Salmonellosis is a group of infectious diseases of humans and animals, the causative agents of which are bacteria of the Enterobacteriaceae family, the genus Salmonella, represented by two species - S. enterica and S. bongori, among which there are seven subspecies.
Salmonella has three main antigens:
O-somatic (thermostable);
N-flagellated (thermolabile);
K-surface (capsular).
In addition, other antigens have been described for some Salmonella serotypes:
Vi-antigen (one of the components of the O-antigen);
· M-antigen (mucous).
Currently, more than 2.5 thousand serological variants of Salmonella are known. Sero- and phage-typing of Salmonella is carried out in national centers for Salmonella, which provide up to 60 times a year information on the isolation of new Salmonella serotypes and their epidemiology. The identification of new Salmonella serovars is confirmed by the WHO Reference Center for Salmonella Research (Pasteur Institute, Paris), which recommends the use of the Kauffman-White (2001) diagnostic antigenic scheme based on the serological identification of Salmonella, taking into account their antigenic structure ( O, H, Vi).
Salmonella - gram-negative rods 2–4 × 0.5 microns; they are mobile, grow well on simple nutrient media at temperatures from 6 to 46 °C (growth optimum 37 °C). Most Salmonella are pathogenic both for humans and for animals and birds, but in epidemiological terms, only a few serotypes that cause 85–91% of human salmonellosis on all continents of the world are the most significant for humans: S. typhimurium, S. enteritidis, S. panama , S. infantis, S. newport, S. agona, S. derby, S. london, etc.
Currently, salmonellosis is one of the most common zoonoses in developed countries with a worldwide trend towards an increase in incidence. This is especially true of large cities with a centralized food supply system.
Outbreaks of salmonellosis caused by antibiotic-resistant strains of salmonella and characterized by high mortality are regularly recorded in medical institutions, especially in maternity, pediatric, psychiatric and geriatric departments. This type of salmonellosis has acquired features
hospital infection with contact-household transmission of the pathogen.
The main pathogenicity factors of Salmonella are cholera-like enterotoxin and LPS-endotoxin. Some strains have the ability to invade the epithelium of the colon (S. enteritidis).
The clinical manifestations of the disease caused by different serotypes of Salmonella do not differ significantly from each other, therefore, at present, only the clinical form of the disease and the serotype of the isolated Salmonella are indicated in the diagnosis, which is of epidemiological significance.
Typhoid fever is considered separately from other salmonellosis due to the strict specificity of its pathogen in relation to the host (anthroponosis) and the presence of clinical features of the course.
salmonellosis
Salmonellosis is an acute zoonotic infectious disease with a fecal-oral mechanism of pathogen transmission, characterized by a predominant lesion of the gastrointestinal tract, the development of intoxication and dehydration.
ICD-10 codes
A02. Other salmonella infections.
A02.0. Salmonella enteritis.
A02.1. Salmonella septicemia.
A02.2. Localized salmonella infection.
A02.8. Another specified Salmonella infection.
A02.9. Salmonella infection, unspecified.
Causes of salmonellosis
Salmonella are gram-negative rods of the Salmonella genus of the Enterobacteriaceae family.
There are two types of Salmonella - S. enterica and S. bongori, not pathogenic for humans. There are 2324 serovars divided into 46 serogroups according to the set of somatic O-antigens. In addition to the somatic thermostable O-antigen, Salmonella have a flagellar thermolabile H-antigen. Many strains show surface Vi antigen. The main pathogenicity factors are cholera-like enterotoxin and endotoxin of lipopolysaccharide nature. Some strains of S. enteritidis are capable of invading the colonic epithelium. Salmonella persist in the environment for a long time: in water - up to 5 months, in soil - up to 18 months, in meat - up to 6 months, in carcasses of birds - more than a year, on eggshells - up to 24 days. They tolerate low temperatures well, at 100 ° C they die instantly.
Epidemiology of salmonellosis
The reservoir and source of the infectious agent are sick animals: large and small cattle, pigs, horses, poultry. Their disease proceeds acutely or in the form of a bacteriocarrier. A person (patient or carrier) may also be a source of S. typhimurium. The transmission mechanism is fecal-oral. The main route of transmission is food, through animal products. Infection of meat occurs endogenously during the life of the animal, as well as exogenously during transportation, processing, storage. In recent years, there has been a significant increase in the incidence of S. enteritidis associated with the spread of the pathogen through poultry meat and eggs. The aquatic route of transmission mainly plays a role in the infection of animals. By contact-household way (through hands and tools), as a rule, the pathogen is transmitted in medical institutions. The greatest risk of infection with salmonellosis is in children of the first year of life and persons with immunodeficiency. Airborne dust plays a large role in the spread of infection among wild birds. The incidence of salmonellosis is high in large cities. Cases of the disease are recorded throughout the year, but more often in the summer months due to the worst storage conditions for food.
Observe sporadic and group incidence. The susceptibility of people to the pathogen is high. Post-infection immunity lasts less than a year.
Prevention of salmonellosis
There is no specific prophylaxis.
Non-specific preventive measures
Veterinary and sanitary supervision of the slaughter of livestock and poultry, the technology of processing carcasses, the preparation and storage of meat dishes. Compliance with sanitary-hygienic and anti-epidemic standards at trade and public catering enterprises.
The pathogenesis of salmonellosis
In the lumen of the small intestine, Salmonella attach to the membranes of enterocytes and reach the lamina propria. This leads to degenerative changes in enterocytes and the development of enteritis. In the lamina propria, macrophages engulf Salmonella, but phagocytosis is incomplete and generalization of the infection is possible. When bacteria are destroyed, a lipopolysaccharide complex (endotoxin) is released, which plays a major role in the development of intoxication syndrome. In addition, it activates the synthesis of prostanoids (thromboxanes, prostaglandins), which trigger platelet aggregation in small capillaries. Prostaglandins stimulate the secretion of electrolytes and fluid into the intestinal lumen, cause smooth muscle contraction and increase peristalsis. The main role in the development of diarrhea and dehydration is played by enterotoxin, which activates the synthesis of cAMP by enterocyte adenylate cyclase, thereby increasing the secretion of Na+, Cl– and water ions into the intestinal lumen. The consequence of dehydration and intoxication is a violation of the activity of the cardiovascular system, which is expressed by tachycardia and a decrease in blood pressure.
Clinical picture (symptoms) of salmonellosis
The incubation period is from 6 hours to 3 days (usually 12–24 hours); with nosocomial outbreaks, it is extended to 3-8 days.
Classification of salmonellosis
Gastrointestinal (localized) form:
- gastric variant;
- gastroenteric variant;
- gastroenterocolitic variant.
Generalized form:
- typhoid-like variant;
- septic option.
Bacterioexcretion:
- acute;
- chronic;
- transitory.
The main symptoms and dynamics of their development
The gastric variant is characterized by an acute onset, repeated vomiting, and epigastric pain. The syndrome of intoxication is poorly expressed. Short duration of illness.
The gastroenteric variant is the most common. The disease begins acutely, with symptoms of intoxication: fever, headache, chills, aching muscles, cramping pain in the abdomen.
Nausea, vomiting, diarrhea join. The stools are initially fecal in nature, but quickly become watery, frothy, fetid, sometimes with a greenish tinge and look like "swamp mud". Paleness of the skin is noted, in more severe cases - cyanosis. Tongue dry, coated.
The abdomen is swollen, painful on palpation in all departments, more in the epigastrium and in the right iliac region, rumbling under the arm. Heart sounds are muffled, tachycardia, blood pressure is reduced. Decreased urine output. Seizures are possible.
With the gastroenterocolitic variant, the clinical picture is the same, but already on the 2nd–3rd day of the disease, the volume of stool decreases. An admixture of mucus, sometimes blood, appears in them. On palpation of the abdomen, spasm and soreness of the sigmoid colon are noted. Tenesmus is possible.
The generalized form of the disease is usually preceded by gastrointestinal disorders. With a typhoid-like variant, the temperature curve acquires a constant or undulating character. Increased headache, weakness, insomnia. The skin is pale, by the 6th–7th day of illness, a roseolous rash appears on the skin of the abdomen. Slight bradycardia is observed. Dry scattered rales are heard over the lungs. Belly swollen. By the end of the first week of the disease, an increase in the liver and spleen is noted. The duration of fever is 1-3 weeks. Relapses are rare. In the first days of the disease, the clinical manifestations of septic and typhoid-like variants are similar. In the future, the condition of patients worsens. Fluctuations in body temperature become irregular, with large daily fluctuations, repeated chills and profuse sweating, tachycardia, myalgia. The formation of purulent foci in the lungs, heart, kidneys, liver and other organs is noted. The disease proceeds for a long time and can be fatal. After the illness, some patients become bacterial carriers. In acute bacterial excretion, the excretion of Salmonella ends within 3 months; if it lasts more than 3 months, it is regarded as chronic. With transient bacterial excretion, a single or double seeding of Salmonella from feces is not accompanied by clinical manifestations and the formation of antibodies.
Complications of salmonellosis
Dehydration and ITSH, circulatory disorders in the coronary, mesenteric and cerebral vessels, acute renal failure, septic complications.
Mortality and causes of death
Mortality is 0.2-0.6%. The cause of death may be one of the above complications.
Diagnosis of salmonellosis
Clinical
It is characterized by an acute onset with fever, nausea, vomiting, diarrhea, and abdominal pain.
epidemiological
Eating food prepared and stored in violation of sanitary standards, eating raw eggs, group outbreaks. In megacities, the identification of group cases of the disease is very difficult if a product contaminated with Salmonella is sold through a distribution network or public catering establishments. Without confirmation of the diagnosis by laboratory tests, the differential diagnosis of salmonellosis with PTI is very difficult.
Specific and non-specific laboratory diagnostics
Bacteriological examination of feces (single or double), vomit, blood, urine, bile, gastric lavage, residues of suspicious products.
Salmonella antigens can be detected in blood and urine by ELISA and RHA. For retrospective diagnosis, the determination of specific antibodies (RNGA and ELISA) is used. Examine paired sera taken at intervals of 5–7 days. An increase in titers four times or more is of diagnostic value.
