Special to OWM: Healing After the Hurricane

    This summer’s hurricanes cut a path of destruction across the US Gulf Coast, killing hundreds and compromising the health of thousands of people exposed to their wrath. The luckier victims escaped to dry ground in Texas and other states across the US. But exposure to hurricane floodwaters put people at risk for a variety of infections, especially if they had wounds. Clinicians caring for the storms’ refugees — wherever they now may be — need to be cognizant of wound-related medical problems.

    Infection risk. Infection is a primary concern. According to the Centers for Disease Control and Prevention (https://www.cdc.gov), anyone with a wound who experienced the hurricane should be evaluated for tetanus immunization. Small non-infected wounds should respond to prompt first aid but additional medical attention is necessary if a foreign object (including dirt and pieces of clothing) is embedded in the wound, a wound demonstrates signs of infection (increased warmth, pain, erythema, and/or exudate), or the risk of infection is increased. Crush wounds, puncture wounds, and wounds contaminated with feces, soil, or saliva, as well as wounds in individuals whose health is compromised by other medical conditions, require infection assessment and management by a qualified healthcare provider.

    Diagnosis and treatment. Generally, wound infection is mostly attributable to staphylococci and streptococci. If these organisms are present, recommended initial treatments include beta-lactam antibiotics with staphylococci activity (eg, cephalexin, dicloxacillin, ampicillin/sulbactam) and clindamycin. Infections that fail to respond to beta-lactam antibiotics may be caused by methicillin-resistant Staphylococcus aureus (MRSA) and may be treated with trimethoprim-sulfamethoxazole (oral), vancomycin (intravenous), or clindamycin (in cases where isolates are susceptible). Wound infection treatment also includes incision and abscess drainage.

    People with wounds exposed to organisms found in fresh or seawater (eg, Aeromonas spp., non-cholera Vibrio spp., and Pseudomonas and other Gram-negative rods) face additional infection risk. When patients fail to respond to the initial therapies previously described, waterborne organism infection should be considered, even though such infection is relatively uncommon. Aeromonas can be treated with trimethoprim/sufamethoxazole, amoxicillin/clavulanate, and the newer fluoroquinolones (levoflaxacin, moxifloxacin, gatifloxacin); Pseudomonas and many other Gram-negative organisms respond to the fluoroquinolones.

    Vibrio vulnificus. Native to warm, coastal waters, the bacterium V. vulnificus also can be found in shellfish and marine creatures during the summer, threatening wounds exposed to these waterways and wildlife. Exposure to V. vulnificus poses a unique risk for severe and life-threatening infection. Although this bacterium is in the same genus as the bacteria that cause cholera (Vibrio cholerae), the resultant illness is different and does not spread directly from person to person; also, V. cholerae rarely causes wound infection. Differential diagnosis is made via a microbiologic culture of the wound, blood cultures, or (in the event of suspected ingestion) stool culture. People at most risk have open wounds (even a small cut or scrape), an underlying illness (eg, hepatic disease), or compromised immune system and have bathed in — or in the most recent situation, waded through — marine waters. The risk of infection is lower in otherwise healthy people. The infection is rare in children and those who succumb have an underlying condition (eg, thalassemia or nephrotic syndrome), although one case of a healthy child acquiring the infection after exposure to contaminated water was reported.

    A wound infected with V. vulnificus initially may present with erythema and pain and subsequently can affect the entire body. Systemic infection begins with acute illness, followed by rapid decline in health. In most cases, illness manifests 1 to 3 days after exposure to the bacteria; symptoms have been known to manifest as many as 7 days after exposure. Systemic symptoms include chills and fever, erythema of the skin on the extremities, hemorrhagic bullae, and low blood pressure (septic shock). Vibrio vulnificus wound infections have a 20% fatality rate — death is preventable with aggressive surgical treatment.

    Treatment. Wounds exposed to marine waters require immediate soap-and-water cleansing. Infected wounds need to be assessed and aggressively monitored by a clinician. If the patient is febrile, has hemorrhagic bullae, or shows signs of sepsis, blood cultures should be obtained from the wound or hemorrhagic bullae and all V. vulnificus isolates forwarded to a public health laboratory. If V. vulnificus is suspected and/or testing confirms its presence, immediate treatment, including attention to the wound site, will improve chances for survival. Although no clinical trials concerning the management of V. vulnificus have been published, infectious disease experts recommend a regimen of antibiotics. Their directions are based on case reports and animal studies.

    Antibiotic therapy consists of a doxycycline (100 mg PO/IV twice daily for 7 to 14 days) and a third-generation cephalosporin (eg, ceftazidime, 1 to 2 g IV/IM every 8 hours). In an animal model, fluoroquinolone (levoflaxacin, moxifloxacin, or gatifloxacin) has been reported to be at least as effective as the combination drug regimen. Because doxycycline and fluoroquinolone are contraindicated in children, young patients can be treated with trimethoprim-sulfamethoxazole plus an aminoglycoside. Vigilant attention to the wound site should include debridement of necrotic tissue. In some cases, fasciotomy or amputation is necessary. Long-term consequences are not expected in patients who recover from the illness.

    Clinicians caring for hurricane victims need to remain alert to the possible long-term effects of exposure to the storms’ floodwaters. Government plans to address the Gulf Coast devastation may be in discussion but there is no doubt that assertive, aggressive wound care can help many hurricane casualties resume healthy, productive lives.

    The information for this article was obtained at https://www.cdc.gov. Accessed September 14, 2005.
    Additional information is available at https://www.bt.cdc.gov/disasters.