In a 2024 clinical consensus document, the American Association for the Surgery of Trauma (AAST) Critical Care Committee provides guidance on antibiotic prophylaxis for adult trauma patients, emphasizing tailored treatment based on the nature of a wound's contamination. The authors recommend specific antibiotic regimens for wounds contaminated by water, which requires coverage for organisms such as Vibrio, Aeromonas, and Pseudomonas. Specifically, saltwater injuries should be treated with a combination of doxycycline and ceftazidime, or a fluoroquinolone. For freshwater wounds, the document advises using ciprofloxacin, levofloxacin, or a third- or fourth-generation cephalosporin. This guidance underscores the importance of antibiotic stewardship while acknowledging the nuanced approach required for treating these types of contaminating wounds. [1]
A 2014 issuance of practice guidelines by the Wilderness Medical Society meticulously crafted evidence-based recommendations for the role of antibiotics in basic wound management in austere environments. The guideline notes that routine systemic antibiotic prophylaxis is generally not indicated for most wounds, with exceptions including open fractures, human bites, and mammalian bites to the hand, for which systemic antibiotic treatment is recommended (Strong recommendation; high-quality evidence to moderate-quality evidence). The document further noted that aquatic exposures have a higher likelihood of gram-negative microbial etiology, and moxifloxacin was cited as a suitable first-choice agent for such infections, including animal bites, particularly in penicillin-allergic patients. Amoxicillin/clavulanate was identified as a common first-line choice for infected animal bites and other skin and soft tissue infections, with alternative options including oral second- or third-generation cephalosporins, doxycycline, and trimethoprim-sulfamethoxazole. Topical antibiotics were noted to promote wound healing and reduce infection risk with minimal downside in nonallergic patients. (Weak recommendation; low-quality or very low quality evidence). [2]
The 2014 Infectious Diseases Society of America (IDSA) guidelines for skin and soft tissue infections (SSTIs) do not specifically address infections from water contamination, however they do provide a detailed overview of erysipeloid, a cutaneous infection that can be acquired through marine and animal exposure. Caused by the gram-positive rod Erysipelothrix rhusiopathiae, erysipeloid presents as a red maculopapular lesion on the hands or fingers 1 to 7 days after exposure. The lesion typically spreads with a central clearing and may form a characteristic blue ring with a peripheral red halo. Although systemic symptoms are uncommon, approximately one-third of cases involve regional lymphangitis or lymphadenopathy. Diagnosis is established by culturing an aspirate or biopsy from the lesion, as blood cultures are rarely positive. Although the condition can resolve spontaneously in 3 to 4 weeks, treatment is recommended to expedite healing and prevent systemic complications. Based on in vitro susceptibilities, penicillin (500 mg four times daily) or amoxicillin (500 mg three times daily) for 7 to 10 days is the recommended therapy (strong recommendation; high level of evidence). For patients intolerant to penicillin, cephalosporins, clindamycin, or fluoroquinolones are considered effective alternatives. [3]
A 2005 review article discussed the management of extremity trauma and associated infections occurring in aquatic environments. The review emphasizes that aquatic injuries, while sharing some principles with land-based trauma, present unique challenges due to the high infection rates associated with exposure to fresh or salt water. Marine and freshwater environments are rich in bacteria, and this necessitates that wounds sustained in these environments be presumed to be infected, with antibiotics serving a therapeutic rather than prophylactic role. Some common pathogens involved in marine and freshwater infections, for which initial antibiotic therapy is recommended, include gram-negative Vibrio and Aeromonas hydrophila as well as gram-positive Mycobacterium marinum and Erysipelothrix rhusiopathiae. For saltwater injuries, the inclusion of Vibrio species coverage is imperative, and treatment with either a combination of doxycycline and ceftazidime, or a fluoroquinolone (i.e. ciprofloxacin or levofloxacin) is recommended. Freshwater injuries should be managed with a fluoroquinolone, or a third- or fourth-generation cephalosporin such as ceftazidime to prevent infections associated with Aeromonas hydrophila. Treatment with either clarithromycin, minocycline, TMP-SMX, or rifampin plus ethambutol is recommended for M. marinum infections, and penicillin, cephalexin, or ciprofloxacin for cutaneous E. rhusiopathiae infections. Overall, the article emphasizes that failure to identify the unique aspects of aquatic trauma may lead to poor clinical outcomes. [4]