Differential Diagnosis
Carried out with infectious and non-infectious diseases (Tables 17-3, 17-4).
Table 17-3. Differential diagnosis of salmonellosis, dysentery, cholera
| Clinical signs | salmonellosis | Dysentery | Cholera |
| Chair | Watery, with an unpleasant odor, often with an admixture of greenery of the color of marsh mud | Meager stoolless, with an admixture of mucus and blood - "rectal spit" | Watery, the color of rice water, odorless, sometimes with the smell of raw fish |
| defecation | Painful with colitis | With tenesmus | Painless |
| Abdominal pain | Moderate cramping, epigastric or mesogastric | Strong, with false urges, in the lower abdomen, left iliac region | Not typical |
| Vomit | Multiple, precedes diarrhea |
Possible with gastroenterocolitic variant | Repeated watery, appears after diarrhea |
| Spasm and soreness of the sigmoid colon | Possible with colitis | Characteristic | Not marked |
| Dehydration | Moderate | Not typical | Typical, pronounced |
| Body temperature | Increased | Increased | normal, hypothermia |
| Chills | typical | typical | not typical |
Table 17-4. Differential diagnosis of salmonellosis, acute appendicitis, thrombosis of mesenteric vessels
| Clinical signs | salmonellosis | Acute appendicitis | Thrombosis of mesenteric vessels |
| Anamnesis | Eating poor-quality food, the possibility of group outbreaks | Without features | ischemic heart disease, atherosclerosis |
| The onset of the disease | Acute, with severe intoxication, clinical picture of acute gastroenteritis | Pain in the epigastrium with movement to the right iliac region | Acute, less often - gradual, with abdominal pain |
| The nature of abdominal pain | Moderate cramping, epigastric or spilled. Disappears before the end of diarrhea or simultaneously with it | Violent constant, aggravated by coughing. Persists or worsens when diarrhea stops | Sharp, unbearable, constant or paroxysmal, without definite localization |
| Chair | Fluid, profuse, offensive, greenish, repeated | Liquid feces, without pathological impurities, up to 3-4 times, more often constipation | Fluid, often mixed with blood |
| Cramps, dehydration, chills | During the peak of the disease | Missing | Missing |
| Examination of the abdomen | Moderately swollen, rumbling on palpation, painful in the epigastrium or mesogastrium | Soreness in right iliac region, with muscle tension. Symptoms of peritoneal irritation are positive | Bloated, diffuse soreness |
| Vomit | Multiple, in the first hours | Sometimes, at the beginning of the disease, 1-2 times | Often, sometimes with an admixture of blood |
| Leukocytosis | Moderate | Expressed, growing | Expressed, growing |
Indications for consulting other specialists
A surgeon's consultation is necessary if you suspect appendicitis, thrombosis of mesenteric vessels, intestinal obstruction.
A gynecologist's consultation is prescribed for suspected ectopic pregnancy, ovarian apoplexy, salpingo-oophoritis.
Consultation with a cardiologist - to exclude myocardial infarction, hypertensive crisis, correction of therapy for concomitant coronary artery disease, hypertension.
Diagnosis example
A02.0. Salmonellosis. Gastrointestinal form. gastroenteric variant. Medium flow.
Indications for hospitalization
Severe course of the disease, the presence of complications; epidemiological evidence.
Treatment of salmonellosis
Mode. Diet
Bed rest is prescribed for severe intoxication and fluid loss. Ward - with moderate and mild course. Diet - table number 4. Food products that irritate the stomach and intestines, dairy products, and refractory fats are excluded from the diet.
Drug therapy for salmonellosis
Etiotropic therapy
Moderate and severe localized form of the disease - enterix♠ two capsules three times a day for 5-6 days; chlorhinaldol 0.2 g 3 times a day for 3-5 days.
Generalized form - ciprofloxacin 500 mg twice a day; ceftriaxone 2 g once daily IM or IV for 7–14 days. For all forms of bacteriocarrier and the decreed category of persons - Salmonella bacteriophage, two tablets three times a day or 50 ml twice a day 30 minutes before meals for 5–7 days; sangviritrin♠ two tablets 3-4 times a day for 7-14 days.
Pathogenic agents
rehydration therapy. Oral (with I-II degree dehydration and absence of vomiting): glucosolan♠, citroglucosolan, rehydron♠. Rehydration is carried out in two stages, the duration of the 1st stage - up to 2 hours, the 2nd - up to 3 days. Volume 30–70 ml/kg, rate 0.5–1.5 l/h, temperature 37–40 °C. Parenteral: chlosol♠, trisol♠. Rehydration is carried out in two stages, the duration of the 1st stage - up to 3 hours, the 2nd - according to the indications (it is possible to switch to oral administration of the liquid). Volume 55–120 ml/kg, average speed 60–120 ml/min.
Detoxification therapy. Only in the treatment of dehydration. Glucose♠, rheopolyglucin♠ 200–400 ml intravenously by drip.
Eubiotics and biological products: bactisubtil♠ one capsule 3-6 times a day 1 hour before meals, linex♠ two capsules three times a day for 2 weeks; lactobacilli acidophilus + kefir fungi (acipol♠) one tablet three times a day; bifidobacteria bifidum (bifidumbacterin♠) five doses three times a day for 1–2 months. Hilak forte♠ 40-60 drops three times a day for 2-4 weeks.
Sorbents: hydrolysis lignin (polyphepan♠) one tablespoon 3-4 times a day for 5-7 days; activated charcoal (carbolong♠) 5–10 g three times a day for 3–15 days; smectite dioctahedral (neosmectin♠) one powder three times a day for 5-7 days.
Enzyme therapy: pancreatin, one powder three times a day for 2–3 months; mezim forte ♠ one dragee three times a day for 1 month; oraza♠ one teaspoon three times a day for 2-4 weeks with meals.
Antidiarrheal drugs: calcium gluconate 1–3 g 2–3 times a day, indomethacin 50 mg three times a day every 3 hours for 1–2 days, Kassirsky powders, one powder three times a day.
Antispasmodics: drotaverine (no-shpa♠) 0.04 g three times a day, papaverine 0.04 g three times a day.
Additional methods of treatment (surgical, physiotherapeutic, spa)
It is necessary to wash the stomach with a tubeless method, if the patient's condition allows.
Approximate terms of incapacity for work with salmonellosis
The length of stay in a hospital with a localized form is up to 14 days, with a generalized form - 28-30 days. An extract is carried out after clinical recovery and a negative result of bacteriological examination of feces, which is carried out 2 days after the end of treatment.
Patients of the decreed group are discharged after two control studies of feces (the first - not earlier than the 3rd day after the end of treatment, the second - after 1-2 days). Patients who do not excrete the pathogen are allowed to work.
Clinical examination
Workers in the food industry and public catering establishments are subject to medical examination within 3 months with a single monthly examination of feces. Persons who excrete salmonella are not allowed to work for 15 days and are assigned to other work. During this period, they are given a 5-fold study of feces and a single study of bile. If bacterial excretion continues for more than 3 months, they are transferred to another job for a period of at least 1 year and examined once every 6 months. After this period, a 5-fold study of feces and a single bile with an interval of 1-2 days is carried out. With negative results, such patients are removed from the register and allowed to work; if positive, they are suspended from work.
Reminder for a patient with salmonellosis
Compliance with the diet for 2-3 months with the exception of spicy foods, alcohol, refractory animal fats, milk. After generalized forms, it is necessary to limit physical activity for 6 months.
Salmonellosis is an acute infectious disease provoked by exposure to Salmonella bacteria, which, in fact, determines its name. Salmonellosis, the symptoms of which are absent in carriers of this infection, despite its active reproduction, is mainly transmitted through food contaminated with Salmonella, as well as through contaminated water. The main manifestations of the disease in the active form are manifestations of intoxication and dehydration.
general description
Salmonellosis itself belongs to a group of diseases representing acute intestinal infections. As the causative agent of the disease, as we have already noted, bacteria representing the Salmonella group act. Most salmonellosis is diagnosed in children under the age of one year, although people of other age groups are also at risk for the possible occurrence of this disease. Remarkably, salmonellosis can also be observed in entire groups of people who have consumed foodstuffs contaminated with the relevant microbes, such foods may include bird eggs, meat, butter, milk, etc. An important feature is the fact that salmonella, being directly in food, does not contribute to a change in their appearance, which only increases the risk of possible infection.
Outbreaks of salmonellosis mainly last long enough, moreover, they are characterized by a fairly high mortality rate. Often these outbreaks occur during the warm season.
Already noted food products, as well as animals infected with salmonella and people with salmonellosis, are determined as sources of infection (infection is excreted by patients, in particular, through feces, through feces). In addition, bacteria carriers are also isolated separately, that is, people who have had the disease in question in the past, but continue to excrete the virus through feces. If we consider food products, which are most often a source of infection, then the main reason for this is their insufficient or poor-quality heat treatment. Salmonellosis in children, the symptoms of which are also manifested due to contact with contaminated objects, dishes and linen, is most dangerous when in contact with an already sick person or with a carrier of this infection.
It should be noted that Salmonella over a long period of time can persist in the environment. So, for about 5 months they can remain in water, about 6 - in meat (if we consider the carcasses of birds, then here the period can even reach 1 year). The duration of preservation in kefir is about a month, in egg powder - within 3-9 months, in beer - up to two months, in eggshells - within 17-24 days, in butter - up to 4 months, in soil - within up to 18 months and up to a year - in cheeses.
Also, on the basis of experiments, it was revealed that long-term storage of chicken eggs in a refrigerator can lead to the penetration of Salmonella through the shell, followed by reproduction in the yolk. The death of salmonella occurs at a temperature of 70 degrees Celsius in up to 10 minutes. When they are in the thickness of the meat, the ability to survive for some time is determined, and when boiling eggs, the survival rate is about 4 minutes of exposure to boiling water. Smoking and salting foods have little effect on the infection, but freezing becomes the key to increasing its survival in foods.
There are also separate varieties of strains, a feature of which is a special resistance to disinfectants and antibiotics that act on them (the so-called hospital strains).
