Skin and soft tissue infections following marine injuries and exposures in travelers

Advancements in seawater immersion wound management: Current treatments and innovations

With advancements in naval warfare, the number and severity of seawater injuries have skyrocketed, necessitating effective seawater immersion (SWI) wound management. The unique marine pathogens, salinity, low temperature and alkalinity of seawater are the main environmental factors that can influence SWI wound healing. The current treatment strategy for SWI wounds follows a standard protocol based on terrestrial wound conditions, neglecting seawater conditions. The key requirements for ideal SWI treatment include good adhesion to the wound surface to minimize further exposure to seawater, enhanced wound healing properties to minimize wound healing time and antibacterial properties to prevent infections from marine pathogens. Current SWI wound-specific treatments range from elaborate techniques like vacuum-sealed drainage and vacuum-assisted closure for severe blast injuries to simple application of hydrogels or collagen dressings for minor injuries. This review discusses the current status and development of various treatment modalities for SWI wounds. The development of these treatment strategies and an understanding of their mechanisms of action make us better prepared to manage and treat SWI injuries.

Impact of Climate Change on Cellulitis: A Literature Review

Climate change is a phenomenon that has had, and will continue to have, wide-ranging effects on the world in both the near and distant future. With regards to human health, research has demonstrated the impact of climate change on heat-related illness, mental health, and vector-borne infectious diseases. Through a review of the literature, this paper aims to elucidate both current and future consequences of climate change on cellulitis, a type of skin infection that is associated with significant morbidity, mortality, and cost. Factors such as elevated temperature, pollution, rising sea levels, and the increased frequency of natural disasters pose an alarming risk for the increased proliferation of infections such as cellulitis. Lastly, in light of these trends, this paper will address potential strategies individuals can implement to reduce the effects of climate change on cellulitis.

Clinical Presentation and Outcomes Following Infection With Vibrio spp, Aeromonas spp, Chromobacterium violaceum, and Shewanella spp Water-Associated Organisms in Tropical Australia, 2015-2022

Background

Water-associated bacterial infections cause a wide spectrum of disease. Although many of these infections are typically due to human host commensal Staphylococcal or Streptococcal spp, water exposure can result in infections with environmental gram negatives such as Vibrio spp, Aeromonas spp, Chromobacterium violaceum, and Shewanella spp (collectively VACS).

Methods

We performed a retrospective analysis of the epidemiology, clinical presentation, and outcomes of deep and superficial infections associated with VACS organisms in our health service between 1 January 2015 and 31 December 2023.

Results

We identified 317 patient episodes of infection with VACS organisms over this period. Of these, Aeromonas spp (63%) was the most common, followed by Vibrio spp (19%), Shewanella spp (13%), and C violaceum (5%). The majority were isolated from males (74.4%) and involved the lower limb (67.5%). Mild infections were more common than severe presentations, with only 15 (4.7%) admissions to the intensive care unit and 8 (2.5%) deaths. Colonization occurred in 6.9% of patients, in contrast to the perceived severity of some of these bacteria. Copathogens were common and included Staphylococcus aureus (48%) and enteric bacteria (57%). The majority of patients (60%) had no documented water exposure. Initial empiric antimicrobial therapy presumptively covered the susceptibilities of the isolated organisms in 47.3% of patients; however, a lack of VACS-covering empirical therapy was not associated with readmission.

Conclusions

The isolation of a VACS organism in our setting was often not associated with documented water exposure, which has implications for empiric antimicrobial therapy. Severe disease and death were uncommon.

Infection dynamics of Shewanella spp. in Nile tilapia under varied water temperatures: A hematological, biochemical, antioxidant-immune analysis, and histopathological alterations

In aquaculture, fluctuating water temperatures can act as a potent stressor, influencing the virulence and transmission dynamics of pathogenic bacteria, potentially triggering outbreaks and impacting fish health. The purpose of this work was to examine the impact of Shewanella spp. infection on hematological, biochemical, and antioxidant-immune parameters of Nile tilapia (Oreochromis niloticus) under different water temperatures. For this purpose, 180 fish were divided into 6 groups in triplicate (30 fish per group; 10 fish per replicate). Group 1 (G1), G2, and G3 were reared at varying water temperatures (22 °C, 28 °C, and 31 °C, respectively) without infection. While G4, G5, and G6 were IP-injected with 0.2 mL of Shewanella spp. (0.14 × 105) and reared at 22 °C, 28 °C, and 31 °C, respectively. Shewanella spp. infection induced significant lowering (p < 0.05) in hematological parameters (red and white blood cells, hemoglobin, and packed cell volume%) and immune-antioxidant responses (phagocytic activity%, phagocytic index, lysozyme, nitric oxide), total antioxidant capacity, catalase, and reduced glutathione, especially at 22 °C. Moreover, a significant increase (p < 0.05) in the hepato-renal function indicators (alanine aminotransferase, aspartate aminotransferase, urea, and creatinine), stress biomarkers (glucose and cortisol), malondialdehyde, and pro-inflammatory cytokines (interleukin-1β and tumor necrosis factor-α) were the consequences of the Shewanella spp. infection, especially at 22 °C. The Shewanella spp. infection exhibited marked histopathological changes in the hepatic and renal tissues. Worthily, Shewanella spp. can cause detrimental alterations in Nile tilapia's hematological, biochemical, and antioxidant-immune parameters at various water temperatures, but the major detrimental changes were observed at a water temperature of 22 °C. Consequently, we can conclude that the infection dynamics of Shewanella spp. are exaggerated at 22 °C. These outcomes could help in understanding the nature of such an infection in Nile tilapia.

Streptococcus iniae in aquaculture: a review of pathogenesis, virulence, and antibiotic resistance

One of the main challenges in aquaculture is pathogenic bacterial control. Streptococcus iniae stands out for its ability to cause high mortality rates in populations of commercially important fish populations and its recent recognition as an emerging zoonotic pathogen. The rise in identifying over 80 strains some displaying antibiotic resistance coupled with the emerging occurrence of infections in marine mammal species and wild fish underscores the urgent need of understanding pathogenesis, virulence and drug resistance mechanisms of this bacterium. This understanding is crucial to ensure effective control strategies. In this context, the present review conducts a bibliometric analysis to examine research trends related to S. iniae, extending into the mechanisms of infection, virulence, drug resistance and control strategies, whose relevance is highlighted on vaccines and probiotics to strengthen the host immune system. Despite the advances in this field, the need for developing more efficient identification methods is evident, since they constitute the basis for accurate diagnosis and treatment.

