Considerations of infections on boats.

[thataway]

The reason I bring this up is that a friend of mine was at Powell for the last few weeks. He slipped and fell down a sandstone bank, and scraped his knees and elbows. He did clean the wounds, but perhaps not to my standards (?). He developed an abscess in the elbow joint "sac" a few days later, and had to have it drained by a surgeon and IV antibiotics given. I don't know what bacteria was involved, but never assume that any water you boat in or soil you come in contact with is not filled with "bad bacteria".

Last week on The Hull Truth, there was a thread about marine infections. This involved Vibrio Vulnificus and a death. this is an infection which is fairly common in warm salt water or even brackish water. It is described as a "flesh eating bacteria" If some of our microbiologist friends don't jump in, I'll go into some of the bacteriology of this. It is a relation of cholera, and several other of the species such as Vibrio Parahaemolyticus, which can also cause gastroenteritis or a stomach infection.

The danger of any of these is sepsis, or a blood stream infection and a simple scrape can go from a simple wound to life threatening in a matter of hours. These bacteria are also carried in oysters, as well as several other marine pathogens. (Apalachicola oysters are tested every day, and are one of the few I eat)

Pardon my reposting what I put on THT here, but it is important, since there are about 35 deaths a year from these type of infections--and a lot of morbidity reported by CDC.

V. vulnificus can cause disease in those who eat contaminated seafood or have an open wound that is exposed to seawater. Among healthy people, ingestion of V. vulnificus can cause vomiting, diarrhea, and abdominal pain. In immunocompromised persons, particularly those with chronic liver disease, V. vulnificus can infect the bloodstream, causing a severe and life-threatening illness characterized by fever and chills, decreased blood pressure (septic shock), and blistering skin lesions. V. vulnificus bloodstream infections are fatal about 50% of the time.

V. vulnificus can cause an infection of the skin when open wounds are exposed to warm seawater; these infections may lead to skin breakdown and ulceration. Persons who are immunocompromised are at higher risk for invasion of the organism into the bloodstream and potentially fatal complications.

There are a number of other bacteria which can live in salt water, but this is the worse. Do not go into the water with open wounds: be cautious eating raw Oysters.

Offshore you are much safer, as in areas away from other people and potential sewage spill.

Next the use of bleach; Both bleach and hydrogen peroxide have been used for "sanitizing wounds" Neither are recommended because they cause the tissue to die, although these agents may or may not kill the pathogens.

Rather, using sterile water or sterile saline (you can boil water to give sterile water), and Betadine, an Iodine based antiseptic surgical soap (be sure the patient is not allergic to iodine), with forceful irrigation with a sterile solution and surgical type of scrub brush to remove any debris, sand, shell etc from the wound.

How to handle wounds in salt water, fresh water, or areas in contact with soil and sand.
Stop bleeding--direct pressure on a wound.
Clean the wound very throughly; use a scrub brush to clean the wound.
Irrigate the wound; do not use sea water or lake water.
Get rid of any debris deep in the wound, and scrub, wash with Betadine solution, leaving it in contact for at least 5 minutes.
If you have to use Steristrips to close the wound, leave them loose, so that if there is any drainage, it can seep out. If there is dead skin or debris, trim this off with sterile scissors or a sharp blade. If any sign of infection, see a physician ASAP.
If there is an access it should be drained--best by a physician. I carry #11 Xacto blades which have been sterilized in my first aid kit for this purpose.

These are some of the infections I saw when in practice: MRSA
Vibrio Vulnificus and Vibro parahaemolyticus , Several species of Pseudomonas and Mycobacterium Marinum. Also a number of species of Staph, Strep and Coliforms are also seen in salt water infections. One other group not often thought of is atypical tuberculosis mycobacteria. If you have an infection, which is recurrent or resistant to treatment a culture, considering all of these other infections agents must be considered.

I was asked about antibiotics:

I suggest that triple antibiotic ointment (bacitracin, neomycin, and polymyxin B) always be carried aboard, and after cleaning and debriding applied to any surface scrape or abrasion. I do not recommend ichthyic ointment.

The question about oral antibiotics is an excellent one. Yes, I do recommend if you are going to be more than a few hours from medical care, that antibiotics prescribed by your physician be aboard. Specifically for Vibrio vulnificus the best oral antibiotics would be Vibramycin and Cepro. However, a Vibrio infection is a medical emergency for a person with an open wound or immune compromised condition. If you are suspicious, go to the ER immediately, don't wait to see if is "better in the morning!"

