Primary skin infections secondary to Vibrio vulnificus: The role of operative intervention

BACKGROUND: Vibrio vulnificus can cause rapidly spreading skin and soft tissue infections with significant associated morbidity and mortality. Patients with underlying chronic illness, such as cirrhosis, diabetes mellitus, or immunosuppression, have been noted to be at high risk for rapid progression of this infection. The importance of early antibiotic therapy has been reported but the role of operative intervention in these patients is less clear. STUDY DESIGN: We report seven patients who were operatively treated from April 28, 1991 to September 22, 1995 for primary skin and soft tissue infections secondary to Vibrio vulnificus. We have also reviewed the recent literature. The impact of several variables including shock, increased white blood cell count, fever, and the timing of operative intervention on the length of hospital stay and intensive care unit stay was analyzed using the Spearman rank correlation. The impact of early compared with late operative intervention was analyzed using the Mann-Whitney U test. All patients had a history of underlying chronic illness and presented with skin infections in association with recent exposure to saltwater and to shellfish. No patient presented earlier than 24 hours from the time of initial infection. All patients underwent operative exploration within 46 hours of admission with thorough operative debridement of all necrotic tissue. infection was confined to the skin and subcutaneous tissue. RESULTS: There was no mortality among our patients. The presence of perioperative shock, fever, or elevated white blood cell count did not correlate with an increased intensive care unit stay or an increased hospital stay. Earlier operative exploration and debridement correlated with a decrease in the intensive care unit stay (p<0.02, correlation coefficient=0.991) and in the hospital stay (p<0.02, correlation coefficient=0.929). Patients who underwent debridement within 72 hours from the time of the infection had a significantly shorter intensive care unit stay (p=0.0323) and total hospital stay (p=0.0339). CONCLUSIONS: We advocate operative exploration and thorough debridement of all necrotic tissue in high-risk patients with primary Vibrio vulnificus skin and soft tissue infections.