Enhancing Vibrio vulnificus infection diagnosis for negative culture patients with metagenomic next-generation sequencing

Objective

To evaluate the diagnostic value of metagenomic next-generation sequencing (mNGS) in Vibrio vulnificus (V. vulnificus) infection.

Methods

A retrospective analysis of patients with V. vulnificus infection at the Fifth Affiliated Hospital of Sun Yat-Sen University from January 1, 2020 to April 23, 2023 was conducted. 14 enrolled patients were diagnosed by culture or mNGS. The corresponding medical records were reviewed, and the clinical data analyzed included demographics, epidemiology laboratory findings, physical examination, symptoms at presentation, antibiotic and surgical treatment, and outcome.

Results

In this study, 78.6% (11/14) patients had a history of marine trauma (including fish stab, shrimp stab, crab splints and fish hook wounds), 7.1% (1/14) had eaten seafood, and the remaining 14.3% (2/14) had no definite cause. Isolation of V. vulnificus from clinical samples including blood, tissue, fester and secreta. 9 cases were positive for culture, 5 cases were detected synchronously by mNGS and got positive for V. vulnificus. 85.7% (12/14) cases accepted surgical treatment, with 1 patient suffering finger amputated. 14 enrolled patients received appropriate antibiotic therapy, and all of them had recovered and discharged. 9 strains V. vulnificus isolated in this study were sensitive to most beta-lactam antibiotics, aminoglycosides, quinolones, etc.

Conclusion

Vibrio vulnificus infection is a common water-exposed disease in Zhuhai, which requires identification of a number of pathogens. Of severe infections with unknown pathogen, mNGS can be used simultaneously, and the potential to detect multiple pathogens is of great help in guiding treatment.

Predatory bacteria as potential biofilm control and eradication agents in the food industry

Biofilms are a major concern within the food industry since they have the potential to reduce productivity in situ (within the field), impact food stability and storage, and cause downstream food poisoning. Within this review, predatory bacteria as potential biofilm control and eradication agents are discussed, with a particular emphasis on the intraperiplasmic Bdellovibrio-and-like organism (BALO) grouping. After providing a brief overview of predatory bacteria and their activities, focus is given to how BALOs fulfill four attributes that are essential for biocontrol agents to be successful in the food industry: (1) Broad spectrum activity against pathogens, both plant and human; (2) Activity against biofilms; (3) Safety towards humans and animals; and (4) Compatibility with food. As predatory bacteria possess all of these characteristics, they represent a novel form of biofilm biocontrol that is ripe for use within the food industry.

Antimicrobial efficacy of composite irrigation solution against dominant pathogens in seawater immersion wound and in vivo wound healing assessment

Seawater immersion wound is inevitably accompanied by bacterial infection. Effective irrigation is critical for bacterial infection prevention and wound healing. In this study, the antimicrobial efficacy of a designed composite irrigation solution against several dominant pathogens in seawater immersion wounds was evaluated, and in vivo wound healing assessment was conducted in a rat model. According to the time-kill result, the composite irrigation solution exhibits excellent and rapid bactericidal effect against Vibrio alginolyticus and Vibrio parahaemolyticus within 30 s of treatment while eliminating Candida albicans, Pseudomonas aeruginosa, Escherichia coli, and the mixed microbes after 1 h, 2 h, 6 h, and 12 h of treatment, respectively. Significant bacterial count reduction of Staphylococcus aureus was observed after 5 h treatment. In addition to its skin non-irritating attribute, the in vivo wound healing results further demonstrated that the irrigation solution showed high repair efficiency in the skin defect model inoculated with the mixed microbes. The wound healing rate was significantly higher than that of the control and normal saline groups. It could also effectively reduce the number of viable bacteria on the wound surface. The histological staining indicated that the irrigation solution could reduce inflammatory cells and promote collagen fibers and angiogenesis, thereby promoting wound healing. We believed that the designed composite irrigation solution has great potential for application in the treatment of seawater immersion wounds.

Bacteremia With Oral Prevotella Salivae in an 18-Year-Old After a Water Skiing Fall Into a Freshwater Lake

Freshwater exposure is associated with a diverse range of infections from pathogens present in soil and water. This includes skin and soft tissue infections and wound infections, gastrointestinal infections, and central nervous system infections acquired through recreational exposure or trauma. Case reports of freshwater-associated infections typically focus on waterborne pathogens as the cause of illness; however, patients who experience significant physical trauma during freshwater exposure may also be at increased risk for infection with their own flora if the nature of the injury allows entry of bacteria through a mechanism such as mucosal injury. Here, we present a case of a healthy 18-year-old man who rapidly developed bacteremia with oral flora following several falls submerging his face into lake water while water skiing, as well as acute polymicrobial sinusitis and subsequent pre-septal cellulitis. Shortly after his water skiing falls, the patient developed sinusitis that rapidly progressed to headaches, emesis, and significant periorbital swelling. Blood cultures grew Prevotella salivae, a bacterium naturally found in the oral cavity. Sinus cultures grew Klebsiella aerogenes and Listeria monocytogenes, which may be associated with lake water. The infection improved with antibiotic therapy, and the patient was discharged on a regimen of amoxicillin/clavulanic acid and trimethoprim-sulfamethoxazole. Reports of bacteremia with oral flora following freshwater injury are not typically reported, and to our knowledge, this is the first report describing bacteremia with P salivae.

Multiorgan Dysfunction With Severe Cardiac Injury Secondary to Septic Cellulitis Due to Vibrio parahaemolyticus

Vibrio parahaemolyticus infection commonly manifests as gastroenteritis, including diarrhea, abdominal pain, nausea, vomiting, and fever. Although uncommon, V. parahaemolyticus has also been associated with wound infection and septic shock. These two manifestations have not been well-reported in medical literature, yet may yield a high risk of death, thus requiring emergent interventions. We present a case of a 42-year-old patient who developed septic shock secondary to a bullous necrotic wound and diarrhea due to V. parahaemolyticus. Multi-organ dysfunction syndrome with extreme cardiac injury developed very early in the course of the disease, prompting ICU admission and management with antibiotics, fluid resuscitation, vasopressors, blood purification, and surgical debridement. The treatment achieved a good clinical outcome. To the best of our knowledge, this is the first case report of V. parahaemolyticus-induced cardiomyopathy. V. parahaemolyticus should be considered as one of the causative agents in patients with sepsis due to cellulitis, particularly in patients with a suggestive history, such as exposure to seawater or eating seafood.

