recommendations are based on the indolent nature and malignant potential of soft tissue infections caused by
Vibrio species:
1. Minor abrasions or lacerations (such as coral cuts or superficial sea urchin puncture wounds) do not require
prophylactic antibiotics in the normal host. Persons who are chronically ill (as with diabetes, hemophilia, or
thalassemia) or immunologically impaired (as with leukemia or AIDS, or undergoing chemotherapy or
prolonged corticosteroid therapy), or who suffer from serious liver disease (such as hepatitis, cirrhosis, or
hemochromatosis), particularly those with elevated serum iron levels, should be placed immediately after the
injury on a regimen of oral ciprofloxacin, trimethoprim-sulfamethoxazole, or tetracycline because these
persons appear to have an increased risk of serious wound infection and bacteremia. Preliminary experience
suggests that cefuroxime may be a useful alternative. Penicillin, ampicillin, and erythromycin are not
acceptable alternatives. Norfloxacin may be less efficacious against certain vibrios. Other quinolones
(ofloxacin, enoxacin, pefloxacin, fleroxacin, lomefloxacin) have not been extensively tested against Vibrio;
they may be useful alternatives, but this awaits definitive evaluation. The appearance of an infection indicates
the need for prompt debridement and antibiotic therapy. If an infection develops, antibiotic coverage should
be chosen that will also be efficacious against Staphylococcus and Streptococcus because these are still the
most common perpetrators of infection. In general, the fluoroquinolones, which are particularly effective for
treating gram-negative bacillary infections, may become less and less useful against resistant staphylococci. If
Staphylococcus is a
-lactamase producing strain, a semisynthetic penicillin (nafcillin or oxacillin) should be
chosen, with a cephalosporin such as cefazolin or cephalothin used if there is a history of delayed-type
penicillin allergy. Vancomycin is recommended in the event of methicillin resistance.
2. Serious injuries from an infection perspective include large lacerations, serious burns, deep puncture
wounds, or a retained foreign body. Examples are shark or barracuda bites, stingray spine wounds, deep sea
urchin punctures, scorpaenid spine envenomations that enter a joint space, and full-thickness coral cuts. If the
victim requires hospitalization and surgery for standard wound management, recommended antibiotics
include gentamicin, tobramycin, amikacin, ciprofloxacin, and trimethoprim-sulfamethoxazole. Cefoperazone
and cefotaxime may or may not be effective, There is a recommendation in the literature advocating the use
of ceftazidime (in combination with tetracycline). Chloramphenicol is an alternative agent less commonly
used because of hematological side effects. Imipenem-cilastatin is an extremely powerful antibiotic that
should be used in a circumstance of sepsis or treatment failure. Patients who simultaneously receive imipenem
or ciprofloxacin and theophylline may have an increased tendency to seizures.
If the victim is managed as an outpatient, the drugs of choice to cover Vibrio are ciprofloxacin,
trimethoprim-sulfamethoxazole, or tetracycline. Cefuroxime is an alternative. It is a clinical decision whether
oral therapy should be preceded by a single intravenous or intramuscular loading dose of a similar or different
antibiotic, commonly an aminoglycoside. Infected wounds should be cultured for aerobes and anaerobes.
Pending culture and sensitivity results, the patient should be managed with antibiotics as described previously.
In a person who has been wounded in a marine environment and has rapidly progressive cellulitis or myositis,
Vibrio parahaemolyticus or V. vulnificus infection should be suspected, particularly in the presence of chronic
liver disease. If a wound infection is minor and has the appearance of a classic erysipeloid reaction
(Erysipelothrix rhusiopathiae), penicillin, cephalexin, or ciprofloxacin should be administered.
FRESHWATER BACTERIOLOGY
Diversity of Organisms
Although it has not been as extensively studied as the marine environment, the natural freshwater
environment of ponds, lakes, streams, rivers, lagoons, harbors, estuaries, and artificial bodies of water is
probably as hazardous as the ocean from a microbiologic standpoint. Water-skiing accidents, propeller
wounds, fishhook punctures, lacerations from broken glass and sharp rocks, fish fin or catfish stings, and
crush injuries during white-water expeditions are commonplace. A large number of bacteria has been
identified in water, sediments, animals, and wounds. In fringe areas of the ocean that carry brackish water
(NaCl content below 3%), marine bacteria, salt-tolerant freshwater bacteria, and brackish-specific bacteria
such as Agrobacterium sanguineum are noted. The combined effects of human and animal traffic and waste
disposal increase the risk for coliform contamination. In Great Britain, antibiotic-resistant Escherichia coli
have been documented in rivers and coastal waters. Coxsackievirus A16 has been isolated from children
stricken ill after bathing in contaminated lake water. Of particular note is the presence of virulent species,
