Septic shock due to Vibrio vulnificus serogroup 04 wound infection acquired from the Baltic Sea

Heatwave-associated Vibrio infections in Germany, 2018 and 2019

Background

Vibrio spp. are aquatic bacteria that prefer warm seawater with moderate salinity. In humans, they can cause gastroenteritis, wound infections, and ear infections. During the summers of 2018 and 2019, unprecedented high sea surface temperatures were recorded in the German Baltic Sea.

Aim

We aimed to describe the clinical course and microbiological characteristics of Vibrio infections in Germany in 2018 and 2019.

Methods

We performed an observational retrospective multi-centre cohort study of patients diagnosed with domestically-acquired Vibrio infections in Germany in 2018 and 2019. Demographic, clinical, and microbiological data were assessed, and isolates were subjected to whole genome sequencing and antimicrobial susceptibility testing.

Results

Of the 63 patients with Vibrio infections, most contracted the virus between June and September, primarily in the Baltic Sea: 44 (70%) were male and the median age was 65 years (range: 2–93 years). Thirty-eight patients presented with wound infections, 16 with ear infections, six with gastroenteritis, two with pneumonia (after seawater aspiration) and one with primary septicaemia. The majority of infections were attributed to V. cholerae (non–O1/non-O139) (n = 30; 48%) or V. vulnificus (n = 22; 38%). Phylogenetic analyses of 12 available isolates showed clusters of three identical strains of V. vulnificus, which caused wound infections, suggesting that some clonal lines can spread across the Baltic Sea.

Conclusions

During the summers of 2018 and 2019, severe heatwaves facilitated increased numbers of Vibrio infections in Germany. Since climate change is likely to favour the proliferation of these bacteria, a further increase in Vibrio-associated diseases is expected.

[Non-cholera Vibrio species - currently still rare but growing danger of infection in the North Sea and the Baltic Sea]

BACKGROUND

The abundance of non-cholera Vibrio spp. in the aquatic environment shows a positive correlation with water temperatures. Therefore, climate change has an important impact on the epidemiology of human infections with these pathogens. In recent years large outbreaks have been repeatedly observed during the summer months in temperate climate zones.

OBJECTIVE

To inform medical professionals about the potentially life-threatening diseases caused by non-cholera Vibrio spp.

MATERIAL AND METHODS

Review of the current literature on infections with non-cholera Vibrio spp. in general and on the epidemiological situation in Germany in particular.

RESULTS

Non-cholera Vibrio spp. predominantly cause wound and ear infections after contact with contaminated seawater and gastroenteritis after consumption of undercooked seafood. As there have not been mandatory notification systems for these pathogens in Germany up to March 2020, a high number of unreported cases must be assumed. Immunosuppressed and chronically ill patients have a much higher risk for severe courses of diseases. If an infection with non-cholera Vibrio spp. is suspected anti-infective treatment should be promptly initiated and surgical cleansing is often necessary for wound and soft tissue infections.

CONCLUSION

Due to the ongoing global warming an increased incidence of human infections with non-cholera Vibrio spp. must be expected in the future. Medical professionals should be aware of these bacterial pathogens and the potentially life-threatening infections in order to enable timely diagnostics and treatment.

[Vibrio vulnificus, an increasing threat of sepsis in Germany?]

BACKGROUND

The prevalence of Vibrio vulnificus heavily depends on the temperature and salinity of the sea water. In the course of climate change an increase in cases of fatal sepsis caused by V. vulnificus at the German Baltic Sea coast could be detected.

OBJECTIVE

To generate awareness for a life-threatening infection with increasing incidence in Germany.

MATERIAL AND METHODS

This article presents an overview of the current state of the literature followed by an exemplary description of cases with V vulnificus sepsis caused by contact with water in the Baltic Sea, which were treated at the Medical University in Greifswald in summer 2018.

RESULTS

In the presence of risk factors, such as liver and kidney diseases, immunosuppression and male sex, there is a danger of severe sepsis if damaged skin comes into contact with contaminated sea water. A pronounced organ dysfunction can frequently be found on admission. In these cases the diagnosis must be made promptly and timely surgical cleansing and antibiotic treatment should be initiated (e.g. a combination of tetracyclines and third generation cephalosporins).

CONCLUSION

Sepsis due to V. vulnificus will probably increase over the coming years. Because there is a latency in some cases between infection and onset of sepsis, physicians beyond the coastal region must also be informed about this disease.