Red legs: how to differentiate between cellulitis, venous eczema and lipodermatosclerosis

Community nurses often encounter people with red legs. There are a number of reasons why an individual may develop red legs. The most common causes of red legs are cellulitis, venous eczema and lipodermatosclerosis. All have different causes and require different treatments. This article aims to enable readers to differentiate between these conditions which can appear similar, and to offer effective evidence-based care.

Envenoming by a Marine Blood Worm (Glycera)

Bites from venomous marine annelid ‘bloodworms’ (e.g., Glycera spp.) do not appear to have been described in the medical literature despite being seemingly well-known to bait diggers and fishermen. The few laboratory study reports describe their venom composition and physiological effects in vitro to be primarily proteolytic enzymes and neurotoxins apparently used for predation and defense. Herein, we present the report of a symptomatic envenoming suffered by a marine ecologist bitten while performing her field research. The local effects included a rapid onset of pain, swelling, and numbness at the bite site “as if injected with local anesthetic”. Additional signs and symptoms appearing over a two-week period were consistent with both delayed venom effects and potentially secondary infection. The late signs and symptoms resolved during a course of antibiotic treatment with doxycycline prescribed as a precaution and lack of resources to consider a wound culture. Comments about annelid bites sporadically appear in the popular literature, especially pertaining to the fishing industry, under names such as ‘bait-diggers hand’. While these bites are not known to be dangerously venomous, they seem to produce painful local symptoms and possibly increase the risk of marine bacterial infections that could be associated with more serious outcomes. More cases need to be formally described to better understand the natural history of these types of envenomation.

Clinical characteristics and risk factors of Aeromonas bloodstream infections in patients with hematological diseases

BACKGROUND

To analyze the clinical features, risk factors and outcomes of Aeromonas bloodstream infections (BSIs) in patients with hematological diseases to establish an effective optimal therapy against it.

METHODS

A retrospective study was performed by reviewing medical records of patients admitted to a tertiary blood disease hospital in China. Patients with hematological diseases who suffered from Aeromonas bacteremia during January 2002 to December 2020 were enrolled in this study.

RESULTS

A total of 63 patients who developed Aeromonas bacteremia were enrolled in the study, and 91.9% of patients were neutropenic at the onset of BSIs. The major complications were skin and soft tissue infection (SSTI) (22.2%), followed by gastroenteritis (19.0%) and pneumonia (14.3%). High carbapenem resistance rates (70.8% for imipenem, 71.4% for meropenem) were note among the cases. Furthermore, Aeromonas strains isolated from five individuals developed resistance to quinolone, β-lactams and tigecycline during the therapy. The 30-day mortality rate was 15.9%, while bacteremia with SSTI showed a much worse prognosis, with 50.0% (7/14) of the patients dying within 30 days of initiating the therapy. In the multivariate analysis, SSTI (OR = 28.72; 95% CI, 1.50-551.30; P = 0.026) and shock (OR = 47.58; 95% CI,1.06-2126.80; P = 0.046) were independent risk factors for mortality.

CONCLUSIONS

Aeromonas bacteremia usually occurred in patients with neutropenic status, and patients with SSTIs were more likely to show a worse prognosis. Carbapenems should be avoided in patients with Aeromonas BSIs and SSTIs given high resistance rate.

Infections following stingray attacks: A case series and literature review of antimicrobial resistance and treatment

BACKGROUND

Injuries sustained following stingray attacks are at high risk of infection and can progress to serious, debilitating consequences for the patient if not appropriately addressed. Antibiotic treatment of such infections is important to minimise the morbidity experienced by patients. However, antibiotic guidelines relating specific to this patient group are not well established. This study aims to report the experience of a single institution at treating stingray associated wound infections and to review the literature for reported cases. Additionally, we review the microbiological risk in these patients and summarise the literature surrounding antibiotic choice.

METHODS

A retrospective review of all patients presenting with injuries sustained following stingray attacks was conducted at a single institution. Additionally, a comprehensive literature review was conducted to identify cases of infected stingray associated trauma and review the causative micro-organisms and antibiotics used to treat such infections.

RESULTS

22 cases of stingray injuries were identified from a single institution. Of these, eight infections were reported. One case grew a highly resistant Vibrio species. Among the literature, 18 cases of infections were identified many of which led to significant complications for patients. The micro-organisms identified were diverse and there was little consistency among the antibiotic regimens utilised.

CONCLUSION

Based on the antibiotic susceptibilities of causative bacteria along with extrapolation from recommendations and guidelines identified in the literature, ciprofloxacin, doxycycline and trimethoprim-sulfamethoxazole appear to be the most appropriate antibiotics choices for prophylaxis or treatment of localised infection. Antibiotic choices for the empiric treatment of systemic infection requires further research and clarification.

Watercraft propellers as a mechanism of orthopaedic injuries: injury patterns, management, and complications

INTRODUCTION AND PURPOSE

Recreational watercraft use is popular across the United States, and there is a high rate of injury associated with the use and misuse of these vehicles. Watercraft propeller injuries represent a particularly devastating mechanism of injury. We aim to describe and analyze the range of orthopaedic injuries sustained from a watercraft propeller with a particular focus on the mechanism, injury pattern, management, and complications associated with these unique, high-energy injuries.

MATERIALS AND METHODS

A retrospective review of 42 patients who sustained injuries from watercraft propeller that presented to a level 1 trauma center was performed. Data collected included patient demographics, mechanism of injury, surgical management, antibiotic use, and complications.

