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SALMONELLA INFECTION Abdelaziz Elamin, MD, PhD, FRCPCH College of Medicine Sultan Qaboos University INTRODUCTION Discovered in 1880 & named after Daniel Salmon, the pathologist who first isolated the organism from porcine intestine.

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salmonella infection

SALMONELLA INFECTION

Abdelaziz Elamin, MD, PhD, FRCPCH

College of Medicine

Sultan Qaboos University

slide2

INTRODUCTION

  • Discovered in 1880 & named after Daniel Salmon, the pathologist who first isolated the organism from porcine intestine.
  • Salmonella is a motile, gram-negative, rod-shaped bacteria, which is a leading cause of bacterial food-borne diseases.
  • Of the 2000 strains recognized, human infection are caused mainly by 5 serotypes, typhi, paratyphi, typhimurium, choleraesuis & enteritidis.
slide3

TRANSMISSION

  • Infection follows ingestion of contaminated food or water. Meat, poultry, eggs & diary products are frequent sources.
  • Pets, domestic animals and infected human are potential reservoirs. Person to person & animal to human transmission is recognized.
  • In healthy humans a dose of about one million bacteria is necessary to produce symptoms.
slide4

PATHOPHYSIOLOGY

After ingestion salmonella must survive the stomach acidic PH & colonize small intestine.

Salmonella then attach to & penetrate the gut mucosa resulting in diarrhea from direct mucosal damage & by action of exotoxins.

Another portal of entry is invasion of lymphoid tissue in the GIT (peyer patches) & multiplication within macrophages leading to bacteremia.

slide5

SALMONELLOSIS

  • Salmonella typically produces 3 distinct syndromes: food poisoning, typhoid fever & asymptomatic carrier state.
  • Salmonella gastroenteritis manifest as vomiting & diarrhea within 6-48 hours after ingestion of food or drink contaminated with bacteria.
  • It is self-limiting, treatment is by water & salts replacement. Antibiotics are not usually needed.
slide6

MORTALITY & MORBIDITY

  • Infection with nontyphoidal salmonella produces self-limiting gastroenteritis and food poisoning.
  • Whereas mortality caused by typhoid fever is rare in western countries, it is associated with significant mortality & morbidity in tropical countries (10-30%).
  • Dehydration is the most common complication of typhoid fever, but serious intestinal & extra-intestinal complications may occur.
slide7

TYPHOID FEVER

  • Typhoid fever is the most serious salmonella infection with significant morbidity & mortality.
  • Caused by salmonella typhi & paratyphi.
  • Incubation period is 1-2 weeks.
  • Salmonella has somatic (O antigen) & flagellar H antigen. The O antigen is more specific for serologic testing.
slide8

FREQUENCY

  • An estimated 15-30 million cases of typhoid fever occur globally each year.
  • The disease is endemic in many developing countries in Asia, Central America & Africa.
  • Outbreak of typhoid fever have been reported recently from Eastern Europe.
  • Incidence in Sudan is not exactly known, but estimated as 50 per 100,000 people/year.
slide9

PRECIPITATING FACTORS

  • Defects in cellular-mediated immunity (AIDS, Transplant patients & malignancy).
  • Defects in phagocytic function (malaria, histoplasmosis & schistosomiasis).
  • Splenectomy or functional asplenia (sickle cell dis)
  • Low stomach PH ( patients on anti-ulcer drug).
  • Prolonged use of antibiotics (altered gut flora).
  • Injured gut barrier (bowel disease or surgery).
slide10

DIFFERENTIAL DIAGNOSES

Cryptosporidiosis

Campylobacter infection

Cyclospora

  • Listeria monocytogenes
  • Escherichia Coli infection
  • Shigellosis
slide11

LAB FINDINGS

  • Salmonella can be grown from blood or bone marrow in the 1st week, from stool in the 2nd week & from urine in the 3rd week.
  • Special media are needed for transport & for culture.
  • leukopeniais typical but WBC may be normal.
  • Widal test is not diagnostic, titer > 1:320 or 4 fold increase in titer support the diagnosis.
slide12

CLINICAL PICTURE

  • Symptoms begin with sudden onset of high-grade fever, headache & dry cough.
  • Fever is swinging or may show step ladder pattern & patient initially feel well & mobile.
  • Abdominal pain & toxicity follow soon & by the end of 1st week spleen is palpable & pink, discrete, skin rash appears over the trunk.
  • Constipation is more common than diarrhea which is usually greenish in color (pea soup).
slide13

CLINICAL PICTURE/2

  • Abdominal tenderness & hepatomegaly occur in 50% of patients.
  • The pulse is relatively slow in relation to fever (Paget sign).
  • The tongue is coated with free margins & halitosis may be present.
  • The sweat of some patients smell like yeast.
slide14

CLINICAL PICTURE/3

  • The 3rd week of illness is the usual time for complications in the untreated patients.
  • Local gut as well as systemic complications may occur.
  • Serious infections may progress rapidly to drowsiness & coma which is usually fatal (coma vigil).
  • Mortality is unlikely after the 4th week & patients may become carrier if not treated.
slide15

LOCAL COMPLICATIONS

  • Intestinal hemorrhage
  • Intestinal perforation
  • Paralytic ileus
  • Zenker degeneration of abdominal muscles
slide16

SYSTEMIC COMPLICATIONS

  • Endocarditis
  • Arteritis & arterial emboli
  • Cholecystitis
  • Hepatic & splenic abscesses
  • Pneumonia or empyema
  • Osteomyelitis & septic arthritis
  • Meningitis
  • Urinary tract infection
slide17

TREATMENT

  • Medical care include rehydration, antipyretics & antibiotics.
  • Drugs of choice are Ceftriaxone & ciprofloxacin but Cotrimoxazole & Chloramphenicol are still used in developing countries. Ampicillin kills bacilli hiding in the bile & hence prevents or reduce the carrier state.
  • Chronic resistant carrier state may necessitate cholecystectomy. Surgical care may also be needed in patients with intestinal complications.
slide18

NURSING CARE

  • Isolation & barrier nursing is indicated
  • Notification of the case to the infection control nurse in the hospital.
  • Trace source of infection.
  • continue breastfeeding infants & young children and give ORS & light diet for other patients in the first 48 hours.
slide19

PREVENTION

  • Education on hygiene practices like hand washing after toilet use & avoidance of eating in non hygienic restaurants.
  • Proper handling & refrigeration of food even after cooking.
  • Salmonella TAB vaccine is available but affectivity is low (50% claimed protection).
  • Antibiotic prophylaxis is not needed for house-hold contacts.
slide20

PROGNOSIS

  • With early diagnosis and prompt treatment most patients with typhoid fever will recover in due time.
  • Fever & toxicity subsides within 72 hours of antibiotic treatment.
  • Mortality is > 50% in untreated severe typhoid fever particularly in children & elderly.
  • Recrudescence is rare but chronic carrier state is reported in 10% of patients.