As for such a moment as the susceptibility to infection of people, it is defined as quite high, in particular, everything depends on a number of factors and their relationship, on the basis of which the specific outcome of the relationship between the pathogen and the person is determined. In particular, this includes the dose of the pathogen, the antigenic structure that characterizes it, the features of its biological properties, as well as the immune status of a person and his individual characteristics, etc. In addition to children under 1 year old, a special emphasis within this age is also placed on premature children due to their special sensitivity, in addition, there are also categories of people with an unfavorable immune status for such exposure and the elderly.
Features of the course of the disease
After salmonella overcome the factors related to nonspecific protection in the oral cavity environment, as well as in the stomach environment, they find themselves in the environment of the lumen of the small intestine - here they attach to enterocytes with the subsequent release of thermostable and/or thermolabile exotoxins. In the process of interaction between bacteria and epithelial cells, degenerative changes begin to occur on the part of microvilli. The process of intervention of the salmonellosis pathogen to the submucosal layer in the intestinal wall begins to be hindered by phagocytes, and this, in turn, leads to the development of an active inflammatory reaction.
The destruction of bacteria is accompanied by the release of endotoxin, which, in turn, plays a major role in the development of intoxication syndrome. In the future, against the background of the specific impact of the infection and the processes relevant for this, diarrhea and dehydration of the body develop, and dehydration is especially facilitated by the action of bacterial enterotoxins, based on the activation of the adenylate cyclase system and the production of cyclic nucleotides.
Due to actual dehydration with intoxication, the activity of the cardiovascular system is disturbed, this manifests itself in a decrease in pressure and the manifestation of tachycardia. Also, the clinical condition is accompanied by an acute form of swelling of the brain and its edema. Due to disorders associated with microcirculation, as well as dehydration, dystrophic processes develop already from the side of the tubules of the kidneys. This, in turn, leads to the development of acute renal failure, the first clinical manifestation of which is oliguria - a condition in which the daily volume of urine output decreases from 1500 ml to 500, which occurs either as a result of reduced filtration or as a result of increased absorption. occurring in the kidneys. Subsequently, in addition to oliguria, there is an accumulation of nitrogenous slags in the blood.
As a rule, in about 95-99% of the total number of cases, the spread of Salmonella beyond the submucosal layer in the intestine does not occur, which, however, causes the development of the disease in the gastrointestinal form. Pathogens enter the blood only in some cases, which, in turn, determines the generalized form of the disease, characterized by a septic or typhoid-like course. Deficiency, which is relevant for humoral and cellular immune responses, determines the transition to such a generalized form.
Conducting a microscopic examination of the intestinal wall area determines the changes occurring in the vessels in the form of hemorrhages occurring in the submucosal and mucous layers of the intestinal wall. The submucosal layer, in addition to microcirculation disorders, is also characterized by the development of a leukocyte reaction and subsequent edema.
Forms of the disease
Depending on the form of salmonellosis, the features of its course are determined, and this, in turn, determines the symptoms that are relevant for the disease. Let's highlight the main options for these forms:
- Form localized (gastrointestinal):
- the course of the disease occurs in the gastric variant;
- the course of the disease occurs in the gastroenteric variant;
- the course of the disease occurs in the gastroenterocolitis variant.
- Generalized form:
- typhoid-like course of the disease;
- septic course.
- Bacterioexcretion:
- in an acute form;
- in a chronic form;
- in transitive form.
Salmonellosis: symptoms
The forms listed above will be considered separately. Their common feature is that the duration of the incubation period in each case is on the order of several hours to two days.
- Gastroenteric salmonellosis
This variant of the course of the disease is its most common form. Development occurs quite acutely, several hours after infection. Manifestations are intoxication, as well as disorders associated with impaired water and electrolyte balance. From the first hours of the disease, the predominant manifestations are reduced to manifestations of intoxication, which, in turn, consists in fever, chills, headache and general body aches.
Somewhat later, pains in the abdomen join, which for the most part manifest themselves spastically, focusing within the umbilical and epigastric regions. In addition, there is also nausea with vomiting, which manifests itself repeatedly. Quite quickly, diarrhea is added to the listed symptoms, in which the stool initially corresponds to the usual characteristics of feces, but gradually they begin to correspond to a more watery and foamy structure, a greenish tint and a pronounced stench appear. Defecation and frequency of vomiting may vary, but the assessment of the overall degree of dehydration is not based on this frequency, but on the basis of the specific volume of fluid excreted during the manifestation of both processes. Tenesmus (false and at the same time painful urge to defecate / urinate) does not appear during defecation.
The temperature in this condition rises, however, on examination, pallor of the skin can be determined, more severe cases are accompanied by cyanosis (cyanosis of the skin, mucous membranes). There is also rumbling in the intestines and bloating (during its palpation, some of the diffuse soreness is determined). Listening determines the muffled heart sounds and tachycardia. There is a predisposition to low blood pressure in this state. Urine in the volume of its excretion is negligible. Severe cases of the condition are accompanied by the occurrence of clonic convulsions, which predominantly occur in the region of the muscles of the lower extremities.
- Gastroenterocolitic salmonellosis
The onset of the disease is characterized by the manifestation of conditions that accompany the previous, gastroenteric variant of its course, however, by the 2nd-3rd day of the disease, a decrease in the volume of feces is noted, and mucus, and in some cases blood, already appears in them. Palpation (palpation) of the abdomen allows you to determine the presence of spasm of the colon and, in general, its soreness. Often the act of defecation is accompanied by false urges with soreness (tenesmus). In this case, his clinic is similar in many ways to the acute form of the course of dysentery.
- Gastritis salmonellosis
This form of the course of the disease is observed much less frequently than the previous two. It is characterized by an acute onset of its own, as well as recurrent vomiting, pain, concentrated within the epigastric region. Mostly, the severity of the intoxication syndrome is insignificant, there is no diarrhea. The disease is generally short-term in its own course, the prognosis for it is favorable.
When considering the general form, which corresponds to the listed variants of the course of the disease, that is, the gastrointestinal form, it can be noted that the severity of its course is determined from its inherent manifestations of the intoxication scale, as well as the general value characterizing in this case water and electrolyte losses. The degree of intoxication is determined, first of all, by taking into account the actual temperature reaction for it. Actually the temperature can be, for example, high enough, which determines the occurrence of chills, weakness, headache, anorexia and body aches as accompanying manifestations. In addition, a mild course of the disease is also possible with a moderate manifestation of fever, which is often accompanied by indicators in the form of subfebrile numbers (within 37-37.5). At the same time, one of the leading conditions, on the basis of which the severity of the disease is subsequently determined, regardless of the variant of salmonellosis, is the severity of water and electrolyte losses (that is, the severity of dehydration).
In the case of a generalization of the process that is relevant for salmonellosis, which determines the infection in the blood, a typhoid-like variant of the course of the disease is diagnosed, as highlighted earlier (the clinical picture is similar to diseases of a typhoid-paratyphoid nature), or a septic variant. For the most part, the generalization of the process is preceded by the course of the previous form of the disease, that is, the gastrointestinal form with the corresponding disorders of the course variant that is relevant in a particular case.
- Typhoid-like salmonellosis
The onset of the disease may be accompanied by manifestations inherent in gastroenteritis. Subsequently, when these manifestations subside or when diarrhea, nausea and vomiting disappear from their number, an increased temperature reaction is noted, which, in turn, is characterized either by its own constancy or undulation. The course of this variant of the disease is accompanied by complaints of insomnia and headache, as well as weakness expressed in its manifestation.
Examination allows you to determine the pallor of the skin, sometimes in the area of the skin of the abdomen and the lower part of the sternum, a separate type of roseolous elements is also noted. On the 3-5th day of the course of the disease, hepatolienal syndrome manifests itself. The pressure is mostly low, bradycardia also joins. When considering the clinical picture of this form of the disease, it is possible to determine its similarity with the course of typhoid fever, as a result of which the diagnosis is greatly complicated. In addition, typhoid-like salmonellosis can occur without symptoms associated with gastroenteritis.
- Septic salmonellosis
The initial period of the course of the disease in this form makes it possible to highlight the relevance in it of manifestations characteristic of gastroenteritis, which are subsequently replaced by a long course of relapsing fever (a nonspecific manifestation of fever, in which daily temperature fluctuations are observed within 1.5-2.5 degrees), as well as chills , tachycardia, severe sweating, noted with a less intense course of fever and myalgia (muscle pain that occurs against the background of increased muscle cell tone, noted both at rest and in a state of tension). In most cases, hepatosplenomegaly also develops (a syndrome accompanied by simultaneous and significant enlargement of the spleen and liver).
In general, the course of this form of the disease is torpid and long, its peculiarity is the tendency to form purulent foci of a secondary type in the lungs (which manifests itself in the form of pneumonia, pleurisy), kidneys (cystitis, pyelitis), heart (endocarditis), as well as in muscles and in the subcutaneous tissue (phlegmon, abscesses). In addition, the possibility of developing iritis, iridocyclitis is not excluded.
Against the background of the transfer of salmonellosis (regardless of the specific form of its course), some patients remain carriers of the infection, acting as bacterial excretors. Isolation of infection lasts mainly within a period of one month (which is defined as acute bacterial excretion), but if the process of isolation of infection lasts longer than a period of three months (from the moment the main clinical manifestations of the disease are completed and upon recovery against the background of their absence), it is advisable to talk about the transition of the process to the chronic form.
Salmonellosis: symptoms in children
The duration of the incubation period is about 4 days, the severity of symptoms and signs characteristic of salmonellosis in children is determined by their age. The disease is most difficult in infants and infants under 1 year old.
The first days of the manifestation of the disease in children proceed with a predominance of symptoms of intoxication, which is characterized by weakness, temperature (within 39 degrees), crying. The child becomes capricious, refuses food. By 3-4 days of salmonellosis, diarrhea (diarrhea) occurs, and there is an increase in stools (up to 10 times per day or more). The nature and structure of the stools correspond to the general manifestation of the disease, respectively, the stool has a greenish tint, it is also watery.
By day 7, blood streaks can be found in the stool. It is important to bear in mind that in the absence of treatment in children with salmonellosis, a fatal outcome occurs. For this reason, you should seek the help of a doctor as soon as possible by calling an ambulance or taking the child to the hospital yourself. It is also necessary to isolate the child from other children.