RESULTS

Forty-two patients sustained 96 fractures. Ninety-one fractures (94.8%) were open and 5(5.2%) were closed. Twenty (20.8%) were of the upper extremity, 70(72.9%) were of the lower extremity, and 6(6.3%) were of the pelvic ring. The majority of open fractures were Gustilo-Anderson Type IIIA or greater (54, 59.3%). There were 9 total infections affecting 8 of 96 fracture sites (cumulative risk of 8.3%), and other complications included stiffness (3), heterotopic ossification (1), non-union (1), flap failure (1), DVT (2), PE (1), and systemic infection (1) for a total of 19 complications.

CONCLUSIONS

Watercraft propellers often result in devastating injuries with high rates of morbidity. The high rate of open fractures and neurovascular injury, necessity for multiple surgeries, and extended length of hospital stay show the need for continued awareness about boat safety and the danger of propellers.

Acquisition of antibiotic resistance genes on human skin after swimming in the ocean

The skin is a complex organ responsible for protecting the body from physical, chemical and biological insults. The skin microbiome is known to play an important role in protecting the host from skin infections. This study examined the skin microbiome and the changes in antibiotic resistance genes (ARGs), antibiotic biosynthesis genes (ABSGs) and virulence factor genes (VFGs) on human skin before and after swimming in the ocean. Skin microbiome samples were collected from human participants before and after they swam in the ocean, and at 6 h and 24 h post-swim. The samples were analyzed using 16S rRNA gene and shotgun metagenomic sequencing. The results showed that not only is the skin microbiome composition altered after swimming, but the abundance and diversity of ARGs, ABSGs and VFGs on the skin increased post-swim. Overall, there was an increase in total ARGs by 70.6% from before to after swimming. The elevated number of ARGs persisted and continued to increase for at least 6 h post-swim with greater than a 300% increase in comparison with samples collected before ocean swimming. The outcomes of the study support the epidemiological observations of increased risk of skin infections after swimming in the ocean. Cleaning the skin immediately after recreational ocean activities is recommended to reduce the opportunity for infection.

Endocarditis caused by Thalassospira sp

We report a case of an infective endocarditis caused by a Thalassospira sp. in a 53-year-old man with pre-existing valvular lesions and living in French Polynesia as a fisherman. The strain was identified with DNA-sequecing methods while it was not by mass spectrometry.

Marine Penetrating Injury to the Shoulder of Uncertain Origin

Penetrating injuries from marine animals are rare events; however, published case reports have detailed critical injuries including death occurring as a result of such incidents. We present a case of a marine penetrating injury to the right posterolateral shoulder of a 10-y-old boy. The patient underwent open surgical debridement and a course of oral antibiotics before returning to normal function. Clinicians should have an appreciation of various clinical patterns of marine penetrating wounds, the need for prompt imaging to exclude foreign bodies, and appropriate antibiotics to cover gram-negative bacteria and Vibrio species, which are commonly found in marine-related injuries.

Human adipose-derived stem cells promote seawater-immersed wound healing via proangiogenic effects

Seawater immersion can increase the damage to skin wounds and produce chronic wounds, and the application of human adipose-derived stem cells can significantly promote healing. However, the mechanism underlying angiogenesis is currently unclear. In this study, we investigated the vascularization effect of human adipose-derived stem cells on the repair of seawater-treated skin wounds and explored the underlying mechanisms using bioinformatics. The results showed that human adipose-derived stem cells differentiated into vascular endothelial cells and promoted seawater-immersed wound vascularization by promoting vascular endothelial cell proliferation and migration. The differentially expressed genes between human adipose-derived stem cells and fibroblasts were identified and analyzed (including via gene ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment, protein–protein interaction network, and correlation analyses). The genes may promote wound healing by regulating the mechanisms of extracellular matrix remodeling, programmed cell death, inflammation, and vascularization. In conclusion, this study provides novel insights into the use of human adipose-derived stem cells in the regeneration of seawater-immersed skin wounds and chronic wounds.

Approach to the Patient with a Skin and Soft Tissue Infection

The diagnosis of a skin and soft tissue infection (SSTI) requires careful attention to a patient's history, physical examination, and diagnostic test results. We review for many bacterial, viral, fungal, and parasitic pathogens that cause SSTIs the clues for reaching a diagnosis, including reported past medical history, hobbies and behaviors, travel, insect bites, exposure to other people and to animals, environmental exposures to water, soil, or sand, as well as the anatomic site of skin lesions, their morphology on examination, and their evolution over time. Laboratory and radiographic tests are discussed that may be used to confirm a specific diagnosis.

Human Adipose-Derived Stem Cells Promote Seawater-Immersed Wound Healing by Activating Skin Stem Cells via the EGFR/MEK/ERK Pathway

Seawater (SW) immersion can increase the damage of skin wounds and produce refractory wounds. However, few studies have been conducted to investigate the mechanisms of SW immersion on skin wounds. In our current study, we investigated the effect of human adipose-derived stem cells (hADSCs) on the repair of SW-treated full-thickness skin wounds and the underlying mechanisms. The results showed that SW immersion could reduce the expression of EGF and suppress the activation of the MEK/ERK signaling pathway. At the same time, the proliferation and migration of skin stem cells were inhibited by SW immersion, resulting in delayed wound healing. However, hADSCs significantly accelerated the healing of SW-immersed skin wounds by promoting cell proliferation and migration through the aforementioned mechanisms. Our results indicate a role for hADSCs in the repair of seawater-immersed skin wounds and suggest a potential novel treatment strategy for seawater-immersed wound healing.

Nontraditional Laboratory Animal Species (Cephalopods, Fish, Amphibians, Reptiles, and Birds)

Aquatic vertebrates and cephalopods, amphibians, reptiles, and birds offer unique safety and occupational health challenges for laboratory animal personnel. This paper discusses environmental, handling, and zoonotic concerns associated with these species.

Hepatic disease and the risk of mortality of Vibrio vulnificus necrotizing skin and soft tissue infections: A systematic review and meta-analysis

Background

Vibrio vulnificus necrotizing skin and soft tissue infections (VNSSTIs) are associated with a high mortality rate that varies remarkably with host susceptibility. Hepatic disease (HD) is considered the key risk factor for high VNSSTIs incidence and mortality; however, there is limited evidence in the literature to support this observation.

