Soft tissue infections following water exposure
- Larry M Baddour, MD, FIDSA
Larry M Baddour, MD, FIDSA
- Professor of Medicine
- Mayo Clinic College of Medicine
Soft tissue infections can occur after both freshwater and saltwater exposure, particularly if there is associated trauma. Trauma can be caused by living creatures or by inanimate objects found in the aquatic environment. In addition, some aquatic creatures can transmit soft tissue infections outside the water environment. This can occur, for example, with the use of leeches for medicinal purposes to relieve venous congestion at surgical sites, as Aeromonas spp, a normal inhabitant of the foregut of leeches, may contaminate the wound and cause a secondary wound infection .
Although the array of microorganisms that can produce soft tissue infections following water exposure is extremely large, this discussion will focus on five bacteria that most commonly produce soft tissue infections in association with exposure to water or water-related animals. These include Aeromonas species, Edwardsiella tarda, Erysipelothrix rhusiopathiae, Vibrio vulnificus, and Mycobacterium marinum. The acronym AEEVM will be used here when referring to these organisms.
The epidemiology, clinical manifestations, diagnosis, and empiric treatment of AEEVM infections and specific treatment of Edwardsiella spp and M. marinum infections will be reviewed here. Treatment of Aeromonas spp, Erysipelothrix spp, and V. vulnificus infections is presented separately. (See "Aeromonas infections" and "Vibrio vulnificus infections" and "Erysipelothrix infection".)
Local trauma or injury, which can be either minor or major, coupled with water exposure is a common theme that predisposes to many of the AEEVM-related infections.
Trauma — Trauma leading to infection with AEEVM includes puncture wounds due to fishhooks and fish spines and lacerations due to boat motor propeller blades and a variety of other inanimate objects present in areas of wading and swimming. In addition to trauma by accidental puncture, bites from fish, alligators, crocodiles, sharks, and turtles can transmit AEEVM infections [2-4].
- Mercer NS, Beere DM, Bornemisza AJ, Thomas P. Medical leeches as sources of wound infection. Br Med J (Clin Res Ed) 1987; 294:937.
- Mekisic AP, Wardill JR. Crocodile attacks in the Northern Territory of Australia. Med J Aust 1992; 157:751.
- Flandry F, Lisecki EJ, Domingue GJ, et al. Initial antibiotic therapy for alligator bites: characterization of the oral flora of Alligator mississippiensis. South Med J 1989; 82:262.
- Pavia AT, Bryan JA, Maher KL, et al. Vibrio carchariae infection after a shark bite. Ann Intern Med 1989; 111:85.
- Voss LM, Rhodes KH, Johnson KA. Musculoskeletal and soft tissue Aeromonas infection: an environmental disease. Mayo Clin Proc 1992; 67:422.
- Aubry A, Chosidow O, Caumes E, et al. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates. Arch Intern Med 2002; 162:1746.
- Vally H, Whittle A, Cameron S, et al. Outbreak of Aeromonas hydrophila wound infections associated with mud football. Clin Infect Dis 2004; 38:1084.
- Slaven EM, Lopez FA, Hart SM, Sanders CV. Myonecrosis caused by Edwardsiella tarda: a case report and case series of extraintestinal E. tarda infections. Clin Infect Dis 2001; 32:1430.
- Hargreaves JE, Lucey DR. Life-threatening Edwardsiella tarda soft-tissue infection associated with catfish puncture wound. J Infect Dis 1990; 162:1416.
- Clarridge JE, Musher DM, Fainstein V, Wallace RJ Jr. Extraintestinal human infection caused by Edwardsiella tarda. J Clin Microbiol 1980; 11:511.
- Baddour LM. Extraintestinal Aeromonas infections--looking for Mr. Sandbar. Mayo Clin Proc 1992; 67:496.
- Tacket CO, Brenner F, Blake PA. Clinical features and an epidemiological study of Vibrio vulnificus infections. J Infect Dis 1984; 149:558.
- Levine WC, Griffin PM. Vibrio infections on the Gulf Coast: results of first year of regional surveillance. Gulf Coast Vibrio Working Group. J Infect Dis 1993; 167:479.
- Oliver JD. The pathogenicity and ecology of Vibrio vulnificus. Marine Tech Soc J 1981; 15:45.
- Czachor JS. Unusual aspects of bacterial water-borne illnesses. Am Fam Physician 1992; 46:797.
- Baddour LM, Baselski VS. Pneumonia due to Aeromonas hydrophila-complex: epidemiologic, clinical, and microbiologic features. South Med J 1988; 81:461.
- Janda JM, Abbott SL. Infections associated with the genus Edwardsiella: the role of Edwardsiella tarda in human disease. Clin Infect Dis 1993; 17:742.
- Edelstein H. Mycobacterium marinum skin infections. Report of 31 cases and review of the literature. Arch Intern Med 1994; 154:1359.
- Collier DN. Cutaneous infections from coastal and marine bacteria. Dermatol Ther 2002; 15:1.
- Burke WA, Jones BE. Cutaneous infections of the coast. N C Med J 1987; 48:421.
- Sia TY, Taimur S, Blau DM, et al. Clinical and Pathological Evaluation of Mycobacterium marinum Group Skin Infections Associated With Fish Markets in New York City. Clin Infect Dis 2016; 62:590.
- Murphey DK, Septimus EJ, Waagner DC. Catfish-related injury and infection: report of two cases and review of the literature. Clin Infect Dis 1992; 14:689.
- Wilson JP, Waterer RR, Wofford JD Jr, Chapman SW. Serious infections with Edwardsiella tarda. A case report and review of the literature. Arch Intern Med 1989; 149:208.
- Wolinsky E. Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 1979; 119:107.
- Collins CH, Grange JM, Noble WC, Yates MD. Mycobacterium marinum infections in man. J Hyg (Lond) 1985; 94:135.
- Donta ST, Smith PW, Levitz RE, Quintiliani R. Therapy of Mycobacterium marinum infections. Use of tetracyclines vs rifampin. Arch Intern Med 1986; 146:902.
- King AJ, Fairley JA, Rasmussen JE. Disseminated cutaneous Mycobacterium marinum infection. Arch Dermatol 1983; 119:268.
- Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007; 175:367.
- Kim R. Letter: Tetracycline therapy for atypical mycobacterial granuloma. Arch Dermatol 1974; 110:299.
- Loria PR. Minocycline hydrochloride treatment for atypical acid-fast infection. Arch Dermatol 1976; 112:517.
- Black MM, Eykyn SJ. The successful treatment of tropical fish tank granuloma (Mycobacterium marinum) with co-trimoxazole. Br J Dermatol 1977; 97:689.
- Chow SP, Ip FK, Lau JH, et al. Mycobacterium marinum infection of the hand and wrist. Results of conservative treatment in twenty-four cases. J Bone Joint Surg Am 1987; 69:1161.
- Lewis FM, Marsh BJ, von Reyn CF. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention. Clin Infect Dis 2003; 37:390.
- Water exposure
- Gender predominance
- Underlying diseases
- CLINICAL MANIFESTATIONS
- Differential diagnosis
- When to hospitalize
- Empiric antibiotic treatment
- Directed antibiotic therapy
- - Aeromonas
- - Edwardsiella tarda
- - Erysipelothrix rhusiopathiae
- - Vibrio vulnificus
- - Mycobacterium marinum
- Duration of treatment
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS