitigation is essential in the regional surgical care scale-up; surgical system strengthening is also necessary for adaptation to climate change.

Health effects of climate change: an overview of systematic reviews

OBJECTIVES

We aimed to develop a systematic synthesis of systematic reviews of health impacts of climate change, by synthesising studies' characteristics, climate impacts, health outcomes and key findings.

DESIGN

We conducted an overview of systematic reviews of health impacts of climate change. We registered our review in PROSPERO (CRD42019145972). No ethical approval was required since we used secondary data. Additional data are not available.

DATA SOURCES

On 22 June 2019, we searched Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane and Web of Science.

ELIGIBILITY CRITERIA

We included systematic reviews that explored at least one health impact of climate change.

DATA EXTRACTION AND SYNTHESIS

We organised systematic reviews according to their key characteristics, including geographical regions, year of publication and authors' affiliations. We mapped the climate effects and health outcomes being studied and synthesised major findings. We used a modified version of A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) to assess the quality of studies.

RESULTS

We included 94 systematic reviews. Most were published after 2015 and approximately one-fifth contained meta-analyses. Reviews synthesised evidence about five categories of climate impacts; the two most common were meteorological and extreme weather events. Reviews covered 10 health outcome categories; the 3 most common were (1) infectious diseases, (2) mortality and (3) respiratory, cardiovascular or neurological outcomes. Most reviews suggested a deleterious impact of climate change on multiple adverse health outcomes, although the majority also called for more research.

CONCLUSIONS

Most systematic reviews suggest that climate change is associated with worse human health. This study provides a comprehensive higher order summary of research on health impacts of climate change. Study limitations include possible missed relevant reviews, no meta-meta-analyses, and no assessment of overlap. Future research could explore the potential explanations between these associations to propose adaptation and mitigation strategies and could include broader sociopsychological health impacts of climate change.

Draft Genome Sequences of Vibrio vulnificus Strains Recovered from Moribund Tilapia

Potentially zoonotic Vibrio vulnificus strains were isolated from vibriosis outbreaks occurring on eastern Mediterranean tilapia farms between 2016 and 2019. In this work, the draft genome sequences of three representative isolates are presented.

Biochemical Characterization of Arylamine N-acetyltransferases From Vibrio vulnificus

Vibrio vulnificus is a zoonotic bacterium that is capable of causing highly lethal diseases in humans; this pathogen is responsible for 95% of all seafood-related deaths in the United States. Arylamine N-acetyltransferases (NAT, E.C. 2.3.1.5) is a major family of xenobiotic-metabolizing enzymes that can biotransform aromatic amine chemicals. In this research, to evaluate the effect of NAT on acetyl group transformation in arylamine antibiotics, we first used sequence alignment to study the structure of V. vulnificus NAT [(VIBVN)NAT]. The nat gene encodes a protein of 260 amino acids, which has an approximate molecular mass of 30 kDa. Then we purified recombinant (VIBVN)NAT and determined the enzyme activity by PNPA and DTNB methods. The DTNB method indicates that this prokaryotic NAT has a particular substrate specificity towards aromatic substrates. However, (VIBVN)NAT lost most of its activity after treatment with high concentrations of urea and H₂O₂. In addition, we also explored the stability of the enzyme at different temperatures and pH values. In analyzing the influence of metal ions, the enzyme activity was significantly inhibited by Zn²⁺ and Cu²⁺. The kinetic parameters K_m and V_max were determined using hydralazine, isoniazid, 4-amino salicylic acid, and 4-chloro-3-methylaniline as substrates, and the T_m, T_agg and size distribution of (VIBVN)NAT were observed. In particular, a molecular docking study on the structure of (VIBVN)NAT was conducted to understand its biochemical traits. These results showed that (VIBVN)NAT could acetylate various aromatic amine substrates and contribute to arylamine antibiotic resistance in V. vulnificus.

