Distribution of Fatal Vibrio Vulnificus Necrotizing Skin and Soft-Tissue Infections: A Systematic Review and Meta-Analysis

Abstract

Vibrio vulnificus necrotizing skin and soft tissue infections (VNSSTIs), which have increased significantly over the past few decades, are still highly lethal and disabling diseases despite advancing antibiotic and infection control practices. We, therefore, examined the spatiotemporal distribution of worldwide reported episodes and associated mortality rates of VNSSTIs between 1966 and 2014. The PubMed and Cochrane Library databases were systematically searched for observational studies on patients with VNSSTIs. The primary outcome was all-cause mortality. We did random-effects meta-analysis to obtain estimates for primary outcomes; the estimates are presented as means plus a 95% confidence interval (CI). Data from the selected studies were also extracted and pooled for correlation analyses.Nineteen studies of 2227 total patients with VNSSTIs were analyzed. More than 95% of the episodes occurred in the subtropical western Pacific and Atlantic coastal regions of the northern hemisphere. While the number of cases and the number of deaths were not correlated with the study period (rs = 0.476 and 0.310, P = 0.233 and 0.456, respectively), the 5-year mortality rate was significantly negatively correlated with them (rs = -0.905, P = 0.002). Even so, the pooled estimate of total mortality rates from the random-effects meta-analysis was as high as 37.2% (95% CI: 0.265-0.479).These data suggest that VNSSTIs are always an important public health problem and will become more critical and urgent because of global warming. Knowing the current distribution of VNSSTIs will help focus education, policy measures, early clinical diagnosis, and appropriate medical and surgical treatment for them.

FIGURE 1

Flow chart of study selection process.

FIGURE 2

Spatial distribution of the reported (A) total and (B) fatal episodes of Vibrio vulnificus necrotizing skin and soft tissue infections.

FIGURE 3

Temporal distribution of the reported episodes of Vibrio vulnificus necrotizing skin and soft tissue infections according to (A) publication date and (B) study period. Note: the size of the circles in (A) indicates the reported number of cases in different studies. In (B), the solid gray arrows represent the recruited case numbers from the expected studies in the future and the dashed arrow the projection of mortality based on the actual recorded mortality from 1996 to 2005.

FIGURE 4

Forest plot of meta-analysis for mortality in patients with Vibrio vulnificus necrotizing skin and soft tissue infections. The width of the horizontal line represents the 95% CI of individual studies. The vertical dotted line represents the overall expected mortality. The combined estimate of mortality was 37.2% (95% CI: 26.5–47.9%, I² = 98%).