Methodology

We examined all reported cases of VNSSTIs and associated mortality rates between 1966 and mid-2018. The PubMed, Medline and Cochrane Library databases were systematically searched for observational studies on patients with VNSSTIs. Twelve studies with 1157 total patients with VNSSTIs were included in the analysis. From the pooled dataset, nearly half (46.8%) of the patients with VNSSTIs had HD. The mortality rate in HD patients with VNSSTIs was 53.9% (n = 292/542), which was considerably higher than the mortality rate of 16.1% (n = 99/615) in non-HD patients. Patients with HD contracted VNSSTIs were found to be two or more times (RR = 2.61, 95% CI = 2.14–3.19) as likely to die compared with those without HD. Besides, liver cirrhosis (LC), the end-stage HD, was confirmed to be a significant risk factor, with risk ratios of 1.84 (95% CI 1.21–2.79) and 2.00 (95% CI 1.41–2.85) when compared to non-LC and non-HD, respectively.

Conclusions

HD with or without LC can be associated with infections and complications from V. vulnificus. Clinicians should aggressively approach care and management of acutely and/or critically ill patients with VNSSTIs.

Columbamine suppresses the proliferation and malignization of colon cancer cells via abolishing Wnt/β-catenin signaling pathway

BACKGROUND

Colon cancer is one of the most common malignancies worldwide. Because of the side effects and defects in tolerance of chemotherapy, it is necessary to discover new drugs for colon cancer treatment. Columbamine has been identified as an effective anti-osteosarcoma compound with only minor side effects. In this study, we analyzed the anticancer effect of columbamine on colon cancer.

METHODS

Human colon cancer cell lines were treatment with columbamine. MTT assay, colony formation assay, apoptosis detection and tumorigenicity assay were performed to detect the protective effect of columbamine on colon cancer development. Western blot assay and luciferase reporter assay were conducted to investigate the potential mechanism of the columbamine treatment.

RESULTS

Columbamine significantly inhibited the proliferation, migration, invasion process of colon cancer cells, and dramatically promoted the apoptosis rate of colon cancer cells to further suppress the development of colon cancer to tumor. Both the signaling transducing and key factors expression of Wnt/β-catenin signaling pathway were obviously repressed by columbamine treatment in a dose-dependent manner.

CONCLUSION

The present study indicated that columbamine exerts its anti-tumor effect in colon cancer cells through abolishing Wnt/β-catenin signaling pathway. Columbamine may be a new therapy compound for colon cancer.

Erysipelothrix rhusiopathiae bacteremia following a cat bite

Erysipelothrix rhusiopathiae is a major causative organism of swine erysipelas, but the infection has rarely occurred in humans. A soft-tissue infection with this organism is described as “erysipeloid.” Most reported cases in human are related to occupational exposure. Endocarditis is a common complication of E. rhusiopathiae bacteremia in human.

We report the case of a previously healthy 52-year-old Japanese female who presented with fever and an inflamed hand after being bitten by a stray cat. Blood culture was positive for E. rhusiopathiae, but no sign of infective endocarditis was observed. It may be prudent to consider E. rhusiopathiae infection in patients with animal bites.

Vibrio parahaemolyticus Induced Cellulitis and Septic Shock after a Sea Beach Holiday in a Patient with Leg Ulcers

Infections with Vibrio parahaemolyticus, a gram-negative bacterium found in salt water, are mainly gastrointestinal or cutaneous. The development of sepsis is not uncommon. We report the case of an 85-year-old patient who developed lower limb cellulitis caused by V. parahaemolyticus, originating from leg ulcers and complicated by septicaemia and septic shock, after a sea beach holiday. We discuss the epidemiology, pathogenesis, clinical manifestations and treatment of V. parahaemolyticus infections.

An Update on the Treatment and Management of Cellulitis

Cellulitis and erysipelas are local soft tissue infections that occur following the entry of bacteria through a disrupted skin barrier. These infections are relatively common and early diagnosis is essential to treatment success. As dermatologists, we need to be familiar with the clinical presentation, diagnosis, and treatment of these infections. In this article, we provide a review of the literature and update on clinical manifestations, predisposing factors, microbiology, diagnosis, treatment, and complications. We also review the current situation in Chile.

Waterborne Infections in Reunion Island, 2010-2017

Gram-negative bacilli Vibrio spp., Aeromonas spp., and Shewanella spp. are a major cause of severe waterborne infection. The aim of this study was to assess the clinical and microbiological characteristics and prognosis of patients hospitalized in Reunion Island for a waterborne infection. This retrospective study was conducted in the two university hospitals of Reunion Island between January 2010 and March 2017. Patients diagnosed with a Vibrio, Aeromonas, or Shewanella infection were evaluated. Over the study period, 112 aquatic strains were isolated at Reunion Island: Aeromonas spp. were found in 91 patients (81.3%), Shewanella spp. in 13 patients (11.6%), and Vibrio spp. in eight patients (7.2%). The in-hospital mortality rate was 11.6%. The main sites of infection were skin and soft tissue (44.6%) and the abdomen (19.6%). Infections were polymicrobial in 70 cases (62.5%). The most commonly prescribed empiric antibiotic regimen was amoxicillin-clavulanate (34.8%). Eighty-four percent of the aquatic strains were resistant to amoxicillin-clavulanate and more than > 95% were susceptible to third or fourth generation cephalosporins and fluoroquinolones. After multivariate analysis, the only independent risk factor of in-hospital mortality was the presence of sepsis (P < 0.0001). In Reunion Island, the most commonly isolated aquatic microorganisms were Aeromonas spp. Sepsis caused by aquatic microorganisms was frequent (> 50%) and associated with higher in-hospital mortality. This study suggests that empiric antibiotic regimens in patients with sepsis or septic shock caused by suspected aquatic microorganisms (tropical climate, skin lesion exposed to seawater…) should include broad-spectrum antibiotics (third or fourth generation cephalosporins).

Approach to Aquatic Skin Infections

Aquatic-based infections can present a treatment challenge for primary care physicians because of the likely polymicrobial nature of the infection and the possibility of uncommon pathogenic organisms. Although Staphylococcus and Streptococcus species that colonize the skin are the most common etiologic agents associated with saltwater and freshwater skin and soft tissue infections, other significant pathogens can include Vibrio, Aeromonas, Edwardsiella, Erysipelothrix, and Mycobacterium. Early detection and appropriate management of aquatic infections can significantly decrease morbidity and mortality. This article reviews the pathophysiology, presentation, and management for the most common water-borne pathogens causing skin and soft tissue infections.

