CDC Warns Doctors to Lookout for Flesh-eating Bacteria in Wounds

According to media reports, 13 people died recently from V. vulnificus infections, which can come from undercooked shellfish or from contact with the bacteria from open wounds.

Healthcare providers, laboratories, and public health departments need to be on the lookout for Vibrio vulnificus (V. vulnificus) infections in wounds that were exposed to coastal waters, particularly near the Gulf of Mexico or East Coast, and during periods with warmer coastal sea surface temperatures, the Centers for Disease Control and Prevention (CDC) warns.

Vibrio cause an estimated 80,000 illnesses each year in the United States. Most people with Vibrio infection have diarrhea. Some people might also have stomach cramping, nausea, vomiting, fever, and chills. One species, V. vulnificus, is known to cause life-threatening infections. About 150–200 V. vulnificus infections are reported to CDC each year and about one in five people with this infection die—sometimes within 1–2 days of becoming ill. According to media reports, 13 people died recently from V. vulnificus infections, which can come from undercooked shellfish or from contact with the bacteria from open wounds. The confirmed deaths have been in Florida, North Carolina, Connecticut and New York, the Post reported.

Vibrio naturally live in coastal waters, including salt water and brackish water, which is a mixture of salt water and fresh water. Most people get infected with Vibrio by eating raw or undercooked shellfish, particularly oysters. Some people get infected when an open wound is exposed to salt water or brackish water containing Vibrio, the CDC states. Extreme weather events, such as coastal floods, hurricanes, and storm surges, can force coastal waters into inland areas, putting people that are exposed to these waters—especially evacuees who are older or have underlying health conditions—at increased risk for Vibrio wound infections. 

V. vulnificus wound infections have a short incubation period and are characterized by necrotizing skin and soft tissue infection, with or without hemorrhagic bullae. Many people with V. vulnificus wound infection require intensive care or surgical tissue removal.

V. vulnificus bacteria thrive in warmer waters—especially during the summer months (May to October) and in low-salt marine environments like estuaries.  Amid increasing water temperatures and extreme weather events (e.g., heat waves, flooding, and severe storms) associated with climate change, people who are at increased risk for V. vulnificus infection should exercise caution when engaging in coastal water activities. Prompt treatment is crucial to reduce mortality from severe V. vulnificus infection. CDC continues to monitor reports of V. vulnificus infections.

CDC Recommendations for Healthcare Professionals
This guidance pertains to managing severe V. vulnificus wound infections.

Diagnosis

If V. vulnificus infection is suspected,

• • Obtain wound or hemorrhagic bullae cultures and send all V. vulnificus isolates to a local, state, territorial, or tribal public health laboratory.
    • Blood cultures are recommended in addition to wound and hemorrhagic bullae cultures if the patient is febrile, has hemorrhagic bullae, or has signs of sepsis.
  • Ask the patient or family about relevant exposures, including whether they entered coastal water with an open wound; acquired a scratch or a cut while in coastal water; or had open-wound contact with raw or undercooked seafood.

Clinical Management

• Early antibiotic therapy and early surgical intervention improve survival. Do not wait for consultation with an infectious disease specialist or laboratory confirmation of V. vulnificus infection to initiate treatment.
• Antibiotic therapy
  • Doxycycline (100mg orally or intravenously twice a day for 7–14 days) and a third-generation cephalosporin (e.g., ceftazidime 1–2g intravenously or intramuscularly every 8 hours) are recommended. 
  • Alternate regimens include a third-generation cephalosporin with a fluoroquinolone (e.g., 500mg ciprofloxacin orally twice a day) or a fluoroquinolone given alone. 
  • Children may also be treated with a combination regimen of a third-generation cephalosporin plus doxycycline or ciprofloxacin, or with an alternative regimen of trimethoprim-sulfamethoxazole plus an aminoglycoside. In selecting a regimen, clinicians should be aware of guidance from the American Academy of Pediatrics:
• Fluoroquinolones should not be used routinely as first-line agents in children younger than 18 years except when specific indications exist or in specific conditions for which there are no alternative agents (including oral agents) and the drug is known to be effective for the specific situation. 
• Use of tetracyclines as a class of drugs in pediatric patients historically has been limited because of reports that this class could cause permanent dental discoloration in children younger than 8 years. More recent data suggest that doxycycline can be administered for short durations (i.e., 21 days or less) without regard to the patient’s age. 
  • Doses should be appropriately adjusted for renal and hepatic function.
  • If appropriate, consult a microbiologist or infectious disease specialist.
• Give careful attention to the wound site. Necrotic tissue should be debrided. Severe cases might require aggressive debridement, fasciotomy, or amputation of the infected limb.

Clinician Reporting

• Healthcare professionals and clinical laboratories should report all cases to their local, state, territorial, or tribal health department.
• Healthcare professionals should consult their health department for guidance on when patients may return to childcare, school, or work.