So carry a scrub brush, a container which you can use to boil water to be sure it is sterile and Betadine solution and gloves so you can work with a wound. I also have used the # 11 Xacto blade to work debris out of wounds.

I have treated abscesses even offshore, as in the TransPac. Where one of my crew members had a puncture wound from a barb on a metal halyard, and developed a deep abscess on his finger within 48 hours of the injury. I drained it almost immediately when I was shown the wound, and started him on antibiotics.

[Wandering Sagebrush]

Dr Bob, thanks! This is good information. We carry all but the betadine, but that is going into the kit ASAP.

[BrentB]

I am not a physician but a medical microbiologist with years of experience working at two hospitals, an off site reference medical
lab and state public health lab.

This is an excellent case study and I am glad to share m2cw

Vibrio species prefer salt containing water or brackish water to thrive and will not grow well and rarely found in fresh water.
Migratory birds can carry Vibrio sp and other infectious agents to inland areas hundreds of miles away from salt water. Seafood is an international food stuff and can cause infections worldwide. Seafood is a non sterile item like other food items and should be carefully prepared and cooked to avoid infections and serving it raw or under cooked should be avoided.

One's immune status changes with age along with if pre existing health condition(s) can increase the chance of infections compared to someone with a healthy immune status where
the body fights off the infection and no medical treatment or hospitalization is required

a little micro trivial

Vibrio has neighbors belonging to the Aeromonas and Pleisomonas genera. All these are Gram negative (bacteria are separated into Gram negative and Gram positive based on the Gram Stain), oxidase positive ( a very simple test but important b/c E coli is oxidase negative) and ferment glucose ( other bacteria do not ferment but oxidize to obtain carbohydrates carbon source) ,and require additional biochemicals for a complete identification.

Vibrio will grow a plain Blood agar plate (BAP) (the most common agar plate used) along many other bacteria so selective media are used like Mac Conkey and EMB agar plates to recover the pathogen and not normal flora. TCBS agar is made to recover Vibrio from stools (feces) and works very well b/c it is inhibitory and selective, and not all labs routinely use it and use MacConkey and other media to recovery stool bacterial enteropathogens. For wound cultures we use 3 or 4 different plates and perform a Gram Stain (rapid less than 60 min test) to quickly tell the doc if white blood cells ( a sign of infection) and type of bacteria are present. This helps them prescribe an antibiotic if one is used along with cleaning the wound. If viral agents in stool are suspected, these can not be easily cultured and other more sophisticated testing is preformed. ex We run PCR for Norovirus and it is fast, same day test compared to a bacterial culture which can take several days to complete. Norovirus infection are not treated with antibiotics so they wree prescribed then patients can stop taking them

Back to this patient's infection, the causative agent is unknown and other bacteria like E. coli, Pseudomonas aeruginosa along a 20 or more come to mind. I guess it caused by a Gram negative rather Gram positive bacteria like Staph or Strep but still possible and Staph and Strep are common on the human skin and break in the skin can cause an infection by something harmless and beneficial before the break

This is a wound and the potential for the causative agent to cause blood stream infections is high so treating doc are well trained and make appropriate treatment

If culture is performed and a pathogen is detected then an antimicrobial susceptibility testing (AST)needs to performed to a panel of antibiotics along with the interpretation to guide the primary care physician to optimize therapy. To me, there are 2 ways to treat skin wounds. clean and no antibiotics, clean and give antibiotics these decisions are based on the physician.

One of the major global public health issue is antibiotic resistant bacteria and the lack of new antibiotics coming out.

Over prescribing of antibiotics is another problem and I see no purpose in using an expensive broad spectrum antibiotic to treat something that is susceptible to something that cost pennies to treat.
that is why AST is important and the lab needs to be using the latest guidelines . In the USA we use CLSI guidelines and in Europe, EUCAST guidelines are used.

I realize that discussing antibiotic resistant bacteria is not common in the media but I am around it every day and been talking about since 1999 and seeing patients infected with multiple drug resistance bacteria that is nearly or impossible occurs every day worldwide is the saddest part of my job and hope the patient has a good doc and prayers do help

Vibrio cholerae produce a highly potent toxin and this bacteria has been around a long times and cause wide spread outbreaks called epidemics and other bacteria can cause but cholera outbreaks last for years.

If you have read this far, then Google Vibrio and Haiti and read the devastation this bacteria has caused. very sad and will probably never be eradicated due to the poor sanitary infra structure in this country plus it has spread to other countries.
They lack safe (potable not portable) drinking and sanitary septic treating systems which is so common in the US


I glad this patient had a full recovery and medical care was prompt and access to well trained health care professionals


for additional information see
Infections of Leisure, 4th Edition
David Schlossberg Infections of Leisure 2009 4th Edition Washington, DC ASM Press 448 pp. $69.95. (paperback)

Peter A. Leggat

+ Author Affiliations

Anton Breinl Centre, James Cook University, Townsville, Queensland, Australia

Dedicated leisure time was enshrined by the International Labour Organization in 1936, when a convention provided for 1 week's leave per year for workers, at least in developed countries [1]. This leave entitlement had expanded to 3 weeks by 1970 and 4 weeks by 1999 [1]. People spend their leisure time in different ways, but leisure is estimated by the United Nations World Tourism Organization to account for 75% of all international travel [1]. The aim of this Fourth Edition of Infections of Leisure is to “identify and organize the infectious risks associated with our leisure time activities” (p xiii) and provide Practical Tips for “prevention and management of infections” (p xiii). Infections of Leisure has a dedication, a table of contents, list of contributors, a preface, a preface to the first edition, 19 chapters, and a comprehensive index. There is no foreword. References are given by chapter. The cover is attractive with a leisure theme and there is good use of the back cover for promoting other publications, although it is a pity that there was not some mention of the special attractions of the present textbook.

Chapters include At the Shore, Freshwater: From Lakes to Hot Tubs, The Camper's Uninvited Guests, Infections in the Garden, With Man's Best Friend, Around Cats, Feathered Friends, Less Common House Pets, With Man's Worst Friend: The Rate, Closed Due to Rabies, Sports: The Infectious Hazards, Traveling Abroad, From Boudoir to Bordello: Sexually Transmitted Diseases and Travel, Infections from Body Piercing and Tattoos, Infectious Diseases at High Altitude, Infectious Risks of Air Travel, Perils of the Petting Zoo, Infections on Cruise Ships, and Exotic and Trendy Cuisine. The Infections of Leisure is easy reading and has an infectious disease focus as its name suggests. Each chapter has extensive references. Highlights include the new chapter on Infectious Risks of Air Travel (chapter 16). Other new chapters are Perils of Petting Zoo (chapter 17) and Infections on Cruise Ships (chapter 1. The largest chapter is that appropriately devoted to infectious diseases associated with the rat (30 pages in length). Discussion of emerging infections diseases, such as Severe Acute Respiratory Syndrome and Avian influenza, have the potential to date a publication rapidly, particularly with the advent of pandemic influenza (H1N1) 2009. Nonetheless, the chapter on infectious diseases of air travel picks up on some of the generic aspects of pandemics. It may be useful for further editions to provide a little more structure within each chapter, perhaps with the inclusion of summary boxes, maps, and provision of further readings or links to further resources. Photos could be used more frequently for greater impact.

Little information is given concerning the editor; however, David Schlossberg is Professor at the Temple University School of Medicine and Medical Director, Tuberculosis Control Program, Philadelphia Department of Public Health, in Philadelphia, Pennsylvania. Interestingly, although there are 33 listed contributors, only 1 contributor is stated to be from outside the United States, with Dr Buddha Basnyat from Nepal being the only external contributor. This is consistent with the publisher being the American Society for Microbiology, which is based in the United States. Many of the contributors will be well known in the United States, and several have international profiles.

The Infections of Leisure is a very useful reference for those specializing in infectious disease, clinical microbiology, and travelers' health. The book will also appeal to physicians and nurses, who may often be the first point of clinical contact with infectious diseases of leisure. It would easily fit into the briefcase or desktop library. It has little in the way of competition, although some of the material may be covered in the many popular references in travel medicine [2, 3]. Academic and research departments of infectious disease and clinical microbiology should also consider the reference as an essential textbook for their libraries and postgraduate courses. This Fourth Edition of Infections of Leisure remains the definitive work in its area.

© 2010 by the Infectious Diseases Society of America

References

↵
International Labour Organization. Working time and work organization (WTWO): International labour standards. 2006 Jul 4 [Accessed 12 December 2009]. http://www.ilo.org/public/english/protection/condtrav/time/time_standards.htm.
↵
Steffen R,
DuPont H,
Wilder-Smith A
. Manual of travel medicine and health. 3rd ed. Hamilton: BC Decker; 2007.
Search Google Scholar
↵
Arguin PM,
Kozarsky PE,
Reed C
. CDC Health Information for International Travel 2008. Atlanta: CDC; 2008.
Search Google Scholar

[hardee]

The hydrogen peroxide is going out and the betadine is going into the kit.

Thanks Dr Bob and Brent. Great info.

Another tip. Wear glove when handling wire rope or chain.

Harvey
SleepyC

[thataway]

Thanks Brent for jumping in there; I had hoped you would.

The case which brought the subject to "The Hull Truth" did not have the good outcome which my friend at Lake Powell has:

http://gma.yahoo.com/blogs/abc-blogs...ws-health.html

This is a non scientific head line, but you get the picture.

I agree 100% with Brent about antibiotics. I spent most of my career undoing some of the "I need an antibiotic" mentality. I started med school in 1957. We only had a handfull of antibiotics at that time: Pencillin, Steptomycin, tetracycline and erythromycin for bacterial infections. Isoniazid was available for Tuberculosis (streptomycin was also used for TB--amphotericin B was not yet available for clinical use). Methicillin came along in the 1959 era. The first generation Cephalosporins did not appear until 1964! We had resistant infections--which nothing could be done for in 1957. Although new drugs came along, until the 1990's they were variants of basic classes discovered in the 1930's and 1940's.

The more antibiotics the more resistance, and cross resistance. The drug companies have been our worse enemies, with "pushing" the newest latest drug--instead of waiting for resistance testing as Brent so well characterized. Unfortunately antibiotics are still given for viral infections.

The reason I mention the two antibiotics, is if there is a rapidly fulminating infection; time is of the essence--and these are the most likely oral medications to be of benefit if medical attention is not available in hours and the patient is getting rapidly worse. When I made my medical kits available to offshore cruisers, the theory is that some one in the middle of the ocean, with no chance of medical attention for at least a few day, has a better chance of survival with basic and a link to a physician vis SSB radio (today satellite communication), and at one time several hospitals on both coasts had both ham operators and MD's standing by to help ships at sea, missionaries and adventurers. Today you "buy" a service which can provide this.

[BrentB]

Exactly the clock is ticking.. tick, tick, tick. tick
( ex patients in Haiti infected with the cholera bacteria can become ill in the morning and die that night without oral re hydration therapy (handful of sugar, pinch of salt and clean water) and antibiotics)....
when dealing serious wound infections that often lead to bacteremia and sepsis (same for urinary infections can progress to urosepsis) .
An appropriate broad spectrum antibiotic ( often called Gorilla - mycin) is given to save the patient if it can safe prescribed (PK and PD values).... one reason is the doc cant wait 2 -4 days for culture and AST results to be available... but therapy can be tailored when they are. Knock it out now is the key word in these cases.... another case study talking point.

As Bob Dylan said in his song the Time r a changing, I gave a talk last week on rapid detection of bloodstream infections..
A blood culture is taken and it flags positive indicating a bacterial agent is present and the rapid Gram stain is reported to the doc. Now using new rapid PNA-FISH assay or other newer detection methods, pcr, MALDI -ToF, etc...) you can tell the doc 20 min later the bacteria (E coli, Pseudomonas, Staph aureus, etc) and if a cumulative antibiotic biogram (a list showing several bacteria species are susceptible to several antibiotics... so giving an antibiotic that does on edit NOT work is avoided) is available not all places do them or keep them current, the doc can made an informed decision on appropriate therapy

This saves lives

fyi
something we worked on many yrs ago
Cholera Associated with Food Transported from El Salvador -- Indiana, 1994
http://www.cdc.gov/mmwr/preview/mmwrhtml/00037127.htm

[redbaronace]

I will keep this as a reference.

Can someone please tell me what items should be in a first aid kit for a cruising vessel.

We have a basic all in one first aid kit which has served us well for primarily minor cuts while on board. I have a feeling that while this is good, that it is severely lacking.

