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Vibrio vulnificus wound infection treated successfully with oral ciprofloxacin
88
Letters to the Editor Vibrio vulnificus w o u n d i n f e c t i o n t r e a t e d s u c c e s s f u l l y w i t h o r a l ciprofloxaein
Accepted for publication 20 July I 9 8 9 Sir, Over the past 20 years, Vibrio species other than Vibrio cholerae serogroup oI have become increasingly recognised as important pathogens in marine-related h u m a n infection. 1'~ A m o n g this group, Vibrio vulnificus in particular is associated with rapidly progressive syndromes of w o u n d infection and septicaemia. 3'~ On 6 July I987, a 69-year-old white male was admitted to hospital with 2 days' history of cellulitis involving the dorsal aspect of his right hand. H e had been peeling shrimps on the same day that swelling and pain in his hand began. T h e patient was in good health and not receiving any medication. Examination revealed a severe haemorrhagic cellulitis of the dorsal aspect of the right hand extending f r o m the metacarpal joints to the wrist. T h i s area was diffusely swollen and the skin was taut. T h e r e were several large bullae and areas of ecchymoses. A necrotic ulcer draining seropurulent fluid was located over the distal aspect of the third metacarpal bone. T h e patient was admitted to hospital and empirical therapy with ciprofloxacin 75o m g orally every ~2 h began. After 24 h, cellulitis had not progressed, the patient was afebrile, and the oedema and erythema of his hand had decreased. T h e w o u n d culture was positive for V. vulnificus while two sets of blood cultures were negative. Following discharge from hospital, the ciprofloxacin therapy was continued for a total of 3 weeks with complete resolution of the cellulitis and complete return of the hand to normal function. Unfortunately, the strain of V. vulnificus isolated did not survive for M I C and M B C tests to be done. However, two isolates obtained from two other patients at our institution were tested. T h e M I C and M B C for ciprofloxacin were very low. I n respect of one organism the M I C was o.o6 mg/1 and the M B C was o.o6 mg/1; in respect of the other organism the M I C was o'o5 mg/1 and the M B C was o'o 3 mg/1. Vibrio vulnificus w o u n d infection may be seen in otherwise healthy persons. Although not a significant cause of septicaemia and mortality, it does result in extensive tissue destruction, usually requiring surgical debridement and skin grafting. D u e to the rapid progression of this type of infection, antibiotic therapy m u s t be started empirically. L a b o r a t o r y as well as clinical data are limited and often conflicting as regards antibiotic therapy of V. vulnificus infections. Doxycycline has been considered the drug of choice.5 T h e severe ischaemia and necrosis that results f r o m V. vulnificus wound infection may limit the tissue penetration of antimicrobial agents. Ciprofloxacin may be effective due to its very low M I C s and M B C s , and its known ability to penetrate well into tissues. T h e unique site of action of the quinolones (inhibition of D N A - g y r a s e ) m a y also relate to the efficacy of ciprofloxacin. Our laboratory data indicate that further clinical and microbiological investigation of ciprofloxacin therapy for V. vulnificus infections should be made.
Department of Internal Medicine, Section on Infectious Diseases, Ochsner Clinic and Alton Ochsner Medical Foundation, 1514 Jefferson Highway, New Orleans, Louisiana 7oi2x, U.S.A.
Michael C. Meadors George A. Pankey
Letters to the Editor
89
References I. Fernandez CR, Pankey GA. Tissue invasion by unnamed marine vibrios. JAMA 1975; 233:1172-1176. 2. Hughes JM, Hollis DG, Gangarosa EJ, Weaver RE. Noncholera Vibrio infections in the United States. Ann Intern Med 1978; 88: 602-606. 3- Castillo LE, Winslow DL, Pankey GA. Wound infection and septic shock due to Vibrio vulnificus. Am J Trop Med Hyg 1981; 3o: 844-848. 4. Hills MK, Sanders CV. Localized and systemic infections due to Vibrio species. Infect Dis Clin NA I986; I : 687-707. 5. Morris JG Jr, Tenney J. Antibiotic therapy for Vibrio vulnificus infection. JAMA 1985; 253: 1121-1122.
W h i t h e r t h e s p e c i a l i s t in i n f e c t i o n ?