"In-Group" Communication in Marine Vibrio: A Review of N-Acyl Homoserine Lactones-Driven Quorum Sensing

N-Acyl Homoserine Lactones (N-AHLs) are an important group of small quorum-sensing molecules generated and released into the surroundings by Gram-negative bacteria. N-AHLs play a crucial role in various infection-related biological processes of marine Vibrio species, including survival, colonization, invasion, and pathogenesis. With the increasing problem of antibiotic abuse and subsequently the emergence of drug-resistant bacteria, studies on AHLs are therefore expected to bring potential new breakthroughs for the prevention and treatment of Vibrio infections. This article starts from AHLs generation in marine Vibrio, and then discusses the advantages, disadvantages, and trends in the future development of various detection methods for AHLs characterization. In addition to a detailed classification of the various marine Vibrio-derived AHL types that have been reported over the years, the regulatory mechanisms of AHLs and their roles in marine Vibrio biofilms, pathogenicity and interaction with host cells are also highlighted. Intervention measures for AHLs in different stages are systematically reviewed, and the prospects of their future development and application are examined.

Orthopaedic Watercraft Injuries: Characterization of Mechanisms, Fractures, and Complications in 216 Injuries

OBJECTIVE

To review the orthopaedic injuries from watercraft treated surgically at our institution and report the mechanisms, fractures, and complications encountered.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

There were 216 fractures from watercraft in 146 patients. Average age was 33 years (range 4-78 years), there were 68% males (99/146), and 16% of the injuries occurred in children.

INTERVENTION

Operative fracture fixation.

MAIN OUTCOME MEASUREMENTS

After IRB approval, data were collected from January 1, 1998, to December 31, 2015, for patients including demographics, watercraft type, mechanism of injury, fracture pattern, infection, organisms, union, and amputation. Descriptive statistics were used.

RESULTS

There were 130 closed fractures (60%) and 86 open fractures (40%). There were 146 (67%) lower extremity injuries, 49 (23%) upper extremity injuries, and 21 (10%) pelvic injuries. The overall postoperative infection rate was 9% (20/216) and was commonly polymicrobial in nature. The postoperative infection rate in closed fractures was 4% (5/130) and the postoperative infection rate in open fractures was 17% (15/86). Open fractures also had a high proportion of nonunion (8%) and amputation (16%).

CONCLUSIONS

This is the largest reported series of orthopaedic injuries from watercraft. These injuries can be devastating in nature and difficult to manage, particularly when they are open (40%). There is a high rate of postoperative infection (17%), nonunion (8%), and amputation (16%) associated with open orthopaedic watercraft fractures.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Potential human pathogenic bacteria in five hot springs in Eritrea revealed by next generation sequencing

Human pathogens can survive and grow in hot springs. For water quality assessment, Escherichia coli or Enterococci are the main thermotolerant enteric bacteria commonly used to estimate the load of pathogenic bacteria in water. However, most of the environmental bacteria are unculturable thus culture methods may cause bias in detection of most pathogens. Illumina sequencing can provide a more comprehensive and accurate insight into environmental bacterial pathogens, which can be used to develop better risk assessment methods and promote public health awareness. In this study, high-throughput Illumina sequencing was used to identify bacterial pathogens from five hot springs; Maiwooi, Akwar, Garbanabra, Elegedi and Gelti, in Eritrea. Water samples were collected from the five hot springs. Total community DNA was extracted from samples using the phenol-chloroform method. The 16S rRNA gene variable region (V4—V7) of the extracted DNA was amplified and library construction done according to Illumina sequencing protocol. The sequence reads (length >200 bp) from Illumina sequencing libraries ranged from 22,091 sequences in the wet sediment sample from Garbanabra to 155,789 sequences in the mat sample from Elegedi. Taxonomy was assigned to each OTU using BLASTn against a curated database derived from GreenGenes, RDPII, SILVA SSU Reference 119 and NCBI. The proportion of potential pathogens from the water samples was highest in Maiwooi (17.8%), followed by Gelti (16.7%), Akwar (13.6%) and Garbanabra (10.9%). Although the numbers of DNA sequence reads from Illumina sequencing were very high for the Elegedi (104,328), corresponding proportion of potential pathogens very low (3.6%). Most of the potential pathogenic bacterial sequences identified were from Proteobacteria and Firmicutes. Legionella and Clostridium were the most common detected genera with different species. Most of the potential pathogens were detected from the water samples. However, sequences belonging to Clostridium were observed more abundantly from the mat samples. This study employed high-throughput sequencing technologies to determine the presence of pathogenic bacteria in the five hot springs in Eritrea.

Edwardsiella tarda Bacteremia with Psoas and Epidural Abscess as a Food-borne Infection: A Case Report and Literature Review

Edwardsiella tarda is commonly isolated from aquatic environments and a variety of animals. We present the first case of E. tarda bacteremia with psoas and epidural abscess. The patient was a 65-year-old woman with recurrent gastric cancer who had frequently consumed raw fish and grilled eel. She was successfully treated with antimicrobials and surgery. We also review reports published in English regarding E. tarda bacteremia in Japan and the experience at our hospital. On the basis of this review, we conclude that the major underlying disease leading to E. tarda bacteremia is malignancy and that the gastrointestinal tract is the most commonly affected organ. The overall mortality rate due to E. tarda bacteremia in our review was 38.1% (8/21). Although E. tarda bacteremia is rare, clinicians should be aware of this fatal food-borne infection.