Pathogenic vibrios in environmental, seafood and clinical sources in Germany

Bacteria of the family Vibrionaceae naturally occur in marine and estuarine environments. Only few species of Vibrionaceae are associated with human cases of gastroenteritis, ear and wound infections, caused by ingestion of seafood or contact with Vibrio containing water. Increasing consumption of seafood (fish, fishery products and shellfish) poses a possible source of Vibrio infections in Germany. Additionally, there is a growing concern that abundances of pathogenic vibrios may increase in German coastal waters as a result of e.g. climate change resulting in probably rising surface water temperatures. According to the One Health concept the VibrioNet consortium started in 2010 to investigate the occurrence and relevance of non-cholera vibrios of human concern in Germany. Vibrios from environmental, seafood and clinical sources were analyzed with the aim to find connections between different reservoirs or sources and to identify potential ways of transmission of these pathogens to assess the risk of infections associated with them. Potentially pathogenic strains mostly belong to the species Vibrio parahaemolyticus, Vibrio vulnificus and non-O1/non-O139 Vibrio cholerae. Investigations on imported seafood and mussels from primary production areas confirmed the frequent occurrence of these species. Moreover, studies of German coastal waters and sediments showed the presence and seasonality of these marine bacteria. So far the incidence of clinical cases of vibriosis in Germany is low. Between 1994 and 2013 thirteen cases of Vibrio spp. associated wound infections and/or septicaemia have been reported. However, the high prevalence of vibrios in aquatic environments and aquatic organisms is of concern and demands continued control of food and surveillance for clinical infections with pathogenic vibrios.

Climate change influences on marine infectious diseases: implications for management and society

Infectious diseases are common in marine environments, but the effects of a changing climate on marine pathogens are not well understood. Here we review current knowledge about how the climate drives host-pathogen interactions and infectious disease outbreaks. Climate-related impacts on marine diseases are being documented in corals, shellfish, finfish, and humans; these impacts are less clearly linked for other organisms. Oceans and people are inextricably linked, and marine diseases can both directly and indirectly affect human health, livelihoods, and well-being. We recommend an adaptive management approach to better increase the resilience of ocean systems vulnerable to marine diseases in a changing climate. Land-based management methods of quarantining, culling, and vaccinating are not successful in the ocean; therefore, forecasting conditions that lead to outbreaks and designing tools/approaches to influence these conditions may be the best way to manage marine disease.

Environmental occurrence and clinical impact of Vibrio vulnificus and Vibrio parahaemolyticus: a European perspective

Vibrio vulnificus and Vibrio parahaemolyticus are ubiquitous Gram-negative bacterial pathogens found naturally in marine and estuarine waters, and are a leading cause of seafood-associated bacterial illness. These pathogens are commonly reported in the USA and in many Asian countries, including China, Japan and Taiwan; however, there is growing concern that V. vulnificus and V. parahaemolyticus may represent an important and increasing clinical problem in Europe. Several factors underlie the need for a greater understanding of these non-cholera vibrios within a European context. First, there is a growing body of evidence to suggest that V. vulnificus and V. parahaemolyticus infections are increasing, and tend to follow regional climatic trends, with outbreaks typically following episodes of unusually warm weather. Such findings are especially alarming given current predictions regarding warming of marine waters as a result of global climatic change. Second, a myriad of epidemiological factors may greatly increase the incidence as well as clinical burden of these pathogens - including increasing global consumption and trade of seafood produce coupled to an increase in the number of susceptible individuals consuming seafood produce. Finally, there is currently a lack of detailed surveillance information regarding non-cholerae Vibrio infections in Europe, as these pathogens are not notifiable in many countries, which probably masks the true clinical burden of many human infections. This review will present a pertinent overview of both the environmental occurrence and clinical impact of V. vulnificus and V. parahaemolyticus in Europe.

Multiplex PCR assay for detection of Vibrio vulnificus biotype 2 and simultaneous discrimination of serovar E strains

In the present work we develop a multiplex PCR assay for the detection and identification of the fish pathogen Vibrio vulnificus biotype 2 with discriminating potential for zoonotic strains (serovar E). The PCR assay allowed the identification of two new biotype 2 serovar E human isolates from culture collections. Finally, the multiplex was successfully applied to both diagnosis and carrier detection in field samples.

Two cases of severe sepsis due to Vibrio vulnificus wound infection acquired in the Baltic Sea

Two severe cases of Vibrio vulnificus wound infection with secondary septicemia occurred during 1 week in August 2003 on the German island of Usedom in the southwestern Baltic Sea. In both cases, pre-existing wounds were inoculated by wading in contaminated sea water. One of the patients died from septic multiorgan failure. To the best of our knowledge, this is the first fatality due to a V. vulnificus infection to have occurred in Germany. Microbiological analysis revealed high concentrations of V. vulnificus in sea water along the coastline, following a period when water temperature exceeded 20 degrees C for more than 2 weeks.

