Clinical Pediatrics

Biography

Biography: Fazal-i-Akbar Danish

Abstract

Introduction:

Vibrio cholerae is a highly diverse species. Whereas almost all cholera-causing strains fall in the serogroups O1 & O139, outbreaks of potentially fatal ‘cholera-like illnesses’ have been reported in estuarine environments in multiple parts of the world with lesser known non-O1/non-O139 serogroups. Phylogenetic studies suggest that all cholera-associated strains tend to cluster closely together in keeping with the concept that the outbreak of an epidemic illness requires the presence of an ‘epidemic genotype’ that comprises of multiple genes coming from a host of serogroups. Non-O1/non-O139 serogroups have been associated with gastroenteritis (either caused by faecal contamination of food & water, or eating raw or undercooked shellfish) and wound infections (caused by environmental exposure to contaminated water). Gastroenteritis/wound infection in turn can lead to septicaemia almost exclusively in immunocompromised patients or in patients with severe underlying liver disease.  

Method:

A comprehensive search of PubMed & EMBASE from their inceptions to October 2019 was made using 3 search items: non-O1/non-O139 Vibrio cholerae, cholera outbreaks, & heat wave-associated vibriosis. The search items were combined using the Boolean operator. A further search was made of the United States Centres for Disease Control & Prevention (CDC) website, & ClinicalTrials.gov with no language restriction.

Results:

Mild gastroenteritis in immunocompetent patients often requires nothing more than fluid resuscitation (oral or intravenous depending upon the need). In severe diarrhoeal illnesses, however, empirical antibiotic therapy with doxycycline is known to reduce the duration of the illness & is therefore recommended pending susceptibility testing results. Alternatives include macrolides & fluoroquinolones. Wound infections even when mild require both debridement & empirical antibiotic therapy with tetracycline or macrolide for 5-7 days. Immunocompromised patients or those with severe underlying liver disease are at risk of developing septicaemia therefore mandating admission to intensive-care unit (ICU) & aggressive combination antibiotic therapy with either minocycline or doxycycline (100 mg orally twice daily), plus a third-generation cephalosporin (either cefotaxime 2 g IV 8 hourly or ceftriaxone 1 g ID once daily) for 1-2 weeks (or even longer) depending upon the response.

Conclusion:

In immunocompetent patients, diarrhoeal illness is often mild & self-limiting. Likewise, wound infections generally respond well to debridement & oral antibiotic therapy in immunocompetent patients. Immunocompromised patients or those with severe underlying liver disease, however, are at most risk of death and therefore require aggressive treatment in ICU settings. Given increasing rates of resistance to antibiotics, susceptibility testing should be performed to rationalize antibiotic selection in all cases.  In resource-rich settings, non-O1/non-O139 Vibrio cholerae infections can be prevented by avoiding consumption of raw or undercooked shellfish. In resource-limited settings especially in the coastal areas, prevention will require avoidance of environmental exposure to contaminated water & cross-contamination of food by seafood.