eMedicine Specialties > Infectious Diseases > Gastrointestinal Tract and Intra-abdominal Infections

Salmonellosis: Follow-up

Author: Alena Klotchko, MD, Fellow, Department of Infectious Diseases, Orlando Regional Medical Center
Coauthor(s): Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
Contributor Information and Disclosures

Updated: Mar 31, 2009

Follow-up

Deterrence/Prevention

  • Salmonella bacteria are primarily transmitted orally. Disease prevention consequently includes proper sanitation and hygiene, as well as the avoidance of insufficiently cooked or mishandled food.
  • To reduce the incidence of Salmonella infections, concerted efforts are needed throughout the food supply chain, from farm to processing plant to kitchen. Recognizing the need to prevent Salmonella contamination of poultry products and other meats, the US Department of Agriculture's Food Safety and Inspection Service (USDA FSIS) launched a Salmonella initiative in 2006, with enhancements in 2008.18
  • Recent Salmonella outbreaks associated with exposure to small turtles highlight the importance of enforcing a 1975 prohibition on their sale and distribution in the United States.18
  • Two typhoid vaccines are commercially available: Ty21a (oral) and Vi polysaccharide (parenteral). Both are moderately effective, with a cumulative efficacy of approximately 70%. Protection may be much poorer in individuals who are frequently exposed to high inocula of S typhi. The new and unlicensed modified conjugated Vi vaccine (Vi-rEPA) is equally efficacious and may confer longer immunity. Neither of the available vaccines is currently registered for administration to children younger than 2 years.37

Complications

  • Bacteremia: Approximately 5-8% of individuals with nontyphoidal Salmonella gastrointestinal illness develop bacteremia, which is more likely to occur in immunodeficient patients. Most healthy hosts clear the bacteremia without complication, but some patients develop a septic or typhoidal picture. Metastatic infection may follow bacteremia.2
  • Cardiovascular: Endocarditis, pericarditis, valve perforation, and arteritis may occur. Prosthetic valves and grafts may become infected. A feared complication of Salmonella bacteremia is endarteritis, especially with involvement of abdominal aorta. Although data are limited, the prognosis with medical therapy alone is typically grim.2
  • CNS infection: Meningitis, ventriculitis, and abscess may develop. CNS complications are more common in infants and young children.
  • Pulmonary: Pneumonia, abscess, empyema, and bronchopleural fistula are possible pulmonary complications of Salmonella infection.
  • Bone/joints: Septic arthritis and osteomyelitis are possible. Salmonella osteomyelitis affects the long bones and typically occurs in patients with sickle cell disease. Severe prolonged polyarticular reactive joint disease can occur after intestinal salmonellosis and is not altered by long-term antibiotic therapy.38
  • Gastrointestinal: Bowel perforation and gastrointestinal bleeding are potential gastrointestinal complications of Salmonella infection. However, bowel perforation is now rare (<1%).17
  • Hepatobiliary: Hepatic abscess, cholecystitis, and peritonitis may occur.
  • Splenic: Abscess may occur.
  • Urinary: Cystitis, pyelonephritis, and renal abscess may occur.
  • Genital: Ovarian abscess, testicular abscess, prostatitis, and epididymitis may occur.
  • Soft tissue: Abscess may occur.

Prognosis

  • Nontyphoidal salmonellosis is generally self-limiting, with symptoms typically lasting 3-7 days.
  • Patients occasionally require hospitalization, but death is rare (<1%).
  • After resolution of symptoms, the mean duration of fecal shedding of Salmonella organisms is 4-5 weeks, depending on the strain.
  • In the absence of risk factors for severe disease, limit treatment for enterocolitis to symptomatic care and fluid and electrolyte repletion. Indeed, some studies suggest that antibiotics actually prolong the carrier state.
  • In the preantibiotic era, approximately 15% of patients with typhoid fever died. More recently, mortality rates as high as 30% have been reported in certain developing countries. The mortality rate in patients with typhoid fever who are appropriately treated is less than 1%.

Patient Education

  • Because salmonellae are ubiquitous, their eradication is unlikely. Consequently, a mainstay of disease prevention and control is public education.
  • Because transmission primarily occurs through ingestion of contaminated foods, information about the importance of sanitary food handling, proper food preparation, and personal hygiene is pivotal.
  • Notably, the emergence of drug-resistant salmonellae illustrates the importance of responsible antibiotic use in medicine and animal husbandry.

Miscellaneous

Medicolegal Pitfalls

Although generally self-limiting, nontyphoidal salmonellosis may be severe in patients who are debilitated, immunocompromised, or at the extremes of age. Failure to correctly diagnose and treat these individuals could result in adverse outcomes. Typhoid fever, like malaria, is an everyday illness in much of the world but an exotic disease in the developed world. The main risk is failing to pursue the diagnosis in a patient with an appropriate exposure/travel history.

Special Concerns

  • In the developing world, HIV infection is a prominent risk factor for nontyphoidal salmonellosis and bacteremia. In recent series of African adults with HIV infection who had documented bloodstream infections, nontyphoidal Salmonella organisms were isolated in up to 35% of cases.2 In pediatric studies from Kenya, the HIV epidemic has been associated with a concomitant increase in community-acquired nontyphoidal Salmonella bacteremia (eg, S typhimurium).39
  • The rate of bacteremia and extraintestinal complications is high in transplant recipients (approximately 60% and 35%, respectively).1
  • Patients with schistosomiasis are at risk of developing chronic systemic Salmonella syndrome.1
  • Neonatal typhoid fever results from vertical transmission during late pregnancy. It usually occurs within 3 days of delivery and causes fever, vomiting, diarrhea, and abdominal distension. It may also cause significant hepatosplenomegaly. Seizures can also occur.40,22
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Michael Zapor, MD, PhD, and previous coauthor David P Dooley, MD, to the development and writing of this article.



More on Salmonellosis

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Differential Diagnoses & Workup: Salmonellosis
Treatment & Medication: Salmonellosis
Follow-up: Salmonellosis
Multimedia: Salmonellosis
References
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Further Reading

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Keywords

salmonellosis, Salmonella infection, salmonellae, Enterobacteriaceae, enteric fever, typhoid fever, Salmonella bacteremia, Salmonella osteomyelitis, Salmonella gastroenteritis, nontyphoid Salmonella infection, nontyphoidal Salmonella infection, Salmonella choleraesuis, Salmonella typhi, Salmonella paratyphi, Salmonella typhimurium, Salmonella enteritidis, Salmonella heidelberg, S choleraesuis, S typhi, S paratyphi, S typhimurium, S enteritidis, S heidelberg, Salmonella enterica, S enterica, Salmonella enteritidis heidelberg, S enteritidis heidelberg, Salmonella enteritidis newport, S enteritidis newport, Salmonella hadar, S hadar, Salmonella enteritidis agona, S enteritidis agona, Salmonella enteritidis montevideo, S enteritidis montevideo, Salmonella oranienburg, S oranienburg, Salmonella muenchen, S muenchen, Salmonella enteritidis thompson, S enteritidis thompson

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Contributor Information and Disclosures

Author

Alena Klotchko, MD, Fellow, Department of Infectious Diseases, Orlando Regional Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
Mark Raymond Wallace, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Mary Nettleman, MD, MS, Chair, Department of Medicine, Michigan State University
Mary Nettleman, MD, MS is a member of the following medical societies: American College of Physicians, Association of Professors of Medicine, Central Society for Clinical Research, Infectious Diseases Society of America, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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