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Vibrio vulnificus Advisory for Healthcare Providers

Severe Vibrio vulnificus Infections Associated with Warming Coastal Waters

Posted Sept. 8, 2023. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.


The Centers for Disease Control and Prevention (CDC) has issued this Health Alert Network (HAN) Health Advisory to:

  • Notify healthcare providers, laboratories, and public health departments about recent reports of fatal Vibrio vulnificus (V. vulnificus) infections, including wound and foodborne infections.
  • Urge healthcare professionals to consider V. vulnificus as a possible cause of infected 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.
  • Share important guidance for managing V. vulnificus wound infections.

Background

Vibrio are bacteria that cause an estimated 80,000 illnesses each year in the United States. About a dozen species of Vibrio are pathogenic to humans. V. parahaemolyticus causes the most infections in the United States, accounting for about 40% of reported cases of vibriosis, followed by V. alginolyticus, which accounts for about 20%. 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.

Vibrio live in coastal waters, including salt water and brackish 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 water containing Vibrio or if an open wound comes in contact with raw or undercooked seafood. Extreme weather events, such as coastal floods, hurricanes, and storm surges, can put people that are exposed to these waters at increased risk for Vibrio wound infections.

Unlike other Vibrio species, V. vulnificus is primarily transmitted through open-wound contact with salt water or brackish water, but occasionally (in approximately 10% of cases) the bacteria also can infect people if they eat raw or undercooked shellfish. People at higher risk for wound infection include those with underlying health conditions such as liver disease, diabetes, and immunocompromising conditions. 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.

In the United States, V. vulnificus infections have been most commonly reported by Gulf Coast states. However, V. vulnificus infections in the Eastern United States increased eightfold from 1988–2018. During July–August 2023, several East Coast states, including Connecticut, New York, and North Carolina, have reported severe and fatal V. vulnificus infections.

Prompt treatment is crucial to reduce mortality from severe V. vulnificus infection. CDC continues to monitor reports of V. vulnificus infections.

Recommendations for Healthcare Professionals

Diagnosis: Consider V. vulnificus as a possible cause of infection in wounds that were exposed to coastal waters (especially in patients with a history of travel to the areas listed above) who are at higher risk for Vibrio infection, including those with underlying health conditions such as liver disease (including alcohol-associated liver cirrhosis), diabetes, and immunocompromising conditions.

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.
    • Contact SRHD Epidemiology before submitting specimens to WA Public Health Laboratory, at 509-869-3133.
    • 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: Initiate treatment promptly. 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.

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.

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.

Clinician Reporting: Vibriosis is a nationally notifiable disease. Healthcare professionals and clinical laboratories should report all cases within 24 hours to SRHD Epidemiology at 509-869-3133. We will help coordinate sending specimens to WA Public Health Laboratory.

Healthcare professionals should consult with SRHD for guidance on when patients may return to childcare, school, or work.

Recommendations for Laboratories: Clinical laboratories should submit known or suspected Vibrio isolates to the local, state, territorial, or tribal public health laboratory.

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