Guideline sources The following summarized guidelines for the evaluation and management of vibrio vulnificus infection are prepared by our editorial team based on guidelines from the Pathway (Pathway 2023), the European Association for the Study of the Liver (EASL 2022), the Center for Disease Control (CDC 2020), the Surgical Infection Society Europe (SIS-E/WSES 2018), the Eastern Association for the Surgery of Trauma (EAST 2018), the Korean Society of Infectious Diseases (KSID 2017), the Infectious Diseases Society of America (IDSA 2014), and the American Association of Family Physicians (AAFP 2007). 1 2 3 4 5 6 7 8 Guidelines 1. Diagnostic investigations Exposure history: As per Pathway 2023 guidelines, elicit recent history of exposures to potential sources of Vibrio vulnificus including: eating raw or undercooked seafood (oysters or other shellfish) contact with salt water or brackish water, including swimming, fishing, or walking on the beach survivors of hurricanes, storm surges, or coastal flooding. E As per CDC 2020 guidelines: https://web.pathway.md/diseases/rec9u7JFwjm9FBT7B 1/5 6/29/23, 3:43 AM Vibrio vulnificus infection Pathway Elicit a history of eating raw or undercooked shellfish, particularly oysters, or wound or soft tissue being exposed to salt water, brackish water, raw seafood, or juice or drippings from raw seafood. E Suspect vibriosis in patients with watery diarrhea recently eaten raw or undercooked seafood, especially oysters, or with a wound infection occurring after exposure to seawater. E As per IDSA 2014 guidelines, elicit a careful epidemiologic history (including exposure to raw seafood and seawater) in immunocompromised patients with skin and soft tissue infection to assess for potential exposure to Vibrio vulnificus. As per AAFP 2007 guidelines, suspect Vibrio vulnificus infection in patients with sepsis and severe skin lesions and ask them about recent raw oyster consumption. B Laboratory testing: diagnose Vibrio vulnificus infection based on the identification of bacteria in the stool, wound, or blood in patients with symptoms of Vibrio vulnificus infection. E Show 4 more Diagnostic imaging: consider obtaining diagnostic imaging to provide useful information when the diagnosis of necrotizing fasciitis is uncertain B while not delaying surgical consultation and intervention. B Show 2 more 2. Medical management Management of gastroenteritis: Do not offer treatment in mild cases. Advise drinking liquids to correct fluid loss from diarrhea. D Administer antibiotics in patients with severe illness. E Management of cellulitis and necrotizing fasciitis: As per CDC 2020 guidelines, suspect Vibrio vulnificus infection as a possible cause of infected wounds exposed to coastal waters. Initiate prompt antibiotic treatment to improve survival. E Show 2 more As per WSES 2018 guidelines: Ensure a multidisciplinary team approach in the management of patients with necrotizing soft tissue infection. B Initiate treatment of necrotizing infection early because of the rapid progression of the inflammatory process. B Initiate early and aggressive supportive treatment to halt the progression of the inflammatory process. A As per KSID 2017 guidelines, administer a combination therapy with a third-generation cephalosporin (such as cefotaxime IV 2 g every 8 hours or ceftriaxone IV 2 g every 24 hours) and doxycycline PO 100 mg BID or tetracycline in patients with skin and soft tissue infection suspected to be caused by Vibrio vulnificus (such as patients with alcohol-related liver cirrhosis or compromised liver function recently eaten seafood or come in contact with seawater). B https://web.pathway.md/diseases/rec9u7JFwjm9FBT7B 2/5 6/29/23, 3:43 AM Vibrio vulnificus infection Pathway As per IDSA 2014 guidelines, administer doxycycline IV 100 mg every 12 hours plus a cephalosporin (ceftriaxone IV 1 g QID or cefotaxime IV 2 g TID) in patients with skin and soft tissue infection caused by Vibrio vulnificus. Consider administering this regimen in pediatric patients only in life-threatening situations. Management of sepsis: As per Pathway 2023 guidelines, treat sepsis in patients with Vibrio vulnificus infection according to