KULIAH MATRIKULASI MAHASISWA APOTEKER

IFRS – RSUD DR. SOETOMO

- Ririn Prasetyo U, Apt., Sp.FRS. -
Salmonella Infections
 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.
MICROBIOLOGY
 Gram-negative flagellated, facultatively
anaerobic bacilli
 Enterobacteriaceae family
 Most serotypes that cause human disease are
in sero- groups A through E
 Salmonella typhi is classified in serogroup D
 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.
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.
TYPHOID FEVER
 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.
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.
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).
DIFFERENTIAL DIAGNOSES
Cryptosporidiosis

Campylobacter infection

Cyclospora

Listeria monocytogenes

Escherichia Coli infection

Shigellosis
LABORATORIUM 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.

leukopenia is typical but WBC may be normal.

Widal test is not diagnostic, titer > 1:320 or 4

fold increase in titer support the diagnosis.
CLINICAL PICTURE (1)
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).
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.

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.
LOCAL COMPLICATIONS
Intestinal hemorrhage

Intestinal perforation

Paralytic ileus

Zenker degeneration of abdominal muscles

SYSTEMIC COMPLICATIONS
Endocarditis
Arteritis & arterial emboli
Cholecystitis
Hepatic & splenic abscesses
Pneumonia or empyema
Osteomyelitis & septic arthritis
Meningitis
Urinary tract infection
 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.
 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.
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.
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