Rapid detection of Vibrio vulnificus in shellfish and Gulf of Mexico water by real-time PCR

In this paper we describe optimization of SYBR Green I-based real-time PCR parameters and testing of a large number of microbial species with vvh-specific oligonucleotide primers to establish a rapid, specific, and sensitive method for detection of Vibrio vulnificus in oyster tissue homogenate and Gulf of Mexico water (gulf water). Selected oligonucleotide primers for the vvh gene were tested for PCR amplification of a 205-bp DNA fragment with a melting temperature of approximately 87 degrees C for 84 clinical and environmental strains of V. vulnificus. No amplification was observed with other vibrios or nonvibrio strains with these primers. The minimum level of detection by the real-time PCR method was 1 pg of purified genomic DNA or 10(2) V. vulnificus cells in 1 g of unenriched oyster tissue homogenate or 10 ml of gulf water. It was possible to improve the level of detection to one V. vulnificus cell in samples that were enriched for 5 h. The standard curves prepared from the real-time PCR cycle threshold values revealed that there was a strong correlation between the number of cells in unenriched samples and the number of cells in enriched samples. Detection of a single cell of V. vulnificus in 1 g of enriched oyster tissue homogenate is in compliance with the recent Interstate Shellfish Sanitation Conference guidelines. The entire detection method, including sample processing, enrichment, and real-time PCR amplification, was completed within 8 h, making it a rapid single-day assay. Rapid and sensitive detection of V. vulnificus would ensure a steady supply of postharvest treated oysters to consumers, which should help decrease the number of illnesses or outbreaks caused by this pathogen.

Sepsis with bullous necrotizing skin lesions due to vibrio vulnificus acquired through recreational activities in the Baltic Sea

This report describes the case of a 59-year-old woman with a history of non-Hodgkin's lymphoma who developed bacteremia with Vibrio vulnificus. The patient had been swimming in the unusually warm Baltic Sea in the summer of 2002. She presented with symptoms of septicemia and severe bullous necrotizing skin lesions of the extremities. Blood culture revealed Vibrio vulnificus as the pathogenic organism. Under treatment with cefotaxime and gentamicin, she recovered slowly without further complications. Vibrio vulnificus is a marine bacterium that is present in aquatic ecosystems worldwide, especially when water temperatures exceed 20 degrees C. Infections with Vibrio vulnificus are uncommon in Europe, and most cases are reported from subtropical or tropical regions.

Comparison of selective media for the detection of Vibrio vulnificus in environmental samples

AIMS

To compare two selective agars, cellobiose-colistin (CC) agar and a modification of the Vibrio vulnificus medium (VVMc agar), for the isolation of Vibrio vulnificus from environmental samples.

METHODS AND RESULTS

The efficiencies of recovery of V. vulnificus collection strains on CC, VVM, VVMc and on thiosulphate-citrate-bile salts-sucrose (TCBS) agar were compared and similar efficiencies were obtained. A slightly higher recovery was observed on VVMc agar. The detection of V. vulnificus in environmental samples (eels and water) was performed by combining culture-based methods (CC and VVMc agars) with DNA-based methods using species-specific probes based on the cytolysin-haemolysin and the 16S rDNA genes. A lower accompanying microbiota was found on CC agar than on VVMc agar.

CONCLUSION

The comparison between CC and VVMc agars confirms that both are useful for the detection of V. vulnificus in environmental samples. However, the use of any of these media should be combined with a species-specific probe.

SIGNIFICANCE AND IMPACT OF THE STUDY

The combined use of a selective medium and a specific probe provides a feasible method for the detection of V. vulnificus for epidemiological and ecological studies.

Low incidence of Vibrio vulnificus among Vibrio isolates from sea water and shellfish of the western Mediterranean coast

A specific search for Vibrio vulnificus in natural marine samples from the Spanish Mediterranean Sea was carried out by nested PCR and cultural approaches using thiosulphate-citrate-bile salts-sucrose agar (TCBS) and cellobiose-polymixin B-colistin agar (CPC), incubated at 40 degrees C, as selective media. Presumptive colonies were identified by PCR using specific primers against 23S rRNA sequences. This species was isolated from sea water and edible bivalves, mainly after preenrichment in alkaline peptone water (APW) at 40 degrees C followed by CPC agar. None of the V. vulnificus isolates identified corresponded to serovar E. Dominant Vibrio species on directly inoculated TCBS plates incubated at 25 degrees C were V. splendidus below 20 degrees C and V. harveyi and V. mediterranei above that temperature. Low percentages of several pathogenic vibrios were recorded but V. vulnificus was never recovered at this incubation temperature. The incidence of this species in the samples studied was lower than that described for other geographical areas, probably due to the high salinity values of the Mediterranean Sea.

