Table 1.

Flow chart from diagnosis to treatment of Vibrio vulnificus.

Strategy

When a patient in his 60s presents with sharp pain in his/her leg, the following clinical history should be examined:

Is he/she at least 60 years old?

Does he/she have hepatic dysfunction and diabetes as underlying conditions?

Did his/her symptoms first appear between June and October?

Does he/she have a history of consuming raw food?

Next, a medical examination should be performed.

Does he/she have fever?

Does he/she have sharp limb pain?

Are certain abnormalities observed on his/her skin?

Does he/she have stomachache, nausea, or vomiting?

Does he/she have systemic inflammatory response syndrome?

When these conditions are confirmed, V. vulnificus infection is strongly suspected.

Medical treatment is initiated according to the following flow chart.

1:

Urgent surgery is planned while maintaining a dynamic circulatory state.

Usually, consciousness is maintained, and the respiratory state is satisfactory in many cases.

We should consider focusing on stabilizing circulation first.

General anesthesia is quickly induced.

2:

Blood and the liquid contents of blood blisters are submitted for culture.

The detection of a banana-shaped Gram-negative bacillus by Gram's staining is indicative of V. vulnificus.

As laboratory culture will require 2 days, medical treatment should be initiated before the result is obtained.

TCBS agar medium cultures should also be prepared.

3:

Sufficient antibiotic doses are prescribed for the patient as soon as possible.

Any antibiotic that is effective against Gram-negative bacilli can be used.

Although it is not a resistant bacterium, the speed of multiplication of this bacterium is extremely rapid.

4:

When performing chest X-rays required for general anesthesia, an X-ray of the affected limb should also be performed to rule out gas gangrene.

Check for gas patterns in subcutaneous tissue.

5:

Clotting abnormalities, hepatic dysfunction, and renal disorders are judged on the basis of the inspection data.

Many patients will meet the criteria for a DIC diagnosis.

6:

First, debridement is performed under general anesthesia.

Although abnormalities such as low blood pressure and bleeding tendencies indicate a poor prognosis, debridement should be performed within 4 h to maximize patient survival.

To stabilize the patient's general condition, do not admit the patients to ICU; the general condition will not improve unless the bacillus is eliminated.

Depending on intraprocedural findings, leg amputation should be performed without hesitation.

The patient's general condition should be stabilized after treatment.

7:

When the general state is not stabilized by debridement and amputation, it is likely that multiplication of the bacillus has not ceased.

In this case, re-amputation should be performed within 8 h.