Salmonellosis: complications
As the most dangerous option, considered as a complication of the disease (in any form), the development of infectious-toxic shock is distinguished, which occurs in combination with acute cerebral edema and swelling, as well as with an acute form of heart failure, which, in turn, develops from - for acute adrenal and renal insufficiency.
Swelling and edema of the brain, manifested due to exsicosis, are characterized by the addition of bradycardia, reddening of the skin and its cyanosis in the neck and face (defined as "strangled syndrome"), short-term hypertension (increased pressure). In addition, there is also a rapid development of muscle paresis (weakening of their voluntary movements), the innervation of which is provided, in particular, by the cranial nerves. Further, shortness of breath joins the condition under consideration, gradually increasing, after which a cerebral coma develops, followed by loss of consciousness by the patient.
The appearance of severe oliguria (a decrease in the volume of urine excreted), as well as anuria (that is, the complete absence of its excretion) - all this is evidence of the possible development of acute renal failure. Strengthening of these suspicions is noted in the event that urine is still not excreted after an adequate level of blood pressure has been restored. In such a situation, it is important to urgently examine the blood in terms of determining the concentration of nitrogenous slags in it. Subsequently, the course of the condition under consideration is accompanied by an increase in symptoms that are relevant for uremia (self-poisoning of the body against the background of a violation of the functions inherent in the kidneys).
As for the complication in the form of acute cardiovascular insufficiency, it is characterized in particular by the gradual development of collapse with a simultaneous decrease in temperature to normal or subnormal values (within 35-36 degrees). The skin becomes pale, its cyanosis is possible, the limbs become cold, the pulse disappears somewhat later, which is accompanied by a sharp decrease in pressure. If the adrenal glands are involved in the process, the state of collapse is accompanied by an extreme degree of resistance to taking therapeutic measures to it (that is, there is no susceptibility to therapy).
Diagnosis
Diagnosis of the disease is made in the laboratory with the study of feces and vomit. If there is a suspicion of a generalized form of the disease, accordingly, blood is also withdrawn for analysis. Wash waters of the intestines, stomach, bile and urine can also be used as research material.
Treatment
For the treatment of the disease, hospitalization is carried out only in case of a severe course of the disease or in a complicated course. In addition, epidemiological indications can act as a reason for hospitalization. With severe intoxication and dehydration, bed rest is indicated.
In the event that the patient's condition, in accordance with its clinical features, allows treatment using the tactics of gastric lavage, the use of siphon enemas and various enterosorbents, they are, respectively, used.
Also, the treatment is focused on eliminating the condition accompanying dehydration (dehydration), which, first of all, requires the internal use of solutions of glucose-salt composition (Regidron, Citroglucosolan, Oralit, etc.), which requires preliminary consideration of salt and water deficiency before it was started. therapy, replenishment is carried out by frequent and fractional drinking (up to 1.5 l / h) for two to three hours. The subsequent loss of fluid (after the implementation of these therapy measures) is also taken into account. It is advisable to use these solutions for I-II degrees of dehydration, but if we are talking about III and IV degrees, then polyionic isotonic crystalloid solutions are already used here, they are administered intravenously, in a stream, until the onset of a state in which the signs indicating dehydration disappear. shock, after which the introduction of solutions occurs by the drip method.
Intoxication with accompanying symptoms is eliminated, in the case of considering the gastrointestinal form of the disease, using, for example, indomethacin. The relevance of its use is determined by the early stages of the course of the disease, the reception consists in a threefold dosage within 12 hours of 50 mg. Antibiotics, like other types of etiotropic drugs, are not prescribed in the case of the gastrointestinal form. The need for their use is dictated exclusively by the generalized form of the course of the disease in the form and form, determined individually. Also in this case, an appropriate option is the appointment of enzyme preparations of a complex type. Additionally, diet No. 4 is prescribed for diarrhea, after the disappearance of diarrhea - diet No. 13.
To diagnose the disease in the presence of relevant symptoms for it, consultation with an infectious disease specialist is necessary.
b) ferment sugars to acid and gas (except S. thyphi)
c) proteolytic properties are poorly expressed
5. AG structure: O- (LPS), H- (in two phases - specific and non-specific), sometimes Vi-AG (special K-AG).
6. Pathogenicity factors and pathogenesis:
a) capsule, drank
b) the third secretory system - prevents the fusion of phagosomes and lysosomes in macrophages
c) endotoxin (LPS) - fever induction, microcirculation disorders
d) cholera-like enterotoxin - activation of adenylate cyclase, watery diarrhea
Adhesion on enterocytes and their colonization penetrate into macrophages reproduction bacteremia (intensive destruction of bacteria is possible with the release of enterotoxin and endotoxin).
The causative agent of nosocomial infections.
7. Clinical features: short incubation period, serious condition, violent sudden onset, short course, benign outcome.
8. Immunity: IO in the form of local (intestinal) immunity (sIgA), CIO is weakly expressed. nine . Features of epidemiology:
a) outbreaks in children's post-natal institutions are gradual
b) the source is a human, the infection is contagious
c) OPP - contact-household, air-dust
d) in children it proceeds as a septic infection
10. Prevention: specific: polyvalent salmonella phage
Causative agents of typhoid fever, paratyphoid a and b, general characteristics. Phage typing. VI-antigen and its significance. Causative agents of typhoid and paratyphoid.
1. Classification: R. Salmonella, c. S. typhi, S. paratyphi.
2. Morphology: Gr-, rod, there is a microcapsule, peritrichia, mobile.
3. Biological properties:
1) lactose-negative, ferment hl and maltose to acid or acid and gas
2) proteolytic properties are poorly expressed
4. AG structure: K-AG, O-AG, N-AG (two phases - specific and group).
5. pathogenicity factors:
a) capsular polysaccharide (Vi-AG) - protects against phagocytosis, suppresses complement
b) adhesins (microcapsule, pili)
c) the third secretory system - is responsible for penetration into cells, prevents the digestion of MB inside cells.
d) endotoxin (LPS) - fever, rash
6. Pathogenesis
Adhesion on enterocytes of the small intestine → colonization of the mucosa → into Peyer's patches, phagocytosis by macrophages and active reproduction in them → total lymph flow → bacteremia → bone marrow, spleen, gallbladder → reproduction in the gallbladder (selective medium) → duodenum → secondary entry into the small intestine and Peyer's patches → immune inflammation, intoxication of the body with endotoxin.
7 Clinical manifestations: intoxication, fever, roseolous rash and hepatolienal syndrome.
8 Immunity: intense post-infectious humoral immunity, local immunity (sIgA), CIO in the form of the formation of HRT effectors in Peyer's patches.
9 Ecology and epidemiology. anthroponotic infection. The source is sick people and bacteria carriers. OPP - alimentary. Resistant to environmental factors, perish under the action of disinfectants.
10. Prevention: specific - chemical adsorbed typhoid-paratyphoid-tetanus vaccine (TABte), a vaccine containing S. typhi Vi-AG.
11 Treatment: chloramphenicol.
CLINICAL FEATURES OF HOSPITAL SALMONELLOSIS
LAVRINOVICH D.N., SEMENOV V.M., DMITRACHENKO T.I.
Educational Establishment “Vitebsk State Order of Friendship of Peoples Medical University Department of Infectious Diseases
Summary. Salmonellosis currently occupies one of the first places in terms of prevalence among intestinal infections. not only in the Republic of Belarus. but throughout the world.
The aim of this work was to assess the clinical course of nosocomial salmonellosis. caused by S. typhimurium. compared to community-acquired salmonellosis. We observed 58 patients with nosocomial salmonellosis. caused by S. typhimurium. of these, 43 patients (74.2%) were children of the first year of life. During the research it was found. that hospital-acquired salmonellosis, compared with community-acquired salmonellosis, often occurs in a severe form. with signs of hemocolitis. long feverish period. accompanied by severe intoxication and impaired stool. Mostly children under one year old are ill. primarily with underlying comorbidity. therefore, the disease is often complicated by the generalization of the process (1.7±1.7%). frequent relapses (3.92±2.74% of patients) and long-term bacterial carriage (44.1±10.28% of patients).
Key words: nosocomial salmonellosis. S. typhimurium.
hemocolitis. complications.
abstract. Nowadays salmonellosis has one of the first places according to its frequency among other intestinal infections. both in the Republic of Belarus and all around the world.
The aim of the presented work was the assessment of the clinical course of no-zocomial salmonellosis caused by S. typhimurium in comparison with out-patient salmonellosis. We have observed 58 patients with nozocomial salmonellosis; 43 of them (74.2%) were the babies of 1st year of life. During the process of study one determined that nozocomial salmonellosis has the more severe clinical course with the manifestations of haemocolitis and protracted fever accompanied by a high level of general intoxication and stool disorders comparing with out-patient salmonellosis. The patients were predominantly babies below 1 year. primary with backgroung accompanying pathology; that’s why this disease is commonly complicated with generalization of the process (1.7±1.7% of patients). frequent relapses (3.92±2.74%) and prolonged bacterial carriage (44.1±10.28%).
Key words: nozocomial salmonellosis. S. typhimurium. haemocolitis. complications.
Correspondence address: Republic of Belarus, Vitebsk, Pobedy avenue, 5, apt. 46. tel. 5984162
Despite. that salmonella. as nosological forms. known for a very long time. changing environmental conditions. the intensity of collective immunity constantly make significant adjustments to the clinical course of diseases. In this regard, a number of scientific studies. dedicated to the clinical and pathogenetic patterns of salmonellosis. does not decrease. Such studies are of decisive importance in the development of rational methods of treatment for this category of patients.
In the clinical aspect, the most important is to characterize the features of the course of salmonellosis. caused by S. typhimurium. Many authors point to the tendency of hospital salmonellosis to form severe forms (33.3%) and protracted course (19.9%). Wherein. very characteristic of hospital salmonellosis is its peculiar dynamics - the slow development of the disease with later involvement of organs and systems in the pathological process. successive onset of clinical symptoms. The researchers note. that is slowly evolving. but deep and persistent toxicosis has a long duration. than community-acquired salmonellosis. In most patients, it occurs after the symptoms of lesions of the gastrointestinal tract and reaches its maximum severity in terms of 2 to 5 days.