Discussions related to fishhook injuries specifically briefly address the role of antibiotics. While well-controlled studies regarding systemic antibiotics are lacking, recommendations from the American Academy of Family Physicians note post-removal wound care may generally consist of application of an antibiotic ointment and simple dressing. Tetanus booster may be administered to those who have not had the booster in the previous 5 years. Systemic antibiotics are generally not indicated, although prophylactic antibiotic therapy may be considered for patients who are immunosuppressed or experience poor wound healing, in addition to those with deeper wounds that involve the tendons, cartilage or bone. In these cases, prophylactic oral fluoroquinolones to cover Aeromonas hydrophila may be recommended. Use of oral antibiotics may not be needed for uncomplicated fishhook injuries to soft tissues due to low risk of progress to cellulitis. [5], [6], [7]
A 2017 prospective observational study investigated the adequacy of amoxicillin and clavulanic acid as a first-line antibiotic treatment for upper limb fish spike injuries. This two-year study enrolled 60 patients who presented to the Department of Plastic and Reconstructive Surgery with injuries caused by fish spikes. Researchers collected wound swabs and tissue samples from each patient and analyzed them to identify the presence of marine-specific bacteria and other pathogens resistant to the empirical treatment. The study's methodology involved using a variety of culture media and advanced mass spectrometry techniques for accurate bacterial identification and antibiotic susceptibility testing. Findings revealed that only 12% of the analyzed samples grew bacteria resistant to amoxicillin and clavulanic acid, including methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacter cloacae. Notably, only one patient in the cohort had an infection with a true marine-specific bacterium, Photobacterium damselae, which was susceptible to the standard empirical treatment. The majority of bacterial growth was attributed to skin flora rather than marine pathogens, leading to the recommendation that flucloxacillin might be a more appropriate empirical therapy for such injuries. The study concluded with the suggestion that clinicians should broaden antimicrobial coverage if patients do not respond to initial therapy or if they present with systemic infection symptoms. [8]
A 2022 observational cross-sectional study examined the epidemiological and clinical characteristics of marine injury patients, specifically focusing on pathogen infection and drug sensitivity. The study involved a retrospective review of 635 patients admitted to Rizhao People’s Hospital, Shandong, China, from March 2019 to March 2021 with injuries sustained at sea. Among these patients, 195 were identified as having infections, leading to an infection rate of 30.71%. Infections were notably more common among older individuals, those with prolonged prehospital visit times, and those with certain blood parameter anomalies, such as lower red blood cells and hemoglobin levels. The injuries leading to these infections were mostly avulsion and puncture injuries, frequently resulting in fractures, vascular injuries, or nerve injuries. The microbial analysis, using the VITEK 2 Compact System for bacterial identification and antimicrobial susceptibility testing, identified a predominance of Gram-negative bacteria, comprising 77% of the isolates, with Proteus species being the most common. Gram-positive bacteria were less prevalent (23%), and dominated by Staphylococcus aureus. The study's findings indicated that Gram-negative bacilli were generally sensitive to a range of antibiotics, including aminoglycosides, carbapenems, and fourth-generation cephalosporins, but exhibited resistance to penicillins and early-generation cephalosporins. Conversely, Gram-positive bacteria showed sensitivity to agents such as rifampicin, linezolid, gentamicin, tigecycline and vancomycin, though they were resistant to penicillin antibiotics. These results emphasize the critical role of pathogen culture and drug sensitivity testing in guiding effective anti-infective treatments for marine-injured patients, where rapid and targeted therapy can significantly impact outcomes due to the unique maritime environment and associated microbial flora. [9]