[Bacterial acute non necrosing cellulitis (erysipelas) in adult]

Erysipelas is defined by a sudden onset (with fever) preceding the appearance of a painful, infiltrated, erythematous plaque, accompanied by regional lymphadenopathy. It is usually localized on the lower limbs, but it can occur on the face. It is due to β-hemolytic streptococcus A and more rarely to staphylococcus aureus. It is important to establish the diagnosis and eliminate the non-bacterial causes of inflammatory edema. The other diagnoses frequently found are contact eczema, acute arthritis, bursitis, inflammatory flare-up of chronic dermohypodermitis of venous origin, flare-up of chronic multifactorial eczema (venous insufficiency, vitamin deficiencies, senile xerosis and/or contact eczema), rare familial periodic fevers, rare neutrophilic dermatoses or eosinophilic cellulitis. It is necessary to identify signs of severity that would justify hospitalization. In front of a typical acute bacterial dermohypodermitis and in the absence of comorbidity, no additional investigation is necessary. Systematic blood cultures have low profitability. Locoregional causes must be identified in order to limit the risk of recurrence which remains the most frequent complication. In uncomplicated erysipelas, amoxicillin is the gold standard; treatment with oral antibiotic therapy is possible if there is no sign of severity or co-morbidity (diabetes, arteritis, cirrhosis, immune deficiency) or an unfavorable social context. In case of allergy to penicillin, pristinamycin or clindamycin should be prescribed. Prophylactic antibiotic therapy with delayed penicillin is recommended in the event of recurrent erysipelas.

Predictors for gram-negative monomicrobial necrotizing fasciitis in southern Taiwan

BACKGROUND

Necrotizing fasciitis (NF) is a rare and life-threatening necrotizing skin and soft-tissue infection. Infectious pathogens of NF must be detected early and treated rapidly to prevent loss of limb or a fatal outcome. This study aimed to detect more reliable predictors between gram-negative and gram-positive monomicrobial NF of limbs.

METHODS

A total of 100 patients with limb monomicrobial NF were diagnosed prospectively from April 2015 to July 2018. These monomicrobial NF pathogens can be divided into gram-negative and gram-positive groups according to the result of Gram staining and final bacterial reports. Data such as demographics, seawater or seafood contact history, infectious location, comorbidities, presenting signs and symptoms, and laboratory findings were recorded and compared.

RESULTS

A total of 55 patients were infected with gram-negative organisms and 45 patients with gram-positive organisms. Among the 55 cases of monomicrobial gram-negative NF, 48 (87.3%) were caused mainly by Vibrio spp. (38, 69.1%) and Aeromonas spp. (10, 18.2%). A higher incidence of chronic kidney disease, cerebrovascular accident, tachypnea, and septic shock; a higher rate of band forms of leukocytes of more than 3%, serum lactate of more than 20 mg/dL, and C-reactive protein level of less than 150 mg/dL; prolonged prothrombin time; and a lower fibrinogen level were observed in patients with gram-negative infection. In a multivariate analysis, a higher incidence of seawater or seafood contact history (odds ratio [OR]: 66.301; 95% confidence interval [CI]: 7.467-588.702), a higher rate of hyperlactatemia (OR: 7.904; 95% CI: 1.231-50.744), and a low fibrinogen level (OR: 1.013; 95% CI: 1.004-1.023) indicated gram-negative infection.

CONCLUSIONS

In southern Taiwan, NF of limbs mainly affected the lower limbs, exhibited monomicrobial infection, and was predominated by gram-negative bacteria. Gram-negative monomicrobial NF of limbs often occurred in individuals with the more seawater or seafood contact history, hyperlactatemia, and low fibrinogen levels.

Hepatic disease and the risk of mortality of Vibrio vulnificus necrotizing skin and soft tissue infections: A systematic review and meta-analysis

Background

Vibrio vulnificus necrotizing skin and soft tissue infections (VNSSTIs) are associated with a high mortality rate that varies remarkably with host susceptibility. Hepatic disease (HD) is considered the key risk factor for high VNSSTIs incidence and mortality; however, there is limited evidence in the literature to support this observation.