Generally. according to the researchers. The dynamics of a slowly developing pathological process in hospital-acquired salmonellosis reflects the mechanism of infection. while the nature of intoxication. depth of organ damage. the frequency of adverse outcomes is a consequence of the interaction of the pathogen with an unusual biological characteristic. in particular. high tissue tropism. and a macroorganism with altered reactivity. high sensitization and sharply disturbed in the course of the previous disease intestinal biocenosis. Analysis of literature data. concerning the clinical features of salmonellosis typhimurium in different age groups. showed. that for children of the first months of life, the gradual development of the disease is characteristic. which corresponds to the initial symptomatology. represented by gastrointestinal disorders. In older age groups, the disease often occurs acutely. with severe toxicity. Wherein. the authors emphasize. that intoxication. reflecting the degree of functional maturity of the body. the level of formation of the central nervous system. being mild and slowly developing in children of the first month of life. significantly changes its character in older age groups. She shows up early. and with increasing age, its frequency increases. intensity. pace of development and at the same time. duration is shortened.
According to V. G. Akimkin, among adults with nosocomial salmonellosis, the gastrointestinal form prevails (up to 75%). Along with this, generalization of infection (10-25%) was quite often noted. Among the gastrointestinal form, gastroenteric and gastroenterocolitic variants of the infection prevailed (more than 95%). Among the generalized forms of infection, a typhoid-like variant was noted in 70% of cases, a septic-pyemic variant in 30%. In addition, in this category of patients, the formation of a long bacterial excretion is also possible.
According to the severity of the course of the disease, in the structure of nosocomial salmonellosis, as noted by many authors, severe (39.7%) and moderate (43.7%) forms of infection predominate. The dynamics of the structure of severe forms of the course of the disease shows that during the time of observation of a chronic epidemic there is a progressive decrease in the proportion of severe forms of the disease in the overall clinical picture of patients with nosocomial salmonellosis (from 49.1% in the 1st year to 14.9% in the 3rd year). th epidemic year). According to the characteristics of the clinical course of the disease, the gastrointestinal form prevails in the structure - 74.8%, however, generalized forms of salmonellosis are often diagnosed - 25.2%. The overall mortality from nosocomial salmonellosis is 0.78%. The highest mortality, as a rule, is observed in the 1st epidemic year, amounting to 7.39%. This indicator significantly differed from the level of mortality in subsequent years of observation. Describing the structure of mortality, it should be noted that the first epidemic year accounts for 72.2% of all deaths. The overall mortality rate is 5.64%.
The aim of this work was to assess the clinical course of nosocomial salmonellosis
All studies were carried out on the basis of the Vitebsk Regional Clinical Infectious Diseases Hospital using general clinical examination methods. The examination was carried out according to the generally accepted algorithm: clinical manifestations were compared
nosocomial salmonellosis with a clinical course of community-acquired salmonellosis, the diagnosis was confirmed by available laboratory methods, such as complete blood count, complete urinalysis, bacteriological examination. Clinical manifestations were compared according to the following criteria: the duration of the febrile period, the frequency and nature of stools, vomiting, the severity of the disease, the presence and duration of intoxication, the presence of concomitant pathology and background diseases, the age of patients, the duration of bacterial excretion. Among the laboratory research methods, we were primarily interested in the following criteria: leukocytosis, increased ESR, shift of the leukocyte formula to the left, leukocyturia, proteinuria.
Under our supervision there were 58 patients with nosocomial salmonellosis caused by BLURTIPITIS. At the same time, the vast majority
of them, 43 patients (74.2%) were children of the first year of life (Table 1). The gastrointestinal form of the disease prevailed in 86.2% (50 patients), in 1 (1.7%) patient, a child of 5 months, a generalized toxic-septic form of salmonellosis was established, which developed 1 month after the transferred gastrointestinal form and persisted bacterial excretion. Generalization of the process occurred against the background of an acute respiratory viral infection. In 7 (12.1%) patients who did not have symptoms of gastrointestinal lesions and excreted BLURItypeitis, a diagnosis of bacteriocarrier was made. (Table 1)
Age structure of examined patients with hospital salmonellosis
up to 3 months from 3 to 6 months from 6 to 12 months from 1 to 2 years from 2 to 10 years over 15 years
abs % abs % abs % abs % abs % abs %
Number of patients 7 12.1 12 20.7 24 41.4 8 13.8 3 5.1 4 6.9
The obtained data were processed on a personal computer using a standard package of statistical programs (NaIBIS 6.0). Variation statistics included the determination of the arithmetic mean, standard deviation, and mean error of the mean correlation coefficient. With a normal distribution of variable values, an unpaired 1-Student's test was used, with non-normal distribution of values - non-parametric Mann-Whitney test Differences were considered reliable at the significance level p<0,05.
Results and discussion
Among 50 patients who underwent the gastrointestinal form of the disease, severe 46.0% (23 patients) and moderate 48.0% (24 patients) forms of the disease prevailed. however, there were no significant differences in the severity of the process depending on the age of the patients. The severity of the process was determined primarily by background concomitant pathology.
All patients with nosocomial salmonellosis had one or another concomitant pathology and in most cases were transferred to the Vitebsk Infectious Diseases Hospital from other hospitals in the city or region (Table 2).
Most often (65.5%), the disease developed against the background of a respiratory tract infection. In different age groups, 50 to 100% of patients had respiratory infections. Among children under the age of 3 months. congenital pathology prevailed. In general, 45.1% (23) of children under the age of two had a congenital pathology. Perinatal encephalopathy was observed in 19 (37.2%) children, hypotrophy of 1-111 degrees - in 9 (17.6%), congenital malformation
hearts - 1 (1.9%). hydrocephalus - 1 (1.9%). congenital rubella - 1 (1.9%). cytomegalovirus infection - 1 (1.9%). Down's disease - 1 (1.9%). Anemia was observed in 17 (33.3%) children, the disease was accompanied by anemia. 16 (27.6%) patients had comorbidities.
The presence and nature of concomitant pathology in patients with nosocomial salmonellosis caused by S.typhimurium
Age Number of patients Concomitant pathology
Respiratory tract infections Congenital pathology Operations Other pathology
abs. % abs % abs % abs %
up to 3 months 7 0 0.0** 6 85.7** 0 0.0** 1 14.3**
from 3* to 6 months 12 10 * * .3 3, 8 6 50.0** 0 0.0** 2 16.7**
from 6* to 12 months 24 16 66.7** 9 37.5** 1 4 2** 5 20.8**
from 1* to 2 years 8 8 100.0** 2 25.0** 0 0.0** 2 25.0**
from 2* to 10 years 3 2 66.7* 0 * * .0 0.1 33.3** 0 0.0**
over 15* years 4 2 50** 0 0.0** 2 50.0** 0 0.0**
Total 58 38 65.5*** 23 39.6*** 4 6 9*** 10 17 2***
* - inclusive
** - share of pathology in the age group *** - share of pathology in the total number of patients
In the gastrointestinal form of salmonellosis, fever was a characteristic symptom. and more than in the majority of patients (82% -42 people) the temperature reached 38°C and above. It should be noted. that only in 2% (1 child) of patients under the age of one year, the temperature remained normal. in 13% (6 patients) it was within 37-37.9°. The duration of the temperature increase depended on the severity of the disease and was 3-6 days in half of the patients (56%-28 patients). An increase in temperature for less than 3 days and more than 6 days was observed in an equal number of patients (22% - 11 patients). the average duration of the temperature rise during nosocomial infection was 4.18 days. while in case of community-acquired infection with BLURTIpitis, the duration of fever was 3.4 days.
Symptoms of intoxication with nosocomial infection developed more gradually. than when infected at home (within 3-4 days) and persisted for an average of 3.8 days. In community-acquired infection
the onset of the disease was sudden. with the development of all symptoms of the disease in the first hours or days. toxicosis lasted an average of 2.4 days.
Vomiting was observed by us only in 16.0% (8) of patients with gastrointestinal form of nosocomial salmonellosis. Usually, vomiting was infrequent (1-2 times a day) and appeared on the 1-3rd and even later than 4 days from the onset of the disease. With community-acquired infection, vomiting was more often noted on the 1st day of illness and this symptom occurred in 36.4% (12) of patients.
Loose stools were observed by us in all patients with manifest forms of the disease. in 12% of patients with nosocomial salmonellosis, the frequency of stools did not exceed 5 times a day. in 48% of patients - 5-10 times and in 40% - over 10 times. At the same time, in 16% of patients, the stool frequency ranged from 15 to 20 times. At the same time, all children of the first 3 months of life had loose stools more than 10 times a day. Hemocolitis was detected in 54% of patients. moreover, in children of the first 6 months of life, this syndrome occurred much more often (66.7%). From 80 to 100% of children, stools with mucus were noted. In some patients, compliance and gaping of the anus were noted. Considering that. that in other acute intestinal infections, hemocolitis in children under one year old does not occur so often. as in salmonella typhimurium. each case of hemocolitis in a child of the first year of life should alert the doctor regarding salmonella infection. In the majority (58.0% - 29 patients) of patients with nosocomial salmonellosis in bacteriological studies of feces, concomitant flora was found. which is probably due to the presence of dysbacteriosis. the cause of which was the previous appointment of massive antibiotic therapy. at the same time, candida and Staphylococcus aureus were most often detected (Table 3)
The presence of concomitant flora in bacteriological cultures of feces of patients with nosocomial and community-acquired salmonellosis S.typhimurium
Isolated flora S V _ m h y tribolic salonellosis n=58) Community-acquired salmonellosis (n=33) Salmonellosis typhimurium in general (n=71)
abs. % abs. % abs. %
S. aureus 8 27.6±5.87 4 36.4±8.37 12 30.0±5.43
S.epidermidis 5 17.2±4.95 4 36.4±8.37 9 22.5±4.95
Proteus spp. 3 10.3±3.99 0 0.0 3 7.5±3.12
P.aeruginosa 1 3.4±2.38 1 9.1±5.01 2 5.0±2.59
Candida spp. 12 41.4±6.47 2 18.2±6.72 14 35.0±5.66
Presence of accompanying flora in bacteriological cultures of feces 29 50.0±6.56 11 33.3±8.2 40 43.9±5.89
For nosocomial salmonellosis, prolonged bacterial excretion was more characteristic. which was not observed in patients with community-acquired salmonellosis. In 41.6% of 24 patients. Bacteria excretion in control crops that had the growth of BLURItypeitis exceeded 30 days. and in 3 patients (12.5%), the carriage of BlurTipitis exceeded 3 months. which, according to the generally accepted opinion, can be interpreted as chronic bacterial excretion. At the same time, 2 out of 3 patients had relapses of the disease 1-3 months after the acute process. one of them developed a generalized form of the disease.
