Vibrio vulnificus

A Physician’s Guide to
Infection, Prevention & Treatment

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"This presentation is part of..."

This presentation is part of a national effort to promote education to health care providers, their high risk patients and other consumers regarding Vibrio vulnficus and ways to prevent it.

Vibrios

V. vulnificus

V. cholera 01

V. cholera non-01

V. parahaemolyticus

V. alginolyticus

V. fluvialis

V. hollisae

V. mimicus

V. carchariae

V. cincinnatiensis

V. damsela

V. furnissii

V. hollisae

V. metschnikovii

Vibrio vulnificus: What is it?

Occurs naturally in coastal waters - especially in warm months

Can cause illness: wound infections, gastroenteritis, primary septicemia

Associated foods - primarily raw oysters, but also clams, mussels, and crabs

Not the result of fecal pollution or poor product handling

Habitat

Oysters are filter-feeders

Vibrios attach to plankton

Oysters filter & concentrate vibrios in oyster tissues ~100x

Rapid multiplication in warm conditions after harvest

Optimal Conditions

Low salinity

Warm temperatures (86 - 95º F)

Best conditions in May-October

Highest number of cases same period

Illnesses Caused by
Vibrio vulnificus

Wound infections

Gastroenteritis

Primary septicemia

No outbreaks reported, only sporadic cases

Infective Dose

Unknown for healthy persons, but for high-risk people, septicemia can presumably occur with < 100 total organisms

Clinical Diagnosis

Culture of V. vulnificus from

wounds,

diarrheic stools, or

blood

Diagnosis

Symptoms

Gastrointestinal illness

Fever

Shock

After

Ingestion of raw seafood (especially oysters)

Wound infection after exposure to seawater

Wound infections

How

Contaminating an open wound with sea water harboring the organism, or

Lacerating part of the body on coral, fish, etc. followed by contamination with the organism.

Range from

Mild, self-limited lesions to

Rapidly progressive cellulitis and myositis

Can mimic clostridial myonecrosis

Gastroenteritis

Consumption of raw or undercooked seafood, primarily molluscan shellfish containing the organism can cause gastroenteritis in otherwise healthy individuals.

Primary Septicemia

Microorganism enters the blood stream

Resulting in septic shock

Hypotension (death in 90% cases)

Distinctive bulbous skin lesions

Followed by death in @ 50% of cases

Symptomology

Early ID & treatment critical, rapid progression into death

Extensive necrosis & tissue destruction around wounds and lower extremities, requiring surgical debridement to avoid amputation

Fluid leakage from capillaries into tissues causing shock

Septicemia - bacteria in blood

Key Characteristics

Highly invasive through host tissues

Resists host defenses

Very rapid growth in tissues, especially where iron present

Highly destructive of tissues - extracellular toxins & enzymmes

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Treatment

Wound infections & primary septicemia require antimicrobial treatment. Most effective:

tetracycline,

fluoroquinolones (e.g. ciprofloxacin);

3rd generation cephalosporins (e.g. ceftazidime),

aminoglycosides (e.g. gentaminicin)

Early administration may reduce morbidity & mortality associated with infection

People at High Risk

Liver disease - accounts for most cases of severe illness

Diseases of the stomach

Diabetes

AIDs or HIV positive

Impaired immune systems due to medication or chronic illness

Who’s getting sick?

5 states account for 79% of all cases in last decade (178/224)

Florida 36%

Texas 12%

Louisiana 11%

California 11%

Alabama 9%

Composite Sketch of the Victim

Male (85% of cases)

White (77%)

Hispanic 88% in California, 21% Texas

Asian 13% in Louisiana

40-59 years old (53 years mean & median)

Slightly younger in Texas & California

Restaurant or Home “Cooked”

70% ate shellfish in restaurants

More frequent in Texas 91% & Florida 79%; Louisiana, Alabama, California ~50%

26% ate shellfish at home

California 44%, Alabama 37%, Louisiana 29%, Florida 18%, Texas 3%

Comparative Risk

Persons with liver disease at very high risk for serious illness & death following exposure to V. vulnificus

RR of infection after exposure 30x higher for person with liver disease

RR of death 200x higher for those with liver disease

A Typical Case

40 - 75 year old male

Heavy drinker, cirrhosis

Unaware of or in denial about dietary risks

# oysters consumed: 3 - 12

Septicemia

50% mortality

Prevention

High risk groups should avoid consumption of raw shellfish (or any raw animal protein)

Cooking shellfish to certain temperatures for specified time periods will kill the organism (along with many other pathogens)

Warnings regarding high risk groups and raw shellfish consumption are required to be posted in Florida at restaurants and retail seafood markets

Industry and regulators are considering several post harvest treatments (PHTs) that could eliminate the organism in oysters including:

Irradiation

Mild pasteurization

Pressure treatments

Freezing and frozen storage

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Vibrio vulnificus, Florida, 2000

Investigation

1. Clinical confirmation

2. Epidemiological interviews

3. Traceback of shellfish source

Epidemiological Investigation

Date and time of shellfish consumption or other exposure

Date and time of symptom onset

Symptoms and duration

Pre-existing conditions

Date of hospitalization

Date of death (where applicable)

Traceback Investigation

NSSP Model Ordinance

for molluscan shellfish

classifies dealer types and requirements

shellfish tag information

dealer name and address

certification number

date of harvest

harvest location

Barriers to Traceback of Shellfish

Tags not kept by seller

Invoices not kept by seller

Numerous intermediate sellers

No leftover shellfish available

Information Coordination

Between physicians, laboratories and health departments

Between laboratories and health departments

Between state agencies

Between state and federal agencies

Recommendations for Clinicians

Urge at-risk patients to avoid eating raw shellfish; to eat only shellfish that has been thoroughly cooked.