Methodology

We examined all reported cases of VNSSTIs and associated mortality rates between 1966 and mid-2018. The PubMed, Medline and Cochrane Library databases were systematically searched for observational studies on patients with VNSSTIs. Twelve studies with 1157 total patients with VNSSTIs were included in the analysis. From the pooled dataset, nearly half (46.8%) of the patients with VNSSTIs had HD. The mortality rate in HD patients with VNSSTIs was 53.9% (n = 292/542), which was considerably higher than the mortality rate of 16.1% (n = 99/615) in non-HD patients. Patients with HD contracted VNSSTIs were found to be two or more times (RR = 2.61, 95% CI = 2.14–3.19) as likely to die compared with those without HD. Besides, liver cirrhosis (LC), the end-stage HD, was confirmed to be a significant risk factor, with risk ratios of 1.84 (95% CI 1.21–2.79) and 2.00 (95% CI 1.41–2.85) when compared to non-LC and non-HD, respectively.

Conclusions

HD with or without LC can be associated with infections and complications from V. vulnificus. Clinicians should aggressively approach care and management of acutely and/or critically ill patients with VNSSTIs.

Epidemiology, pathogenetic mechanism, clinical characteristics, and treatment of Vibrio vulnificus infection: a case report and literature review

Vibrio vulnificus is a Gram-negative bacterium that belongs to the Vibrionaceae family. It represents a deadly opportunistic human pathogen which grows in water with the proper temperature and salinity, and is mostly acquired from seafood eating or direct contact. In susceptible individuals, a traumatic infection could be fatal, causing severe wound infection and even septic shock, and may require amputation. Global warming plays an important role in the geographical area expanding of Vibrio disease. The pathogenesis of Vibrio vulnificus-associated sepsis is very complex, including iron intake, cell injury, and adhesion-related protein and virulence regulation. Vibrio vulnificus infection mainly manifests clinical subtypes such as primary sepsis, traumatic infection, and gastroenteritis, with rapid symptom progression and signs of multiple organ dysfunction syndrome (MODS). It is important to assess these pathogenetic mechanisms in order to select more appropriate measures to prevent and treat Vibrio vulnificus infections, including antibiotic usage and surgical intervention. In this work, we report a typical case of successful treatment of necrotizing fasciitis caused by Vibrio vulnificus, and review the epidemiology, pathogenetic mechanism, clinical characteristics, and treatment of Vibrio vulnificus infection.

Necrotizing skin and soft-tissue infections in the intensive care unit

BACKGROUND

Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission.

OBJECTIVES

To review all aspects of care for a critically ill individual with NSTI.

SOURCES

Literature search using Medline and Cochrane library, multidisciplinary panel of experts.

CONTENT

The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial.

IMPLICATIONS

Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.

Etiology, characteristics, and outcomes of community-onset necrotizing fasciitis in Korea: A multicenter study

Background

Necrotizing fasciitis (NF) is a serious skin and soft tissue infection causing high mortality. Investigating region specific epidemiologic factors associated with NF is important for establishing appropriate treatment strategies. This multicenter study was done to provide an update of the microbial etiology, clinical characteristics, and outcomes of NF in Korea.

Materials and methods

A retrospective cohort of adult patients with NF was established using patient data from 13 general hospitals between January 2012 and December 2015 in Korea. We evaluated microbial etiology and clinical characteristics to identify risk factors associated with in-hospital mortality; analyses were performed using binary logistic regression models.

Results

A total of 161 patients with NF were included. The most common underlying disease was diabetes mellitus (66 cases, 41.0%). A total of 148 organisms were isolated from 119 (73.9%) patients. Enteric Gram-negative organisms (36 patients) were the most common pathogen, followed by Staphylococcus aureus (30 patients) and streptococci (28 patients). Methicillin-resistant Staphylococcus aureus (MRSA) was identified in 6.2% (10/161) of patients. Of 37 enteric Gram-negative isolates tested, 26 (70.3%) isolates were susceptible to ceftriaxone. The in-hospital mortality rate was 22.4%. Intensive care unit admission, septic shock, and Gram-negative organism infections were significantly associated with in-hospital mortality, and surgery was not a favorable prognostic factor.

Conclusions

As initial empirical antibiotics, glycopeptides against MRSA and broad-spectrum antibiotics against third-generation cephalosporin-resistant organisms should be considered for patients with community-onset NF in Korea.