Necrotizing fasciitis caused by Vibrio vulnificus: first published infection acquired in Turkey is the second time a strain is isolated in Germany

Vibrio vulnificus, a marine vibrio, has recently been recognized as a potential human pathogen. It causes human infections with mortality rates up to 60%. Until 1991, most human isolations were reported from the USA, Japan and Taiwan. The second strain isolated in Germany is documented and a significant case of V. vulnificus infection acquired in Turkey is published for the first time.

Genetic relatedness among environmental, clinical, and diseased-eel Vibrio vulnificus isolates from different geographic regions by ribotyping and randomly amplified polymorphic DNA PCR

Genetic relationships among 132 strains of Vibrio vulnificus (clinical, environmental, and diseased-eel isolates from different geographic origins, as well as seawater and shellfish isolates from the western Mediterranean coast, including reference strains) were analyzed by random amplified polymorphic DNA (RAPD) PCR. Results were validated by ribotyping. For ribotyping, DNAs were digested with KpnI and hybridized with an oligonucleotide probe complementary to a highly conserved sequence in the 23S rRNA gene. Random amplification of DNA was performed with M13 and T3 universal primers. The comparison between ribotyping and RAPD PCR revealed an overall agreement regarding the high level of homogeneity of diseased-eel isolates in contrast to the genetic heterogeneity of Mediterranean isolates. The latter suggests the existence of autochthonous clones present in Mediterranean coastal waters. Both techniques have revealed a genetic proximity among Spanish fish farm isolates and a close relationship between four Spanish eel farm isolates and some Mediterranean isolates. Whereas the differentiation within diseased-eel isolates was only possible by ribotyping, RAPD PCR was able to differentiate phenotypically atypical isolates of V. vulnificus. On the basis of our results, RAPD PCR is proposed as a better technique than ribotyping for rapid typing in the routine analysis of new V. vulnificus isolates.

Occurrence of Vibrio vulnificus biotypes in Danish marine environments

During the unusually warm summer in Denmark in 1994, 11 clinical cases of Vibrio vulnificus infection were reported. These reports initiated an investigation of the occurrence of V. vulnificus biotypes in Danish marine environments. Samples of coastal water, sediment, shellfish, and wild fish were analyzed by preenrichment in alkaline peptone water amended with polymyxin B (2.0 x 10(4) U/liter) followed by streaking onto modified cellobiose-polymyxin B-colistin agar. V. vulnificus-like colonies were tested with a V. vulnificus-specific DNA probe. Low densities of V. vulnificus were detected in water (0.8 to 19 CFU/liter) from June until mid-September and in sediment (0.04 to > 11 CFU/g) from July until mid-November. The presence of V. vulnificus was strongly correlated with water temperature. However, we isolated V. vulnificus from water from a mussel farm at a lower temperature than previously reported (7 degrees C). In 1 of the 13 locations studied, V. vulnificus was found in mussels in 7 of 17 samples analyzed; this is the first report of V. vulnificus in European shellfish. V. vulnificus was also isolated from gills, intestinal contents, and mucus from wild fish. Although biotyping of 706 V. vulnificus strains isolated during our investigations revealed that the majority of the strains (99.6%) belonged to biotype 1, biotype 2 was detected in seawater at a low frequency (0.4%). Our findings provide further evidence that seawater can serve as a reservoir and might facilitate spread of V. vulnificus biotype 2 to eels, with subsequent spread to persons handling eels. In conclusion, our data demonstrate that V. vulnificus is ubiquitous in a temperature marine environment and that V. vulnificus biotype 2 is not strictly confined to eels.

Phenotypic and genotypic characterization of Vibrio vulnificus: proposal for the substitution of the subspecific taxon biotype for serovar

The classification of Vibrio vulnificus strains into two biotypes has been maintained on the basis of phenotypic properties and eel virulence. Biotype 2 is virulent for eels, negative for the indole reaction, and serologically homogeneous (serogroup E), whereas strains of biotype 1 are avirulent, indole positive, and serologically heterogeneous. In the present study, we phenotypically and genotypically characterized 21 V. vulnificus isolates, recovered mainly from northern Europe, by comparing them with reference strains of both biotypes to look for new isolates of biotype 2. The results of this work revealed that the majority of isolates virulent for eels presented phenotypic traits previously considered characteristics of biotype 2 and specific ribotypes with HindIII. However, among the new isolates we found (i) a serogroup E strain virulent for eels but indole positive and (ii) one isolate not belonging to serogroup E but pathogenic for eels. Since no biochemical test for specific serogroup can with certainty be associated with eel virulence, we propose to classify V. vulnificus strains into serovars instead of biotypes. Thus, we suggest serovar E as the denomination of those strains previously classified as biotype 2. Finally, the occurrence of serogroup E in eels cultured in Norway and Sweden, as well as from human infections and shrimp, has been demonstrated.