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Reducing the Mortality of Vibrio vulnificus Infections

Combination antibiotic therapy reduced mortality in a Taiwanese cohort.

Vibrio vulnificus, a gram-negative bacillus that grows in warm salt water, can cause human infection via contact of wounds with seawater or from eating raw or inadequately cooked seafood, especially by patients with liver disease. Symptoms typically begin within 48 hours of ingesting the contaminated food. The usual clinical findings are fever, chills, hypotension, and erythematous plaques that rapidly evolve first into hemorrhagic bullae and then necrotic ulcers. Necrotizing fasciitis might develop. Cases occur worldwide but in restricted geographical areas, such as Taiwan, Korea, and the Gulf Coast states of the U.S. Although the organism is susceptible to many antibiotics, the optimal treatment is uncertain. The mortality rate is about 50%, with death commonly occurring within 48 hours of hospitalization. The authors of a retrospective study of 93 patients with V. vulnificus bacteremia admitted to five large medical centers in Taiwan from 1995 to 2003 examined whether any specific antibiotic program produced a better outcome than the others. These patients had received 1 or more of 13 different agents, alone and in various combinations.

The overall mortality rate was 33%. The authors divided the patients into those with hemorrhagic bullous skin lesions (63) and those without (30). Among those with cutaneous involvement, multivariate analysis showed that the combination of a third-generation cephalosporin and a tetracycline was associated with a statistically significant lower mortality rate (10%) than other antibiotic regimens.

Comment: V. vulnificus infections are potentially devastating, with a substantial fatality rate. In survivors, debridement of necrotic skin lesions is often necessary, sometimes to the extent of fasciotomy or limb amputation. In this report, 80% of the patients with cutaneous involvement underwent surgery. Previous studies have indicated an in vitro synergism between third-generation cephalosporins and tetracyclines, with the combination offering results superior to either agent alone. Given these results, a good program for suspected or confirmed V. vulnificus infection is intravenous ceftriaxone plus doxycycline.

— Jan V. Hirschmann, MD

Published in Journal Watch Dermatology November 17, 2006

Citation(s):

Liu JW et al. Prognostic factors and antibiotics in Vibrio vulnificus septicemia. Arch Intern Med 2006 Oct 23; 166:2117-23.

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