JPED Journal

At the same time, the peripheral blood culture tested positive for methicillin-susceptible Staphylococcus aureus. According to both antibiograms, amikacin and teicoplanin were discontinued and treatment with ceftriaxone alone was prosecuted for a total of 14 days. Fever subsided in five days and all the inflammatory and biochemical parameters returned normal within a week. CVC blood culture tested negative after five days of ELT and the parenteral support via CVC resumed as usual. More than one year later, our patient is in good health and his CVC is still in site and perfectly working.

Discussion

The Vibrio genus encompasses over 100 different species of brackish water niche Gram-negative bacteria spread worldwide [1]. Vibrio spp. include some well-known enteropathogenic species (V.vulnificus, V. parahaemolyticus, and V.cholera), but also other less known species, like V.alginolyticus, that have been isolated mainly from marine organisms (farm fish, shellfish, shrimp), but recently also from wild and domestic birds [2,17-18]. Very recently the presence of a V.alginolyticus diarrheogenic strain has been demonstrated also in non-saline potable water systems [19].

Climate change and marine traffic are the leading causes of the growing preponderance of V.alginolyticus even in temperate zones, such as the coastal areas of Europe [20]. In addition, along with the growing spread, an increasing pathogenic power has been reported and a multi-drug resistant V.alginolyticus strain, OS1T47, was isolated from an offshore site in the Red Sea [21].

In spite of their spread, Europe lacks mandatory notification systems for Vibrio-associated illnesses other than those caused by V.cholerae O1/O139, andcurrent European guidelines for foodstuffs do not include their assessment in food. Humans V.alginolyticus infections typically occur through contact with contaminated seawater or consumption of raw or undercooked seafood. Most often V.alginolyticus causes gastro-intestinal infections, with diarrhea, abdominal cramps, vomiting and fever [5,6], but superinfection of skin lesions [11-13] and otitis [79] have also been described, the latter mostly in children with recent exposure to infested seawater around Europe and the Mediterranean, mainly in the warmer times of the year [22].

Very rarely, V.alginolyticus invasive infections, such as intracranial abscess [14], septicemia and necrotizing fasciitis [15,16], have been reported in immunocompromised or otherwise sick adults patients living outside the European continent. Although Vibrio spp. and V.alginolyticus have been increasingly isolated from mussels and other marine gastropods in the Mediterranean Sea [23,24], no cases of infection have been reported so far in Italy, neither in adults nor children.

To our knowledge, ours is the first pediatric case of a V.alginolyticus sepsis in an immunocompetent Italian child, affected by SBS and carrying a CVC for parenteral support. In our opinion, two are the key aspects of this case worth highlighting. First of all, our experience testifies the possibility of severe human infections sustained by bacteria, such as V. alginolyticus, hardly pathogenic until some time ago, that can benefit from warmer temperatures. This  is undoubtedly another proof of the dangerous effects of climate change affecting our planet, expected to expose humans to increasing types of environmental risks hitherto unknown.

Besides that, due to the extraordinary progress in medicine, the population of adult and pediatric patients surviving severe and rare diseases is steadily increasing, thus causing a progressive increase in the number of subjects potentially susceptible to infections, as the result of the combined effect of the disease itself, the immunosuppression and the indwelling long-lasting devices.

As a consequence of above, also in our country, pediatricians facing febrile immunocompromised or immunocompetent children with devices should evaluate not only their medical history, but also investigate the possible recent exposure to environmental risks, such as bathing in the Mediterranean sea, bearing in mind the risk of multi-drug-resistant V. alginolyticus infection.

Conclusion

As our experience shows, Vibrio alginolyticus can be responsible for sepsis and other invasive infections also in immunocompetent patients carrying devices such as CVC that create a direct connection between blood and the environment. In this type of patients or in case of deep wounds, if fever or other clinical manifestations suggest the possibility of an ongoing invasive infection, a recent exposure to seawater, also in Italy, should be carefully investigated. If the risk of an invasive infection sustained by V. alginolyticus is high, an appropriate empiric antibiotic therapy should be promptly started. Due to the recent emergence of more pathogenic strains of V. alginolyticus with higher level of antibiotic resistance, treatment should be rapidly changed according to the antibiogram. Moreover, to better assess the actual environmental risk, it would be advisable to extend the European notification systems to all Vibrio-associated illnesses.

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