Accepted for publication 25 August 1989 Sir, D r Wilkins' article in the Journal of Infection last year (I8, 25--27) m u s t have given m a n y microbiologists food for thought. H e correctly describes the current status of infections in this country with increasing problems relating to nosocomial infection and reduced problems related to the well recognised infections. T h e sharp clinical end is now in the general hospital and not in the infectious diseases hospital. As a result, medical microbiologists have been driven to spend more and m o r e time on clinical microbiology, and infectious disease physicians are also adapting to the changed circumstances. H o w e v e r correct the diagnosis and description by D r Wilkins, I find the suggestion for homogenisation he puts forward not quite the right treatment. T h e main problem is the workload created by infection today. One has only to list the infection problems which arise in the c o m m u n i t y and in hospital to realise that a major increase in medical m a n p o w e r is needed to cope with the flood. A I D S is only one p r o b l e m and not the most time-consuming in most hospitals. O f the well recognised infectious diseases, salmoneltosis, listeriosis, campylobacter infection, meningitis, chlamydia, diarrhoea and n u m e r o u s virus diseases all compete for time. Floods of new antibiotics appear; but the largest increase by far in infectious workload has resulted from hospital-acquired infections among the increasing n u m b e r s of patients who have serious diseases, the m o d e r n therapy of which makes them vulnerable to infection. This produces m u c h work both in the laboratory and at the bedside. Also, hospital infections are becoming a p r i m e target for the litiginous. In addition, m a n y reports and recommendations on, for example, laboratory safety, cooked and chilled food preparation as well as the public health have to be absorbed, interpreted and implemented. F u r t h e r m o r e , all work is nowadays p e r f o r m e d in the full glare of government and the news media. T h e single-handed hospital practitioner in infection is an anachronism. Continuous 24 hour cover, 7 days a week, is needed more and more. T h e degree of expertise required is such that a considerable a m o u n t of sub-specialisation has already taken place, e.g. with virology, control of infection/epidemiology, molecular biology, clinical practice in infectious diseases and antimicrobial therapy. A year ago, I suggested that three consultants were needed in most districts to cope with the workload. T h i s was received with shock by some of m y colleagues but the trend of events is now flowing rapidly in that direction. Formation of departments of communicable disease is only a matter of time. F o r these, three major types of expertise are needed.
Letters to the Editor Vibrio vulnificus w o u n d i n f e c t i o n t r e a t e d s u c c e s s f u l l y w i t h o r a l ciprofloxaein
Accepted for publication 20 July I 9 8 9 Sir, Over the past 20 years, Vibrio species other than Vibrio cholerae serogroup oI have become increasingly recognised as important pathogens in marine-related h u m a n infection. 1'~ A m o n g this group, Vibrio vulnificus in particular is associated with rapidly progressive syndromes of w o u n d infection and septicaemia. 3'~ On 6 July I987, a 69-year-old white male was admitted to hospital with 2 days' history of cellulitis involving the dorsal aspect of his right hand. H e had been peeling shrimps on the same day that swelling and pain in his hand began. T h e patient was in good health and not receiving any medication. Examination revealed a severe haemorrhagic cellulitis of the dorsal aspect of the right hand extending f r o m the metacarpal joints to the wrist. T h i s area was diffusely swollen and the skin was taut. T h e r e were several large bullae and areas of ecchymoses. A necrotic ulcer draining seropurulent fluid was located over the distal aspect of the third metacarpal bone. T h e patient was admitted to hospital and empirical therapy with ciprofloxacin 75o m g orally every ~2 h began. After 24 h, cellulitis had not progressed, the patient was afebrile, and the oedema and erythema of his hand had decreased. T h e w o u n d culture was positive for V. vulnificus while two sets of blood cultures were negative. Following discharge from hospital, the ciprofloxacin therapy was continued for a total of 3 weeks with complete resolution of the cellulitis and complete return of the hand to normal function. Unfortunately, the strain of V. vulnificus isolated did not survive for M I C and M B C tests to be done. However, two isolates obtained from two other patients at our institution were tested. T h e M I C and M B C for ciprofloxacin were very low. I n respect of one organism the M I C was o.o6 mg/1 and the M B C was o.o6 mg/1; in respect of the other organism the M I C was o'o5 mg/1 and the M B C was o'o 3 mg/1. Vibrio vulnificus w o u n d infection may be seen in otherwise healthy persons. Although not a significant cause of septicaemia and mortality, it does result in extensive tissue destruction, usually requiring surgical debridement and skin grafting. D u e to the rapid progression of this type of infection, antibiotic therapy m u s t be started empirically. L a b o r a t o r y as well as clinical data are limited and often conflicting as regards antibiotic therapy of V. vulnificus infections. Doxycycline has been considered the drug of choice.5 T h e severe ischaemia and necrosis that results f r o m V. vulnificus wound infection may limit the tissue penetration of antimicrobial agents. Ciprofloxacin may be effective due to its very low M I C s and M B C s , and its known ability to penetrate well into tissues. T h e unique site of action of the quinolones (inhibition of D N A - g y r a s e ) m a y also relate to the efficacy of ciprofloxacin. Our laboratory data indicate that further clinical and microbiological investigation of ciprofloxacin therapy for V. vulnificus infections should be made.
Department of Internal Medicine, Section on Infectious Diseases, Ochsner Clinic and Alton Ochsner Medical Foundation, 1514 Jefferson Highway, New Orleans, Louisiana 7oi2x, U.S.A.
Michael C. Meadors George A. Pankey
Letters to the Editor
89
References I. Fernandez CR, Pankey GA. Tissue invasion by unnamed marine vibrios. JAMA 1975; 233:1172-1176. 2. Hughes JM, Hollis DG, Gangarosa EJ, Weaver RE. Noncholera Vibrio infections in the United States. Ann Intern Med 1978; 88: 602-606. 3- Castillo LE, Winslow DL, Pankey GA. Wound infection and septic shock due to Vibrio vulnificus. Am J Trop Med Hyg 1981; 3o: 844-848. 4. Hills MK, Sanders CV. Localized and systemic infections due to Vibrio species. Infect Dis Clin NA I986; I : 687-707. 5. Morris JG Jr, Tenney J. Antibiotic therapy for Vibrio vulnificus infection. JAMA 1985; 253: 1121-1122.
W h i t h e r t h e s p e c i a l i s t in i n f e c t i o n ?
Accepted for publication 25 August 1989 Sir, D r Wilkins' article in the Journal of Infection last year (I8, 25--27) m u s t have given m a n y microbiologists food for thought. H e correctly describes the current status of infections in this country with increasing problems relating to nosocomial infection and reduced problems related to the well recognised infections. T h e sharp clinical end is now in the general hospital and not in the infectious diseases hospital. As a result, medical microbiologists have been driven to spend more and m o r e time on clinical microbiology, and infectious disease physicians are also adapting to the changed circumstances. H o w e v e r correct the diagnosis and description by D r Wilkins, I find the suggestion for homogenisation he puts forward not quite the right treatment. T h e main problem is the workload created by infection today. One has only to list the infection problems which arise in the c o m m u n i t y and in hospital to realise that a major increase in medical m a n p o w e r is needed to cope with the flood. A I D S is only one p r o b l e m and not the most time-consuming in most hospitals. O f the well recognised infectious diseases, salmoneltosis, listeriosis, campylobacter infection, meningitis, chlamydia, diarrhoea and n u m e r o u s virus diseases all compete for time. Floods of new antibiotics appear; but the largest increase by far in infectious workload has resulted from hospital-acquired infections among the increasing n u m b e r s of patients who have serious diseases, the m o d e r n therapy of which makes them vulnerable to infection. This produces m u c h work both in the laboratory and at the bedside. Also, hospital infections are becoming a p r i m e target for the litiginous. In addition, m a n y reports and recommendations on, for example, laboratory safety, cooked and chilled food preparation as well as the public health have to be absorbed, interpreted and implemented. F u r t h e r m o r e , all work is nowadays p e r f o r m e d in the full glare of government and the news media. T h e single-handed hospital practitioner in infection is an anachronism. Continuous 24 hour cover, 7 days a week, is needed more and more. T h e degree of expertise required is such that a considerable a m o u n t of sub-specialisation has already taken place, e.g. with virology, control of infection/epidemiology, molecular biology, clinical practice in infectious diseases and antimicrobial therapy. A year ago, I suggested that three consultants were needed in most districts to cope with the workload. T h i s was received with shock by some of m y colleagues but the trend of events is now flowing rapidly in that direction. Formation of departments of communicable disease is only a matter of time. F o r these, three major types of expertise are needed.