Impact of climate change on dermatological conditions related to flooding: update from the International Society of Dermatology Climate Change Committee

Climate change contributes to the increase in severity and frequency of flooding, which is the most frequent and deadly disaster worldwide. Flood-related damage can be very severe and include health effects. Among those health impacts, dermatological diseases are one of the most frequently encountered. Both infectious and noninfectious dermatological conditions are increasing after flooding. We searched PubMed using the search term climate change OR global warming OR rainfall OR flooding OR skin. Articles published in the English-language literature were included. We also searched the International Society of Dermatology website library on climate change for additional articles. There is an increased risk of trauma during the course of a natural disaster. The majority of post-tsunami wound infections were polymicrobial, but gram-negative bacteria were the leading causes. Infectious diseases with dermatological manifestations, such as impetigo, leptospirosis, measles, dengue fever, tinea corporis, malaria, and leishmaniasis, are important causes of morbidity among flood-afflicted individuals. Insect bites and stings, and parasite infestations such as scabies and cutaneous larva migrans are also frequently observed. Inflammatory conditions including irritant contact dermatitis are among the leading dermatological conditions. Dermatological conditions such as alopecia areata, vitiligo, psoriasis, and urticaria can be induced or exacerbated by psychological conditions post disaster. Prevention is essential in the management of skin diseases because of flooding. Avoiding exposure to contaminated environments, wearing protective devices, rapid provision of clean water and sanitation facilities, prompt vector controls, and education about disease risk and prevention are important.

Field Wound Care: Prophylactic Antibiotics

Adequate management of wounds requires numerous interventions, one of which is the appropriate use of antimicrobials to attempt to minimize the risk of excess morbidity or mortality without increasing toxicity or multidrug resistant bacterial acquisition. There are numerous recommendations and opinions for not only the use of systemic prophylactic antimicrobials, but also the agent, dose, route, and duration. To best address the implementation of systemic antimicrobials in a field scenario, one must weigh the factors that go into that decision and then determine the best agents possible. The epidemiologic triangle (ie, the host, the agent, and the environment) forms the basis for selecting the correct prophylactic antibiotic for field wound care. Extreme conditions can be encountered in both military and nonmilitary systems, requiring a unique selection process to make the right antibiotic choice. A modifiable weighted matrix, recommended previously for point of injury combat casualty care, assists in selecting the best oral and intravenous/intramuscular agent based on the epidemiologic risk determination.

Aetiology and clinical features of facial cellulitis: a prospective study

BACKGROUND

In the early 20th century, the face was the predominant site of cellulitis. Despite a relative decrease in the incidence of facial cellulitis, it is still common. There are few studies on this condition during the last decades. The aim of this study was to describe contemporary aetiological and clinical characteristics of patients admitted to hospital with non-suppurative facial cellulitis.

METHODS

Patients were included prospectively. Clinical details, comorbidities and biochemistry results were recorded. Investigations included cultures of skin swab and blood and tests for streptococcal antibodies during the acute and convalescent stages.

RESULTS

Sixty-five patients were included. Serology, cultures and response to penicillin monotherapy identified probable or confirmed β-haemolytic streptococci (BHS) aetiology in 75% (49/65) of cases. Significant comorbidities were present in 54% (35/65). Fever, chills or rigors before or at admission was noted in 91% (59/65). Patients presented most often with sharply demarcated erythema and raised borders (54/64). Penicillin or penicillinase-resistant penicillin alone or in combination cured 68% (44/65) of the patients. Supplementary clindamycin was used in 28% (18/65), most often only for 1-3 days. Only four patients needed a second course of antibiotics. Clinical failure was more often seen in patients with non-BHS aetiology (p = .037). Few complications were noted; 14.5% (9/62) experienced transient diarrhoea, and only one had confirmed Clostridium difficile infection. No patients developed cerebral venous sinus thrombosis, and there were no fatalities.

CONCLUSIONS

Our findings indicate that BHS are the leading cause of facial cellulitis. Most patients exhibit sharply demarcated lesions and systemic symptoms. Narrow-spectrum β-lactam antibiotics and short hospital stay appear sufficient. Few complications and low recurrence rates were seen.

Freshwater Catfish Envenoming in a Tropical Country

OBJECTIVE

Freshwater catfish are known to cause painful stings in humans. Stings usually cause mild envenomation and, in some instances, can lead to severe secondary bacterial infections. Sri Lanka is a tropical country where catfish stings are not rare. However, presenting signs and symptoms, complications, and management options are scarce in the literature.

METHODS

A retrospective, descriptive, cross-sectional study was conducted by reviewing patient records in the university surgical units and surgical clinic in the teaching hospital in Anuradhapura, Sri Lanka, during 2015.

RESULTS

Ten patients presented to the hospital following catfish stings. The common presenting features following stings were severe pain, swelling, and lymphadenopathy followed by cellulitis. Late complication such as tenosynovitis were also observed.

CONCLUSIONS

Routine procedures are sufficient to reduce further complications. However, people who are at high risk of encountering catfish, and travelers visiting tropical countries, should be aware of the possibility of stings and take necessary precautions.

Case Report: Disseminated Shewanella algae Infection with Meningoencephalitis in a Traveler Secondary to Marine Injury in Madagascar

Marine microorganisms such as Shewanella spp., Vibrio spp., and Aeromonas spp. can cause sepsis secondary to a wound infection in the context of swimming. These microorganisms are most often susceptible to fluoroquinolones. Here, we report a unique case of Shewanella algae bacteremia associated with meningoencephalitis and disseminated via hematogenous spread secondary to a skin injury. The patient suffered the injury while swimming in saline water during a cruise holiday in Madagascar, and she was initially treated with amoxicillin. The neurological evolution was unsatisfactory. Better knowledge of such infections (and especially of the context in which they occur), as well as greater familiarity with the susceptibility profile of different marine microorganisms would have allowed health professionals to provide presumptive microbiological diagnosis and effective treatment earlier.

Effect of vacuum sealing drainage on the expression of VEGF and miRNA-17-5p in seawater-immersed blast-injury wounds

The aim of the present study was to compare and observe the expression levels of vascular endothelial growth factor (VEGF) and miRNA-17-5p during the treatment of seawater-immersed blast-injury wounds (SIBIW) under different conditions of vacuum sealing drainage (VSD), and to identify the optimized range of VSD treatment and partially explain its mechanisms. The bilateral hips and scapulae of experimental pigs (weight, 25-30 kg) were subjected to blast-injury wounds, followed by the seawater immersion. The animals then underwent conventional dressing treatment under 120, 180 and 240 mmHg VSD. Visual observation, in addition to histological, immunohistochemical and molecular biological techniques were applied to compare and observe the extent of wound healing and expression levels of VEGF and miRNA-17-5p. The wound healing of the VSD treatment group was improved compared with the control group, with 120 mmHg negative pressure producing the most marked effect. miR-17-5p expression was detected in the SIBIW granulation tissues. There was significant difference between each VSD treatment group and control group at each time point (P<0.05). Thus, the present results show that miR-17-5p can be expressed in SIBIW granulation tissues, and this effect is most evident under 120 mmHg negative pressure, which may inform the optimized negative range for the treatment of SIBIW.