Outcomes of Third-Generation Cephalosporin Plus Ciprofloxacin or Doxycycline Therapy in Patients with Vibrio vulnificus Septicemia: A Propensity Score-Matched Analysis

Background

Combination therapy with a third-generation cephalosporin (TGC) and a tetracycline analogue is recommended for Vibrio vulnificus infection. The combination of a TGC and ciprofloxacin has synergistic in vitro bactericidal activity against V. vulnificus. No clinical study has compared the standard regimen with TGC plus ciprofloxacin therapy for V. vulnificus infection.

Methods

Patients with a confirmed V. vulnificus infection at two medical centers in Korea from 1991 to 2016 were enrolled in this study. The patients were grouped according to the type of antibiotic administered. A retrospective propensity-score-matched case-control study of patients treated with TGC plus doxycycline or TGC plus ciprofloxacin was performed. The clinical characteristics and outcomes of the patients were analyzed.

Results

A total of 218 patients were confirmed to have V. vulnificus septicemia during the study, and the 30-day survival rate was 39% (85/218). The patients were classified into the following six treatment groups: TGC monotherapy (n = 82), TGC plus doxycycline therapy (n = 42), TGC plus ciprofloxacin therapy (n = 39), ciprofloxacin monotherapy (n = 14), other β-lactam monotherapy (n = 10), and other (n = 31). The survival rates of these groups were as follows: TGC monotherapy (35%), TGC plus doxycycline (38%), TGC plus ciprofloxacin (54%), ciprofloxacin monotherapy (29%), other β-lactam (20%), and other (39%). The 30-day survival rate showed no significant difference between the TGC plus doxycycline and TGC plus ciprofloxacin groups (log-rank test, P = 0.18). Among the 81 patients treated with TGC plus doxycycline or TGC plus ciprofloxacin, 12 per treatment group were selected by propensity-score matching. There was no significant difference in the baseline characteristics or the frequency of fasciotomy between the two groups. The 30-day survival rate showed no significant difference between the TGC plus doxycycline (50%) and TGC plus ciprofloxacin (67%) groups (log-rank test, P = 0.46).

Conclusion

Our data suggest that the outcome of TGC plus ciprofloxacin therapy was comparable to that of TGC plus doxycycline therapy in patients with V. vulnificus septicemia.

The combination of a third-generation cephalosporin (TGC) and ciprofloxacin has synergy in vitro bactericidal activity against V. vulnificus. No clinical study has compared the standard regimen with TGC plus ciprofloxacin therapy for V. vulnificus infection. A total of 218 patients were enrolled who are confirmed to have V. vulnificus septicemia in two medical centers in Korea from 1991 to 2016. The 30-day survival rate was 39% (85/218) for all patients, 38% (16/42) for TGC plus doxycycline and 54% (21/39) for TGC plus ciprofloxacin (log rank test, P = 0.18). A propensity score-matched analysis was performed and 12 per treatment groups were selected. The 30-day survival rate showed no significant difference between the TGC plus doxycycline (50%, 6/12) and TGC plus ciprofloxacin (67%, 4/12) groups (log-rank test, P = 0.46). The outcome of TGC plus ciprofloxacin therapy was comparable to that of TGC plus doxycycline therapy in patients with V. vulnificus septicemia.

Vibrio vulnificus in aquariums is a novel threat to marine mammals and public health

Vibrio vulnificus is a Gram-negative, curved, obligate halophilic marine bacterium that exclusively exists in coastal seawaters. Previous studies revealed that V. vulnificus is one of the most dangerous foodborne zoonotic pathogens for human beings. However, it remains unknown whether marine mammals can be infected by V. vulnificus. In May 2016, a captive spotted seal (Phoca largha) died due to septicemia induced by V. vulnificus. Upon post-mortem examination, V. vulnificus was isolated, identified, and named as BJ-PH01. Further analysis showed that BJ-PH01 belongs to biotype 1 and the Clinical genotype. Furthermore, we performed an epidemiological investigation of V. vulnificus in six aquariums in northern China. As a result, V. vulnificus was successfully isolated from all investigated aquariums. The positive rates ranged from 20% to 100% in each investigated aquarium. During the investigation, 12 strains of V. vulnificus were isolated, and all 12 isolates were classified into biotype 1. Eleven of the 12 isolates belonged to the Clinical genotype, and one isolate belonged to the Environmental genotype. All 12 isolated V. vulnificus strains showed limited antibiotic resistance. Overall, our work demonstrated that V. vulnificus is frequently distributed in aquariums, thus constituting a threat to captive marine mammals and to public health.