current published guidelines on sepsis and septic shock. E As per WSES 2018 guidelines, perform early source control, initiate antimicrobial therapy, and provide supportive care for the treatment of patients with sepsis or septic shock caused by necrotizing soft tissue infection. B 3. Therapeutic procedures Negative pressure wound therapy: consider offering negative pressure wound therapy for wound care after complete removal of necrosis in patients with necrotizing soft tissue infection. B 4. Surgical interventions Surgical debridement: As per CDC 2020 guidelines, pay careful attention to the wound site. Perform aggressive debridement or amputation of the infected limb as clinically necessary: debride necrotic tissue; perform fasciotomy or limb amputation in severe cases. E As per EAST 2018 guidelines, perform early initial debridement within 12 hours of diagnosis in patients with necrotizing soft tissue infection. B As per WSES 2018 guidelines: Perform surgical source control in patients with suspected necrotizing soft tissue infection as soon as possible, but at least within the first 12 hours after admission. B Consider performing the first surgical re-exploration within 12-24 hours and repeat re- explorations until the patient is free of necrosis. B As per IDSA 2014 guidelines, obtain prompt surgical consultation for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene. B As per AAFP 2007 guidelines, obtain prompt surgical evaluation for possible debridement in patients presenting with painful, rapidly progressive hemorrhagic bullae. B 5. Preventative measures Primary prevention: As per EASL 2022 guidelines, advise patients with hemochromatosis and iron overload to avoid direct handling and consumption of raw or undercooked shellfish and wound exposure to seawater since the Vibrio vulnificus is a siderophilic pathogen. E https://web.pathway.md/diseases/rec9u7JFwjm9FBT7B 3/5 6/29/23, 3:43 AM Vibrio vulnificus infection Pathway As per AAFP 2007 guidelines, advise patients with chronic liver disease or immunocompromising conditions to avoid eating raw or undercooked seafood and open wound exposure to warm seawater. B Clinical findings Symptoms Past medical history Abdominal pain ALD Chills CKD Confusion Cellulitis Diarrhea Diabetes mellitus Fever HBV infection Nausea HCV infection Shortness of breath Immunocompromising condition Vomiting Liver cirrhosis Malignancy Past events Necrotizing fasciitis Sepsis Hurricane, coastal flooding, or storm surges Social history Vital signs Consumption of raw or undercooked seafood Hypotension Exposure to salt water Signs of shock Wound contact with seawater Integument exam Neurological exam Ecchymosis Altered mental status Gangrene Hemorrhagic bullae Lab findings Maculopapular rash Skin blisters Vibrio vulnificus deoxyRNA Skin erythema Microbiological findings Skin wounds Tissue necrosis vibrio vulnificus culture Hematological findings blood platelet count References 1. Sartelli M, Guirao X, Hardcastle TC et al. 2018 WSES/SIS E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg. 2018 Dec 14;13 58. Open 2. Rondi B Gelbard, Paula Ferrada, D Dante Yeh et al. Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the https://web.pathway.md/diseases/rec9u7JFwjm9FBT7B 4/5 6/29/23, 3:43 AM Vibrio vulnificus infection Pathway Surgery of Trauma. J Trauma Acute Care Surg. 2018 Jul;85 1 208 214. Open 3. Centers for Disease Control and Prevention. Vibrio Species Causing Vibriosis: Information for Health Professionals & Laboratorians. CDC. 2020 Nov 16. Open 4. Stevens DL, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59 2):e10 52. Open 5. Michael H Bross, Kathleen Soch, Robert Morales et al. Vibrio vulnificus infection: diagnosis and treatment. Am Fam Physician. 2007 Aug 15;76 4 539 44. Open 6. Karapetyan H, Grigoryan A, Mullie L. Recommendations & Algorithms. Pathway Editors. Open 7. Yee Gyung Kwak, Seong Ho Choi, Tark Kim et al. Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection. Infect Chemother. 2017 Dec;49 4 301 325. Open 8. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on haemochromatosis. Hepatol. 2022 Aug;77 2 479 502. Open https://web.pathway.md/diseases/rec9u7JFwjm9FBT7B 5/5