Suspect V. vulnificus infection in those at risk who have recently eaten shellfish or been exposed to warm sea water.

Request specific testing for V. vulnificus in stool, blood or wound cultures.


	This presentation is part of a national effort to promote education to health care providers, their high risk patients and other consumers regarding Vibrio vulnficus and ways to prevent it.


	V. vulnificus
	V. cholera 01
	V. cholera non-01
	V. parahaemolyticus
	V. alginolyticus
	V. fluvialis
	V. hollisae

	V. mimicus
	V. carchariae
	V. cincinnatiensis
	V. damsela
	V. furnissii
	V. hollisae
	V. metschnikovii


	Occurs naturally in coastal waters - especially in warm months
	Can cause illness: wound infections, gastroenteritis, primary septicemia
	Associated foods - primarily raw oysters, but also clams, mussels, and crabs
	Not the result of fecal pollution or poor product handling


	Oysters are filter-feeders
	Vibrios attach to plankton
	Oysters filter & concentrate vibrios in oyster tissues ~100x
	Rapid multiplication in warm conditions after harvest


	Low salinity
	Warm temperatures (86 - 95º F)
	Best conditions in May-October
	Highest number of cases same period


	Wound infections
	Gastroenteritis
	Primary septicemia
	No outbreaks reported, only sporadic cases


	Unknown for healthy persons, but for high-risk people, septicemia can presumably occur with < 100 total organisms


	Culture of V. vulnificus from
		wounds,
		diarrheic stools, or
		blood


	Symptoms
		Gastrointestinal illness
		Fever
		Shock
	After
		Ingestion of raw seafood (especially oysters)
		Wound infection after exposure to seawater


	How
		Contaminating an open wound with sea water harboring the organism, or
		Lacerating part of the body on coral, fish, etc. followed by contamination with the organism.
	Range from
		Mild, self-limited lesions to
		Rapidly progressive cellulitis and myositis
		Can mimic clostridial myonecrosis


	Consumption of raw or undercooked seafood, primarily molluscan shellfish containing the organism can cause gastroenteritis in otherwise healthy individuals.


	Microorganism enters the blood stream
	Resulting in septic shock
	Hypotension (death in 90% cases)
	Distinctive bulbous skin lesions
	Followed by death in @ 50% of cases


	Early ID & treatment critical, rapid progression into death
	Extensive necrosis & tissue destruction around wounds and lower extremities, requiring surgical debridement to avoid amputation
	Fluid leakage from capillaries into tissues causing shock
	Septicemia - bacteria in blood


	Highly invasive through host tissues
	Resists host defenses
	Very rapid growth in tissues, especially where iron present
	Highly destructive of tissues - extracellular toxins & enzymmes


	Wound infections & primary septicemia require antimicrobial treatment. Most effective:
		tetracycline,
		fluoroquinolones (e.g. ciprofloxacin);
		3rd generation cephalosporins (e.g. ceftazidime),
		aminoglycosides (e.g. gentaminicin)
	Early administration may reduce morbidity & mortality associated with infection


	Liver disease - accounts for most cases of severe illness
	Diseases of the stomach
	Diabetes
	AIDs or HIV positive
	Impaired immune systems due to medication or chronic illness


	5 states account for 79% of all cases in last decade (178/224)
		Florida 36%
		Texas 12%
		Louisiana 11%
		California 11%
		Alabama 9%


	Male (85% of cases)
	White (77%)
		Hispanic 88% in California, 21% Texas
		Asian 13% in Louisiana
	40-59 years old (53 years mean & median)
		Slightly younger in Texas & California


	70% ate shellfish in restaurants
		More frequent in Texas 91% & Florida 79%; Louisiana, Alabama, California ~50%
	26% ate shellfish at home
		California 44%, Alabama 37%, Louisiana 29%, Florida 18%, Texas 3%


	Persons with liver disease at very high risk for serious illness & death following exposure to V. vulnificus
		RR of infection after exposure 30x higher for person with liver disease
		RR of death 200x higher for those with liver disease


	40 - 75 year old male
	Heavy drinker, cirrhosis
	Unaware of or in denial about dietary risks
	# oysters consumed: 3 - 12
	Septicemia
	50% mortality


	High risk groups should avoid consumption of raw shellfish (or any raw animal protein)
	Cooking shellfish to certain temperatures for specified time periods will kill the organism (along with many other pathogens)
	Warnings regarding high risk groups and raw shellfish consumption are required to be posted in Florida at restaurants and retail seafood markets
	Industry and regulators are considering several post harvest treatments (PHTs) that could eliminate the organism in oysters including:
		Irradiation
		Mild pasteurization
		Pressure treatments
		Freezing and frozen storage


	1. Clinical confirmation
	2. Epidemiological interviews
	3. Traceback of shellfish source


	Date and time of shellfish consumption or other exposure
	Date and time of symptom onset
	Symptoms and duration
	Pre-existing conditions
	Date of hospitalization
	Date of death (where applicable)


NSSP Model Ordinance
for molluscan shellfish
	classifies dealer types and requirements
	shellfish tag information
		dealer name and address
		certification number
		date of harvest
		harvest location


	Tags not kept by seller
	Invoices not kept by seller
	Numerous intermediate sellers
	No leftover shellfish available


	Between physicians, laboratories and health departments
	Between laboratories and health departments
	Between state agencies
	Between state and federal agencies


	Urge at-risk patients to avoid eating raw shellfish; to eat only shellfish that has been thoroughly cooked.
	Suspect V. vulnificus infection in those at risk who have recently eaten shellfish or been exposed to warm sea water.
	Request specific testing for V. vulnificus in stool, blood or wound cultures.