Aeromonas as a Cause of Purulent Folliculitis: A Case Report and Review of the Literature

Aeromonas species are rarely an identified cause of folliculitis. Here, we describe the case of a patient who had purulent folliculitis of the breast caused by an Aeromonas species and review 4 other cases presented in the literature, highlighting the commonalities observed. Aeromonas infection should be considered in patients who present with purulent folliculitis, particularly those with exposure to nonchlorinated pools or baths.

Marine and Other Aquatic Dermatoses

Occupational and recreational aquatic activity predisposes our population to a wide variety of dermatoses. Sunburn, urticaria, jellyfish stings, and contact dermatitis to rubber equipment are common allergies that are encountered in the aquatic environment. Among the infections, tinea versicolor, intertrigo, and verruca vulgaris are widespread. Swimmer's itch may occur due to skin penetration by schistosome cercariae, while free-floating nematocysts of marine coelenterates may precipitate seabather's eruption. "Suit squeeze" due to cutaneous barotrauma and lymphoedematous peau d'orange due to decompression are rare, described entities. This review serves as a ready reckoner for Indian dermatologists and medical practitioners to identify and manage these conditions.

Shewanella putrefaciens – a new opportunistic pathogen of freshwater fish

In recent years, Shewanella putrefaciens, commonly known as a halophilic bacteria, has been associated with serious health disorders in freshwater fish. Therefore, it has been described as a new aetiological agent of the disease, named shewanellosis. S. putrefaciens is a heterogeneous group of microorganisms, belonging to the Alteromonadaceae family. Based on different criteria, three biovars and biogroups as well as four genomic groups have been distinguished. The first infections of S. putrefaciens in fish were reported in rabbitfish (Siganus rivulatus) and European sea bass (Dicentrarchus labrax L.). Outbreaks in farmed fish were reported in Poland for the first time in 2004. The disease causes skin disorders and haemorrhages in internal organs. It should be noted that S. putrefaciens could also be associated with different infections in humans, such as skin and tissue infections, bacteraemia, otitis. Investigations on pathogenic mechanisms of S. putrefaciens infections are very limited. Enzymatic activity, cytotoxin secretion, adhesion ability, lipopolysaccharide (LPS), and the presence of siderophores are potential virulence factors of S. putrefaciens. Antimicrobial resistance of S. putrefaciens is different and depends on the isolates. In general, these bacteria are sensitive to antimicrobial drugs commonly used in aquaculture.

Marine envenomations in returning French travellers seen in a tropical diseases unit, 2008-13

BACKGROUND

Travel and aquatic activities are increasing in tropical regions. The risk and the spectrum of marine envenomation are unknown in travellers. This work aims to evaluate the prevalence and the characteristics of marine envenomations in returning travellers.

METHODS

We retrospectively studied the medical charts of all returning travellers presenting with a health problem in a French tropical disease unit between 2008 and 2013, with focus on travellers complaining of marine envenomation. Characteristics of each type of envenomation are described.

RESULTS

Of the 3315 travellers seen during the study period, 43 consulted for a presumed marine envenomation. Six patients were excluded, leaving 37 cases of confirmed marine envenomation. It corresponds to a prevalence of 1.1%. Sex ratio was balanced with 18 men and 19 women. Median age was 42 years (range 25-68 years). Median travel duration was 14 days (range: 6-62 days). The main travel destination was Southeast Asia in 10 cases, followed by islands of East Africa in seven cases. Median elapsed time between envenomation and consultation was 14 days (range: 2-130 days). The purpose of travel was tourism in all cases. The main clinical aspects were oedema, sting marks, cellulitis and flagellations. Eleven cases were presumably caused by corals, 10 by stonefish, 8 by jellyfish, 2 by weever fish, 2 by starfish, 2 by stingray, 1 by lionfish and 1 by sea anemone.

CONCLUSION

Prevalence of marine envenomation is low in returning travellers. They are mostly caused by corals, stonefish and jellyfish.

Marine Scorpaenidae Envenomation in Travelers: Epidemiology, Management, and Prevention

BACKGROUND

The Scorpaenidae are a large family of venomous marine fish that include scorpionfish, lionfish, and stonefish. Although most stonefish are confined to the Indo-Pacific, scorpionfish are distributed in the tropics worldwide, and two species of Indo-Pacific lionfish were inadvertently introduced into the Eastern Atlantic in the 1990s. Since then, lionfish have invaded shallow reef systems in the Eastern Atlantic, Gulf of Mexico, and Caribbean Sea. All of these regions are popular travel destinations for beachcombing, fishing, swimming, and scuba diving-recreational activities that increase risks of Scorpaenidae envenomation.

METHODS

To meet the objectives of describing species-specific presenting clinical manifestations, diagnostic and treatment strategies, and outcomes of Scorpaenidae envenomation in travelers, Internet search engines were queried with the key words.

RESULTS

Well-conducted, retrospective epidemiological investigations of Scorpaenidae envenomation case series concluded: (1) most cases occurred in young adult male vacationers visiting endemic regions; (2) victims sought medical attention for pain control within 2 hours of injury and presented with intense pain, edema, and erythema in affected extremities; (3) systemic manifestations and surgical interventions were relatively uncommon following initial management with hot water soaks and parenteral analgesics; (4) all cases required tetanus prophylaxis; deeply penetrating, lacerated, and necrotic wounds required antibiotic prophylaxis; and (5) equine Fab stonefish antivenom does have antigen-neutralizing cross-reactivities with both Indo-Pacific and Atlantic Scorpaenidae species and is indicated in severe scorpionfish and stonefish envenomation worldwide.

CONCLUSIONS

Travel medicine practitioners should counsel their patients about Scorpaenidae envenomation risks in endemic regions and maintain a high index of suspicion regarding Scorpaenidae envenomation in all travelers returning from tropical beach and ocean holidays and reporting painful fish sting injuries.