Thanks,
Bryan

[Levitation]

Hmmm. Small story from long ago - I was in the micro lab and the final exam was to analyze a sample containing multiple bacteria with one being a virulent pathogen. (meaning it could kill you) The challenge was to isolate and identify the virulent pathogen.
A passing grade was isolating and identifying the pathogen.
A failing grade was infecting yourself and dieing (or failing to isolate/identify)

Using various types of growth media (blood agar plates, stab tubes, etc. as mentioned above) and antibiotics it was a relatively simple and mechanical process of separation of the various species and keying in on the pathogen. I went about it confidently. Well, after some 10 days I had separated and identified every species present - but no pathogen. (yes Virginia - in those days before pcr, etc. it could take a weeks for slow growing pathogens)

So I went over to a classmate, whom I knew had the same unknown (#23C) as I did. She was a bit high strung. And I said 'I'm not asking what you have found I merely need to know if you have isolated a pathogen yet?'
Well sir, you would have thought that the fox walked through the henhouse for all the clucking and flapping and feathers flying.
"Are YOU trying to get me thrown out of school you &%^$#*!"

With that piece of information I smiled and went back to my bench, gathered my materials and walked into the professor's office. He was, as usual, enveloped in a cloud of tobacco smoke reading a german microbiology journal.
"What the hell do you want O'Connor." was the greeting.
I dumped my armload of plates and beakers on his rolling trolly.
"Your 23C pathogen has, sadly, died."
"Not likely" he grunts (our relationship was a bit tenuous as always). Stirs a few of my agar plates around with one disdainful finger. Holds one studded with multiple antibiotic discs up to the light. Gets a calculating glint in his eye and taking a key from his pocket unlocked the incubator where he kept the pathogens.
"Which number was that?"
"23C, sir".
Removing a beaker he carefully pulls the cotton plug and takes short sniff of the contents. Then he swirls it and holds it to the light. He grunts. (no Shakespeare he) sits back down, picks up his pipe and goes back to reading his journal.
"So?" I offer conversationally. "Do you want me to start over?"
"No. Good catch. You pass. Keep your mouth shut." Billowing clouds surround him. I leave.
And that was that. I got an A for the course.

I never knew what grade "sally" got as she never spoke to me again. OTOH she never spoke to me before that so I am unsure of the depth of the rupture in our relationship.

[AstoriaDave]

Great story, Levitation. In the old days, we protected students minimally. One term we had a an incident in the organic qual ID lab I oversaw, owing to poor decisions by a TA. Fortunately, no one seriously injured. No one would operate that way today.

[Sunbeam]

I sometimes smile (slightly forced), but rarely actually grin this early in the morning. But this morning I did. Good story

[Granath]

Question. My wife is allergic to iodine. What would be a proper substitute?

Thanks

[Sea Wolf]

Denny-O

I'm joining my friends on the C-Brat LOL Bench this Sunday morning!

Thanks for your tale! Great story, well told!

Joe.

[AstoriaDave]

Granath,

Dr. Bob will have a more definitive answer, but you might test Bactine on her skin. Bandaid Antiseptic Wash, same thing. Both have a little lidocaine for pain relief, but the germ killer is benzalkonium chloride. I think you can get prepackaged wipes with the same stuff. However, if you have a significant injury, the Bandaid version comes in a squeeze bottle so you can do some irrigation while killing bugs.

[BrentB]

I agree a good story


There are several methods to treat wounds

again m2cw
in this case this a new or fresh wound, I would
remove any foreign bodies, irrigate with saline, apply pressure to let clotting occur and apply a wound care topical gel, paste (which I call goo old hospital saying), something for pain management and bandage ( gauze and tape as minimal) then head to a immediate care facility, ER, doc in a box for a thorough exam as soon as possible. They are better trained than me. I would not only be concerned about an infection but it may need sutures, a tetanus shot (I have never see Clostridium tetani in a culture but have seen others esp V vulnificus), X -ray, antibiotics, ......

also I would not use betadine on this wound, it burns and the wound has not clotted, it is overkill at this point

[localboy]

Being an R.N. Meredith would be in complete agreement. We have a pretty well stocked med kit on board, including the items mentioned for cleaning wounds. Better to have it and not need it than need it and not have it.