In 42% (21) of patients with nosocomial salmonellosis, leukocytosis was observed. which had significant differences compared with community-acquired salmonellosis (p<0.05). У 30% (15 больных) отмечалось повышение СОЭ. у 58% (29 больных) сдвиг формулы влево. однако данные показатели не имели достоверных различий с внебольничным сальмонеллезом тифимуриум.
Only 18% of the examined patients had proteinuria. while the level of protein in the urine did not exceed 0.8-1.0 g/l. leukocyturia was noted by us only in 1 patient (2%) with the gastrointestinal form of salmonellosis. None of the patients examined by us showed an increase in the level of urea.
The generalized form of the disease was observed by us only in one patient. which amounted to 1.7% of the patients with nosocomial salmonellosis observed by us and 1.1% of all patients with salmonellosis typhimurium included in our studies.
Given the differences in sensitivity to antibiotics and disinfectants of nosocomial and community-acquired strains of the serovar Ivytypium. determining different tactics in the selection of antibacterial drugs. and in carrying out disinfection measures, the differential diagnosis of nosocomial and out-of-hospital salmonellosis is of great importance. Table 4 presents statistically significant differences between nosocomial and community-acquired salmonellosis.
Table 4
Comparative characteristics of patients with salmonellosis caused by various pathogen serovars and infection mechanisms
abs. % abs. %
1. 8. 9. 10. 11.
female 28 48.3±6.56 14 42.4±8.6
male 30 51.7±6.56 19 57.6±8.6
Symptom Nosocomial S.typhimurium salmonellosis (n=58) Nosocomial S.typhimurium salmonellosis (n=33)
abs. % abs. %
up to 1 year* 43 74.1±5.75 0 0
from 1 to 2 years 8 13.8±4.53 1 3.0±2.97
from 2 to 5 years 2 3.4±2.38 0 0
from 5 to 10 years 1 1.7±1.7 1 3.0±2.97
from 10 to 15 years old 1 1.7±1.7 0 0
over 15 years* 3 5.2±2.91 31 93.9±5.74
Form of the disease
Gastrointestinal 50 86.2±4.53 33 100
Generalized 1 1.7±1.7 0 0
Bacteriocarrier* 7 12.1±4.28 0 0
Disease severity (for localized forms)
light 3 5.9±3.09 6 18.2±6.72
moderate* 24 47.0±6.55 24 72.7±7.75
severe* 23 47.1±6.55 3 9.1±5.01
Fever duration
1 did not increase 7 (n-in) 12.6±4.39 3 9.1±5.01
1 increased (localization f-ma) 50 87.9±4.39 30 90.9±5.01
1-2 days 11 22.0±5.86 12 40.0±8.52
3-4 days 20 40.0±6.43 10 33.3±8.2
5-6 days 8 16.0±5.18 6 20.0±6.96
> 6 days* 11 22.0±5.86 2 6.7±4.35
Duration of intoxication
1-2 days* 18 36±6.79 23 69.7±7.99
3-4 days* 19 38±6.86 6 18.2±6.72
> 4 days 13 26±6.2 4 12.1±5.68
D, duration of diarrhea in the hospital
1-2 days* 13 26.0±6.2 17 51.5±8.7
3-4 days 16 32.0±6.6 9 27.2±7.75
5-6 days 10 20.0±5.66 3 9.1±5.01
7-8 days 4 8.0±6.84 3 9.1±5.01
> 8 days 7 14.0±4.9 1 3.1±3.02
Hemocolitis 27 54.0±7.04 12 36.4±8.37
Presence of associated flora in the tank. stool cultures* 29 58.0±6.98 11 33.3±8.2
Symptom Nosocomial salmonellosis 8.1urbіbіgіnіm (n=58)
abs. % abs. %
Vomiting* 8 16.0±5.18 12 36.4±8.37
Leukocytosis* 21 42.0±6.98 4 12.1±1.51
ESR increase 15 30.0±6.48 9 27.3±7.75
Neutrophilosis 29 58.0±6.98 17 51.5±8.7
Proteinuria 9 18.0±5.43 7 21.2±7.11
Leukocyturia 1 2.0±1.98 0 0
Positive control stool culture 24 (out of 33) 72.7±6.3 13 (out of 20) 65.0±10.66
Duration of bacterial excretion
< 1 мес* 14 58,3±8,58 13 100,0
from 1 to 2 months 3 12.5±5.75 0 0
from 2 to 3 months* 4 16.7±6.49 0 0
> 3 months* 3 12.5±5.76 0 0
Thus, the differences in the biological properties of Salmonella of various serovars noted in the literature review determine the features of the clinical picture of community-acquired salmonellosis and nosocomial salmonellosis.
The more pronounced ability of S. enteritidis to form thermolabile enterotoxin explains the more frequent violent manifestation of dyspeptic syndrome and longer diarrhea in patients with community-acquired salmonellosis caused by this serovar, which led to the predominance of severe and moderate forms of the disease.
On the contrary, the lack of a pronounced ability to form thermolabile enterotoxin in S.typhimurium strains, along with increased invasiveness and adhesiveness, led to more frequent lesions of the large intestine, longer bacterial excretion in patients with both community-acquired and nosocomial salmonellosis.
Based on our results, the existing opinion in the literature about a more severe course of salmonellosis caused by S.typhimurium is unjustified, and is associated only with the association of this serovar with nosocomial infection. The severity of the process in nosocomial salmonellosis is determined by the background disease preceding infection, which is aggravated by infection and itself, causing immunosuppression, can contribute to the severe course and generalization of salmonellosis.
Conclusion
1. Nosocomial salmonellosis is characterized by: age up to 1 year, bacterial carriage, the presence of concomitant flora in stool cultures, leukocytosis, bacterial excretion for more than 2 months.
2. Hospital salmonellosis significantly more often (p<0,01) протекает в тяжелой форме по сравнению с внебольничным вариантом, достоверно чаще у больных госпитальным сальмонеллезом наблюдается длительная интоксикация (р<0,05) и диарея (р<0,01).
3. Nosocomial salmonellosis is characterized by prolonged bacterial excretion, in 41.6 ± 10.28% of patients, bacterial excretion exceeds 30 days, in 12.5 ± 5.75% - 3 months, and in 3.92 ± 2.74% of patients there are relapses of the disease 1-3 months after the acute process.
4. Community-acquired salmonellosis is characterized by: age over 15 years, duration of intoxication 1-2 days, duration of diarrhea during treatment 1-2 days, vomiting, bacterial excretion less than 1 month.
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10. Bukharin, O. V. Bacteriocarrier / O. V. Bukharin, B. Ya. Usvyatsov. - Yekaterinburg: UrO RAN., 1996. - 206 p.
11. Mamyan, DV Some hygienic aspects of salmonellosis and their prevention: author. dis. ... cand. honey. Sciences: 14.06.07 / D. V. Mamyan; USSR Academy of Medical Sciences; Research Institute of Nutrition. - Minsk, 1983. - 23 p.
12. Akimkin, V. G. Experience in the elimination of intrahospital salmonellosis in a large diversified medical institution / V. G. Akimkin // Military. honey. magazine - 1995. - 49 p.
Salmonellosis is an acute zoonotic-anthroponotic bacterial infectious disease with a fecal-oral mechanism of pathogen transmission. It is characterized mainly by damage to the gastrointestinal tract and intoxication, occurring most often in the form of gastrointestinal, less often generalized forms.
Historical information .
Etiology .
Salmonella are rods (2–4) x 0.5 µm in size, mobile due to the presence of flagella, anaerobes. They do not form spores or capsules and are Gram-negative. Grow on normal nutrient media. Salmonella are stable in the environment, live in water for up to 120 days, in faeces - from 80 days to 4 years.
In some products (milk, meat), salmonella can even multiply. Low temperatures are well tolerated, at high temperatures they die instantly. Salmonella are capable of producing exotoxins: enterotoxins (thermolabile and thermostable), which enhance the secretion of fluid and salts into the intestinal lumen, and cytotoxin, which disrupts protein-synthetic processes in the cells of the intestinal mucosa and affects the cytomembranes. When bacteria are destroyed, endotoxin is released, which is associated with the development of intoxication syndrome.
The antigenic structure of Salmonella is complex: they contain O- and H-antigens. The antigenic structure of Salmonella is the basis of the International Serological Classification of Salmonella (Kaufman-White scheme). Differences in the structure of O-antigens made it possible to distinguish serological groups A, B, C, D, E, etc. Within each serological group, serological variants are distinguished for the H-antigen. Currently, more than 2,300 Salmonella serovars have been described, of which more than 700 are found in humans. The following Salmonella are most common: Typhimurium, Heidelberg, Enteritidis, Anatum, Derby, London, Panama.
Epidemiology .
Salmonellosis can occur both in the form of individual sporadic cases and in the form of outbreaks. Currently, the incidence of salmonellosis remains relatively high throughout the year with some rise in the warm season. Animals and humans can be sources of infection, and the role of animals in epidemiology is the main one. Salmonellosis in animals occurs in the forms of a clinically pronounced disease and bacteriocarrier. Being outwardly healthy, bacteria carriers can excrete pathogens with urine, feces, milk, nasal mucus, and saliva. The greatest epidemiological danger is infection of cattle, pigs, sheep, cats, house rodents (mice and rats). Salmonella are found in many species of wild animals: foxes, beavers, wolves, arctic foxes, bears, seals, monkeys. A significant place in the epidemiology of salmonellosis is occupied by birds, especially waterfowl. Salmonella is found not only in meat and internal organs of animals and birds, but also in eggs.