Efficacy of Ceftriaxone, Cefepime, Doxycycline, Ciprofloxacin, and Combination Therapy for Vibrio vulnificus Foodborne Septicemia

Foodborne Vibrio vulnificus infections are associated with higher rates of sepsis and mortality than wound infections; however, antibiotic efficacy studies have not been performed in foodborne infection models. The efficacies of ceftriaxone, cefepime, doxycycline, ciprofloxacin, and combination therapy were assessed in V. vulnificus intestinal infection in mice in order to model foodborne infections. In accordance with prior studies of cefotaxime, cefepime was synergistic with doxycycline and ciprofloxacin in vitro; combination therapy significantly decreased bacterial growth, by ≥2 log₁₀ units, from that with antibiotic monotherapy (P < 0.01). In vivo, survival rates in the ceftriaxone (50%), doxycycline (79%), and ciprofloxacin (80%) groups were significantly higher than those in the control group (0%) (P < 0.0001). Survival was significantly higher with ceftriaxone-doxycycline (91%) or ceftriaxone-ciprofloxacin (100%) therapy than with ceftriaxone (50%) (P ≤ 0.05). Survival with cefepime-doxycycline (96%) or cefepime-ciprofloxacin (90%) therapy was significantly higher than that with cefepime alone (20%) (P < 0.001). There was no difference in survival between the combination therapy groups. Thus, we conclude that combination therapy was the most effective treatment for foodborne V. vulnificus septicemia. In a septic patient with a recent ingestion of raw seafood, cefepime in combination with doxycycline or ciprofloxacin should be initiated for coverage of resistant Gram-negative organisms and V. vulnificus pending a microbiological diagnosis. Once a diagnosis of foodborne V. vulnificus septicemia is established, treatment can safely transition to ceftriaxone in combination with doxycycline or ciprofloxacin.

Rapid identification of pathogens responsible for necrotizing fasciitis on an integrated microfluidic system

Necrotic fasciitis (NF) is a particularly aggressive and serious infection of the fascia that can penetrate into the musculature and internal organs, resulting in death if not treated promptly. In this work, an integrated microfluidic system composed of micropumps, microvalves, and micromixers was used to automate the detection of pathogens associated with NF. The entire molecular diagnostic process, including bacteria isolation, lysis, nucleic acid amplification and optical detection steps, was enacted on this developed system. Mannose binding lectin coated magnetic beads were first used as probes to isolate all bacteria in a sample. In this work, polymerase chain reaction assays featuring primers specific to genes from each of four NF-causing bacteria (Vibrio vulnificus, Aeromonas hydrophila, and methicillin-sensitive and resistant Staphylococcus aureus) were used to rapidly and exclusively verify the presence of the respective bacterial strains, and the limits of detection were experimentally found to be 11, 1960, 14, and 11 400 colony forming units/reaction, respectively; all values reflect improvement over ones reported in literature. This integrated microfluidic chip may then be valuable in expediting diagnosis and optimizing treatment options for those with NF; such diagnostic improvements could ideally diminish the need for amputation and even reduce the morality rate associated with this life-threatening illness.

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.

Atypical Wound Pathogens

BACKGROUND

Atypical wound pathogens may be so described because they are uncommon pathogens of soft tissue among human beings, or because they may be fastidious and difficult to recover/isolate in the laboratory.

METHODS

A review of pertinent English-language literature was performed.

RESULTS

These wound pathogens are a diverse lot, including aerobic and anaerobic gram-positive and gram-negative bacilli, non-tuberculous mycobacteria, and bacteria that cannot be characterized conventionally because they lack a cell wall (the Mycoplasmataceae). They are diverse with respect to their virulence, but many are opportunistic pathogens.

CONCLUSIONS

Among these atypical pathogens, clinical reports are most common of wound infections caused by Mycoplasma/Ureaplasma (sometimes as co-infecting agents), and the so-called rapidly growing non-tuberculous mycobacteria (Runyon Type IV; e.g., M. chelonae).