1. Vibrio Infections
Michael Addidle

2. Vibrios Taxonomy Species V. cholerae Genera V. vulnificus Vibrios
Family
Vibrionaciae
V. parahaemolyticus
(amongst others)
Non-enteric, fermentative, gram-negative rods that are oxidase positive and motile by means of a polar flagella
Aeromonas
Plesiomonas

3. Vibrios
Most vibrios require saline for growth.(halophilic). However Vibrio cholerae & Vibrio mimicus can survive in both saltwater and freshwater.
Prefer alkaline environments.
Flourish in shallow waters with temperatures greater than 20 degrees. Ie Estuarine environments in the summer.
Survive quite happily in filterfeeding shell fish, such as oysters and pipis.
Greater than 90% of clinical disease due to vibrios in NZ occurs during the summer months.

4. Vibrio cholerae Aetiological agent of cholera
Divided into Serogroups on basis of O (somatic antigen)
Only serogroups 01 and 0139 are associated with epidemic and pandemic cholera. Often clinically more serious because of production of classical cholera toxin.

5. Vibrio cholerae: bacteriology
Curved gram negative bacillus
Single polar flagellum
Flagellar H antigen and somatic O antigen.
O antigen used to classify V. cholerae into serogroups (01 and 0139 are most well known)
Two biotypes of 01 (classical and El Tor)

6. History of Cholera
“Cholera like illness” described by Hippocrates circa 500 BC
Cholera means “flow of bile”
The Italian doctor Filippo Pacini was the first to discover the cholera bacterium (Vibrio cholerae) in 1854 when cholera hit Florence.
The first recorded cholera pandemic of spread from India to Southeast Asia, Central Asia, the Middle East and Russia.
s - Seventh pandemic began in Indonesia, called El Tor. Has since spread to many countries.

10. Epidemiology of Vibrio cholerae
Large infective dose required. Person to person spread uncommon. Most common where poor sanitation and in particular where mass displacement of population has occured
Usually acquired through contaminated food or water. Avoidance of unboiled water, ice cubes, food from street vendors, undercooked seafood.
To cause infection, organisms must first pass the highly acidic secretions in stomach. (alkaline loving) Infecting dose 10,000,000,000 orgs
Therefore people with gastrectomy or on ant- acids are more susceptible orgs.
Incubation period few hours to 5 days.

11. Vibrio cholerae: Pathogenicity
Classical cholera 01/0139 strains usually produce a classical toxin. Non 01/0139 strains usually don’t
Classical Cholera toxin:- Non-invasive, consists of A and B subunits. B subunit facilitates binding and A subunit activates Adenylate Cyclase, leading to increase in cAMP in enterocyte.
cAMP leads to increased Chloride excretion from the enterocyte and decreased sodium reabsorption, leading to osmotic gradient, and water passes out of the cells into the intestinal lumen. “Rice water stool”
Many non-01/0139 strains are “non-toxigenic”. Actually other toxins some of which are invasive.

12. It has also been hypothesized that the cystic fibrosis genetic mutation has been maintained in humans due to a selective advantage: heterozygous carriers of the mutation (who are thus not affected by cystic fibrosis) are more resistant to V. cholerae infections.

13. “Cholera gravis”
Most people asymptomatic or mild illness only. However shed bacteria for 1-2 wks into the environment.
Severe illness, dehydration renal failure, metabolic acidosis and death.