The main route of infection for salmonellosis is alimentary, and various food products (meat of animals, fish, frogs, oysters, crabs, eggs and egg products, milk and dairy products, vegetable dishes) are the factors of infection transmission. Water often acts as a direct factor in the transmission of infection. Cases of airborne infection in children's groups are described. There are known cases of direct infection of people from sick animals while caring for them. Sources of salmonellosis can be people with salmonellosis or bacterial excretors. Salmonellosis occurs throughout the year, but more often in the summer months, which can be explained by the deterioration of food storage conditions.
The incidence of salmonellosis has generally increased. The reason for this phenomenon, according to most researchers, is associated with the intensification of animal husbandry on an industrial basis, the changed nature and scale of food sales, a significant increase in export-import relations between countries, the intensification of migration processes, etc.
Another epidemiological feature of salmonellosis at present is the predominantly sporadic nature of its distribution. It has been established that the sporadic morbidity is essentially a consequence of the occurrence of outbreaks of salmonellosis, the nature of which has changed, as a result of which their epidemiological interpretation is difficult. They arise mainly as a result of the entry into the trade network of various food products infected with Salmonella.
Waterborne outbreaks of salmonellosis have been described. The air-dust route of infection transmission is discussed. The airborne route of transmission is not legal, but outbreaks that have a flu-like type of infection process are increasingly common. Possible infection of the child during childbirth, transplacental transmission of infection is allowed.
One of the important problems of modern medicine is salmonellosis as a nosocomial (nosocomial, hospital) infection. Salmonella that cause nosocomial diseases are called hospital strains, since it is believed that their biological characteristics (lack of sensitivity to typical bacteriophages, multidrug resistance, etc.) are formed in a hospital. Nosocomial outbreaks are characterized by high contagiousness, rapid spread and severity of the clinical course.
Pathogenesis .
For the development of manifest forms of the disease, it is necessary to penetrate into the gastrointestinal tract not only Salmonella toxins, but also live pathogens. The massive intake of live bacteria (with the alimentary route of infection) is accompanied by their destruction in the upper sections of the gastrointestinal tract (in the stomach and mainly in the intestines), as a result of which a large amount of endotoxin is released, which, being absorbed into the blood, causes the occurrence of endotoxic syndrome, which determines the clinical picture of the initial period of the disease. The severity of toxemia depends on both the infectious dose and the bactericidal properties of the gastrointestinal tract. At this stage, the infectious process may end. Clinically, the disease will proceed according to the type of toxic infection (gastroenteric form).
If the intensity of bacteriolysis is insufficient, there is no specific immunity, and the factors of nonspecific protection of the gastrointestinal tract are imperfect, Salmonella overcome the epithelial barrier of the small intestine and penetrate into the thickness of the tissues (enterocytes and the proper layer of the intestinal mucosa), where they are captured (phagocytosed) by neutrophils and macrophages. There is an inflammatory process in all parts of the gastrointestinal tract (gastroenterocolitic form).
Depending on the state of the body's immune system, either only a local process occurs, or a breakthrough of the intestinal and lymphatic barriers occurs and the next stage of the infectious process occurs - bacteremia.
The process of accumulation of Salmonella in the body is simultaneously accompanied by their intensive death and decay, and, consequently, a significant release of toxins, which marks the end of the incubation period and marks the beginning of the intoxication syndrome. The result of the combined action of endotoxin and bacterial bodies on enterocytes is diarrheal syndrome.
The local reaction is the development of enteritis. Inflammatory phenomena in the mucous membrane occur after Salmonella pass through the epithelial barrier and are captured by macrophages and leukocytes. As a result, not only the pathogen, but also part of phagocytes and other cells die under the action of endotoxin and salmonella metabolism products, as well as the release of additional portions of toxins, histamine and other biologically active substances: serotonin, catecholamines, kinins, etc. Salmonella toxins cause activation of synthesis prostaglandins and cyclic nucleotides, which leads to a sharp increase in the secretion of fluid and potassium and sodium ions into the lumen of the gastrointestinal tract. Diarrhea develops with subsequent disturbances in water-electronic balance. The general reaction of the body to endotoxins is characterized by a violation of functional-adaptive processes in many organs and systems.
Large fluid losses lead to a reduction in the volume of circulating blood, a decrease in blood pressure, compensatory spasm of peripheral vessels and the development of hypoxia. Hypoxia, in turn, leads to the development of acidosis. A further increase in intoxication occurs mainly due to metabolic disturbances, which causes an increase in the blood of underoxidized products and the level of histamine-like substances and ultimately leads to the expansion of capillaries, blocking their response to adrenaline. As a result of enteritis, the processes of digestion and absorption in the intestine are disturbed, a deficiency of lipase and lactase occurs, which persists for about 4 weeks after the disappearance of the clinical manifestations of the disease. Often the composition of the intestinal microflora is disturbed - dysbacteriosis develops.
With generalized forms, the accumulation and reproduction of Salmonella occur in the internal organs and lymphatic formations. In these cases, the disease proceeds according to a typhoid-like variant or septicopyemia develops.
pathological anatomy .
With the most common gastrointestinal form of salmonellosis, the presence of edema, hyperemia, small hemorrhages and ulcerations in the mucous membrane of the gastrointestinal tract is noted. Histologically, excessive secretion of mucus and desquamation of the epithelium, superficial necrosis of the mucous membrane, vascular disorders, and nonspecific cellular infiltration are detected. In addition to these changes, in severe and septic forms of the disease, signs of dystrophy and foci of necrosis in the liver, kidneys and other organs are often observed. The reverse development of morphological changes in most patients occurs on the 3rd week of illness.
Clinical picture .
The incubation period for salmonellosis is 12–24 hours. Sometimes it is shortened to 6 hours or extended to 2 days. There are the following forms and variants of the course of Salmonella infection:
I. Gastrointestinal form:
- gastric variant;
- gastroenteric variant;
- Gastroenterocolitic variant.
II. Generalized form:
- typhoid-like variant;
- septicopyemic variant.
III. Bacterioexcretion:
- acute;
- chronic;
- transitory.
Most often, the gastrointestinal form of salmonellosis is recorded, which can proceed according to the indicated options, and according to severity it is divided into mild, moderate and severe. The severity of the course of the disease is determined by the degree of dehydration and the severity of intoxication.
The gastritis variant (Salmonella gastritis) rarely develops, clinically accompanied by moderate symptoms of intoxication, pain in the epigastric region, nausea, repeated vomiting. Diarrhea with this form of the course of the disease does not happen.
The gastroenteric variant is the most common clinical variant of Salmonella infection. The beginning is sharp. In the initial period, both signs of damage to the gastrointestinal tract and signs of intoxication are noted. Nausea and vomiting are noted in many patients. Vomiting is single, sometimes indomitable. The stool is liquid, plentiful, as a rule, retains a fecal character, sometimes it can resemble rice water. Most often, the stool is mixed with mucus, less often - watery, without pathological impurities. Sometimes the stool has a greenish color. The abdomen is usually moderately swollen, painful on palpation in the epigastrium, around the navel, in the ileocecal region, rumbling is detected in the loops of the small intestine. Normalization of feces in most patients occurs in the first week of illness, and only in some cases diarrhea persists for more than 10 days.
The gastroenterocolitic variant of salmonellosis can begin as gastroenteritis, but then the symptoms of colitis appear more and more clearly in the clinic. In this case, salmonellosis in its course resembles acute dysentery. The disease begins acutely, the temperature rises, other symptoms of intoxication appear. From the first days of the disease, the stools are frequent, liquid, with an admixture of mucus, sometimes blood. There may be tenesmus and false urges. When sigmoidoscopy in such patients, inflammatory changes of varying intensity are detected - catarrhal, catarrhal-hemorrhagic, catarrhal-erosive.
With the gastrointestinal form of salmonellosis, there is no characteristic type of temperature curve. There is a constant, rarely remitting or intermittent type of fever. Sometimes the disease proceeds at normal or subfebrile temperature. Often the pancreas is involved in the process, clinical symptoms of pancreatitis appear. Salmonella can also affect the liver. Symptoms of damage to the pancreas and liver are usually transient. Characteristic of salmonellosis is the defeat of the cardiovascular system, the degree of its damage depends on the severity of general toxicosis. The frequency, filling and tension of the pulse change, blood pressure decreases, in severe cases, collapse occurs. The myocardium is also affected. Toxic damage to the renal parenchyma is manifested, as a rule, by the symptom of "infectious-toxic kidney": proteinuria, microhematuria, cylindruria. Violation of the blood circulation of the kidneys, along with changes in the water and electrolyte balance, can cause the development of acute functional renal failure. At the height of the disease, water-salt metabolism is disturbed, leading to dehydration and demineralization of the body. Shifts in acid-base balance are found, especially in severe cases. In the blood, the level of hemoglobin and red blood cells sometimes rises; moderate leukocytosis with a neutrophilic shift is determined, ESR, as a rule, does not change.
The long course of gastrointestinal forms of moderate severity is short-lived. The temperature drops to normal within 2-4 days; even earlier, intoxication disappears, the stool returns to normal by the 3rd-7th day of illness. Normalization of the functional state of the intestine occurs much later than clinical recovery. In a number of patients, violations of the absorption and digestive functions can persist for several months.
The generalized form of salmonellosis can occur in two variants: typhoid-like and septic-pyemic.
The typhoid-like variant of salmonellosis usually begins with lesions of the gastrointestinal tract, but can occur from the very beginning without bowel dysfunction. Clinically, this form is very similar to typhoid fever and especially paratyphoid. The syndrome of intoxication is pronounced and is accompanied by inhibition of the functions of the central nervous system.