14. Diagnosis of Cholera
In epidemic “field situation”, dark field or wet film showing motile comma shaped bacteria usually sufficient. Motility inhibited by specific anti-sera.
Stool can be cultured in Alkaline Peptone water to select out vibrios.
TCBS (Thiosulphate Citrate Bile Salts) agar or Tellurite Taurocholate Gelatin Agar (TTGA).
Yellow oxidase positive colonies are suspicious
Suspicious colonies confirmed using API20E
V cholerae 01 and 0139 strains can be detected with specific anti-sera.
Latex agglutination, EIA or PCR can be used to look for cholera toxin

16. TCBS Medium
The high concentrations of thiosulfate and citrate and the strong alkalinity of this medium largely inhibit the growth of Enterobacteriaceae. Ox bile and cholate suppress
primarily enterococci. Any coliform bacteria, which may grow, cannot metabolize
sucrose. Only a few sucrose-positive Proteus strains can grow to form yellow,
vibrid-like colonies

17. Treatment of Cholera
Aggressive rehydration is necessary for serious cases.
Tetracyclines are the drug of choice. However in some parts of the world, resistance is becoming a problem. Quinolones also have good activity.
In pregnant and breastfeeding women, and children, Azithromycin is useful.

18. Cholera Vaccine
Parenteral whole cell killed vaccine is available. Only 50% protection from 01 for 6 months, not recommended by WHO
Oral, killed, whole cell vaccine licensed for use in Europe, 1-2yrs protection after 2 doses.

19. Vibrio vulnificus
First identified in the 1970s, can cause serious wound infections and septicaemia.
Usually infects patients with immunocompromise, particularly patients with underlying liver disease.
V. vulnificus found commonly in saltwater estuarine environments. (Isolated from virtually all oysters harvested in the Chesapeake Bay and the United States Gulf Coast when water temperatures exceeded 20ºC)

20. Vibrio vulnificus: Pathogenicity Factors
Polysaccheride Capsule
Anti-capsular antibodies are protective
Iron
Bacterial growth in human serum is directly related to percentage transferrin saturation with iron.

21. Vibrio vulnificus Infection: Acquisition
Eating uncooked shellfish(especially in summer)
Wading in shallow estuarine environments where patient has skin breaks to the legs.

22. Risk Factors for Vibrio vulnificus septicaemia
Alcoholic cirrhosis — 31 to 43 percent
Underlying liver disease including cirrhosis (unspecified etiology) and chronic hepatitis — 24 to 31 percent
Alcohol abuse without documented liver disease — 12 to 27 percent
Hereditary hemochromatosis — 12 percent
Chronic diseases such as diabetes mellitus, rheumatoid arthritis, thalassemia major, chronic renal failure, "preleukemia", and lymphoma — 7 to 8 percent

23. Diagnosis of Vibrio vulnificus Infection
Severe clinical picture
Blue Green colonies on TCBS agar
Halophilic
API20E will give you a good idea, but other Vibrio species closely related biochemically.

24. Treatment of Vibrio vulnificus Infection
Should consist of a 3rd generation Cephalosporin and a Tetracycline
Newer fluoroquinolones also effective.
Macrolides probably are also effective.

25. Vibrio parahaemolyticus : What diseases does it cause?
Causes seafood associated diarrhoeal illness(usually oysters), and less commonly wound infections & septicaemia.
Pathogenicity associated with production of a thermostable haemolysin (Vp-TDH) in most cases.
A lot of V. parahaemolyticus bacteria don’t contain pathogenicity factors and are non-pathogenic.

26. Vibrio parahaemolyticus How is it diagnosed and treated?
TCBS agar. Alkaline peptone water may be used as an enrichment broth, particularly when culturing stools.
Non-sucrose fermentor, therefore blue-green colonies on TCBS.
API 20 E ID, ?with additional NaCl
Clinically significant isolates will generally either be haemolytic or be urease positive.
Again treatment of severe disease should involve a 3rd generation cephalosporin and oral tetracycline

27. Other Vibrios Diarrhoeal Illness V. fluvialis V. mimicus V. furnissii
V. Hollisae
Diarrhoeal Illness
V. alginolyticus
V. damsela
Wound Infections

28. Summary
Vibrios can cause serious disease. The main three are V.cholerae, V. vulnificus & V. parahaemolyticus.
Appropriate plates should be set up when clinically suspected.
Reasonably easy to identify to Vibrio genus level, more difficult sometimes to get the species.