Patients complain of headache, sleep disturbance (drowsiness during the day and insomnia at night), lethargy, severe weakness. In severe cases, adynamia, lethargy are noted, delirium and hallucinatory syndrome are possible. Fever reaches 39–40 °C, is often permanent and lasts 10–14 days. A roseolous rash sometimes appears on the skin of the chest and abdomen. There is an enlargement of the liver and spleen. The pulse is often slowed down, blood pressure is reduced. In some cases, there are phenomena from the upper respiratory tract, bronchitis and pneumonia develop. In the peripheral blood, leukopenia is found, but there may also be moderate leukocytosis.
The septic-pyemic variant is essentially a sepsis of Salmonella etiology. After a short initial period, proceeding according to the type of gastroenteritis, a typical pattern of septicopyemia develops with a hectic temperature, headache and pain in the muscles of the legs, chills, sweats, tachycardia. There may be delirium and excitement. The skin is pale, sometimes greenish-yellow, with petechial or hemorrhagic rashes. The formation of secondary septic-pyemic foci of various localization (pneumonia, pleurisy, endocarditis, abscesses, soft tissue phlegmon, pyelitis, periostitis, arthritis, osteomyelitis, iridocyclitis) and enlargement of the liver and spleen are characteristic.
The septic-pyemic variant can also proceed according to the type of chroniosepsis with local damage to individual organs. Typically a long and severe course, an unfavorable outcome is possible.
Bacterial excretion as a result of salmonellosis can be acute and chronic.
Acute bacterial excretion, in which the pathogen continues to be isolated up to 3 months after clinical recovery, is much more common.
In chronic bacterial excretion, the pathogen is found in the feces for more than 3 months after clinical recovery.
Transient bacterial excretion is diagnosed in cases where there is only one or two salmonella excretions, followed by repeated negative results of bacteriological studies of feces and urine.
In addition, the necessary diagnostic conditions are the absence of any clinical manifestations of the disease at the time of the examination and over the previous 3 months, as well as negative results of serological studies over time.
Features of the course of salmonellosis in children .
Salmonellosis is a widespread intestinal infection in children over the past two decades due to the emergence of new, so-called "hospital" strains of Salmonella typhimurium, which are drug-resistant and can cause outbreaks (including nosocomial ones) with contact-household transmission. In contrast to dysentery, this salmonellosis is much more common in children of the first year of life, mainly with a burdened premorbid background and who are bottle-fed. In recent years, Samonella has become the second dominant strain. enteritidis spread mainly among older children through eggs and chicken meat. The seasonality of diseases caused by group B salmonella is more often spring-summer (with the maximum number of cases in May-June). Salmonellosis caused by pathogens of other serological groups (C, D, E) occurs with different frequency in different seasons of the year.
The clinical picture of the disease is determined by the age of the patient and the properties of the pathogen, as well as by infection. In children of the first year of life, salmonellosis is caused in the vast majority of cases by "hospital" strains of Salmonella typhimurium, it is most often spread by contact-household, including in hospitals, and has a characteristic clinical picture. The onset of the disease is usually subacute or gradual with the maximum development of all symptoms by the 3-7th day from the onset of the disease. A combination of symptoms of intoxication (febrile temperature, lethargy, pallor, cyanosis of the nasolabial triangle, loss of appetite, tachycardia) with symptoms of damage to the gastrointestinal tract (more often by the type of enterocolitis and gastroenterocolitis, less often - enteritis) is characteristic. Vomiting is noted in half of the patients, it can appear both from the first day of the disease, and join later, and in a third of patients it is persistent. The stool is plentiful, liquid, fecal, brown-green in color (such as "swamp mud"), with an admixture of mucus and greenery, and in 2/3 of patients - blood, which, as a rule, appears in the stool on the 5-7th day illness. Frequent manifestations are also the syndrome of watery diarrhea, flatulence, enlargement of the liver and spleen. Salmonellosis in this group of children is characterized by moderate and severe course, often long and recurrent, generalization of the infectious process is possible. The severity of the disease is determined both by the symptoms of intoxication, and by disturbances in water and mineral metabolism (exicosis II–III degree), as well as the occurrence of secondary focal complications (pneumonia, meningitis, osteomyelitis, anemia, DIC). Salmonellosis caused by multidrug-resistant biovar is especially unfavorable. S. typhimurium Copenhagen in children from closed children's institutions (children's homes, neuropsychiatric hospitals) suffering from various immunodeficiencies. In them, the disease often takes a protracted course with a long (up to 3-4 months) bacterial excretion (from feces and urine).
Differential diagnosis of salmonellosis with dysentery in young children presents significant difficulties due to the similarity of clinical manifestations:
- the possibility of both acute and gradual onset of the disease;
- frequent development of hemocolitis in both infections and the possibility of blood impurities in the stool not from the first day of illness;
- rare occurrence of distal colitis syndrome.
Differences in the clinical manifestations of dysentery and salmonellosis are as follows:
- greater severity of salmonellosis compared to dysentery at this age (with more pronounced and prolonged fever and more frequent development of hemodynamic disorders in salmonellosis);
- hepatolienal syndrome - although not an early, but reliable differential diagnostic sign characteristic of salmonellosis;
- great severity in salmonellosis syndromes of watery diarrhea and flatulence;
- a significantly longer duration of the course of salmonellosis, often with waves of exacerbation, as well as with the development of generalization of the disease.
Epidemiological data obtained during the collection of anamnesis (indication of staying in another hospital or being discharged from it 2–4 days before the present illness with salmonellosis), as well as different seasonality and frequency of these infections in young children, can also help in differential diagnosis. .
Salmonellosis in children older than one year is often caused by antibiotic-sensitive strains of Salmonella of different serovars with a predominantly food-borne route of infection and occurs in two clinical variants.
Option I - the most frequent - proceeds according to the type of food poisoning (gastritis, gastroenteritis, gastroenterocolitis). It is characterized by an acute onset of the disease with an increase in temperature to febrile numbers, the appearance of vomiting, often repeated, symptoms of intoxication (headache, weakness, loss of appetite, hemodynamic disturbances) and the appearance of copious liquid fecal stools with an admixture of mucus and greenery, moderate abdominal pain (more often in epigastric region and around the umbilicus). Half of children have more than 10 stools per day. With the timely initiation of therapy, the disease quickly stops, the infectious process does not develop further, and in such cases, salmonellosis is difficult to differentiate from food poisoning of another etiology.
Option II - dysentery-like - occurs in a third of children of this age. As with dysentery, there is an acute onset of the disease with an increase in temperature for 1-3 days, the appearance of symptoms of intoxication and the development of signs of colitis.
In the differential diagnosis of salmonellosis from dysentery in children older than one year, the following should be considered:
- a rare development in salmonellosis of isolated colitis and more frequent - enterocolitis and gastroenterocolitis, while the stool remains abundant, watery for a long time, despite the admixture of mucus and even blood, while with dysentery, the stool usually acquires a typical appearance by the end of the first day of the disease " rectal spit";
- unlike dysentery with salmonellosis, in most patients, an admixture of blood in the stool does not appear on the first, but only on the 3-5th day of illness and persists for a longer time (especially often with salmonellosis typhimurium);
- distal colitis syndrome, even in the presence of blood in the stool, as a rule, is not characteristic of salmonellosis, and flatulence is much more common;
- an increase in the liver with salmonellosis in older children is observed, although less frequently than in young children, but much more often than with dysentery, so the presence of this symptom can help in differential diagnosis.
In the coprogram for salmonellosis, unlike dysentery, there are no specific features, and the nature of the changes depends on the localization of the infectious process and the severity of digestive disorders. When the mucosa of the small and large intestine is involved in the inflammatory process, blood cells (leukocytes and erythrocytes) appear in the feces, and with functional digestive disorders, a lot of undigested neutral fat, starch, and muscle fibers are found.
Complications .
The complications of salmonellosis are many and varied. With the gastrointestinal form of the disease, the development of vascular collapse, hypovolemic shock, acute heart and kidney failure is possible. Patients with salmonellosis are prone to septic complications: purulent arthritis, osteomyelitis, endocarditis, abscess of the brain, spleen, liver and kidneys, meningitis, peritonitis, appendicitis. In addition, pneumonia, ascending urinary tract infection (cystitis, pyelitis), infectious toxic shock may occur. In all clinical forms of the disease, relapses are possible.
The prognosis for the gastrointestinal form and typhoid-like variant of salmonellosis is favorable, especially in cases of early diagnosis and proper treatment. The prognosis for the sentico-pyemic variant is always serious, the mortality rate is 0.2-0.3%.
Diagnosis and differential diagnosis .
Salmonellosis is diagnosed on the basis of epidemiological data, characteristic clinical signs and laboratory results. Salmonellosis begins acutely with chills, nausea, vomiting; there is pain in the epigastric and umbilical regions, later copious watery stools of dark brown or green color with a sharp fetid odor join.
Of the epidemiological data, the group nature of the disease, the connection with the use of poor-quality products, is important.
In conditions of sporadic morbidity, the diagnosis of salmonellosis is competent only if there is a complex of characteristic clinical and epidemiological data and laboratory confirmation. Of the laboratory methods, the most important are bacteriological and serological. Excrements of patients, vomit, gastric lavage, urine, blood, bile, suspected products are subjected to bacteriological examination. To confirm the "hospital" properties of Salmonella typhimurium, it is recommended to determine their antibiogram.
Of the serological methods, RA and RNGA are used. In recent years, highly sensitive serological methods for determining specific Salmonella antigens in the blood and other biosubstrates of patients have been used by latex agglutination, coagglutination, enzyme immunoassay.
Differential diagnosis of salmonellosis should be carried out with a large group of infectious diseases - food toxic infections of another etiology, acute dysentery, cholera, viral gastroenteritis, typhoid fever, influenza, meningitis, therapeutic and surgical diseases (myocardial infarction, acute appendicitis, cholecystitis, subarachnoid hemorrhage), as well as with poisoning by poisons and salts of heavy metals.
Treatment .
The complexity of pathogenetic mechanisms in salmonellosis, the variety of clinical forms of the disease dictate the need for an individual approach to treatment. The choice of treatment method depends on the form and severity of the disease. Patients with a subclinical form of salmonellosis and persons with acute bacterial excretion do not require therapeutic measures. Bacterial excretion, as a rule, stops on its own, and the appointment of any drugs only prolongs the rehabilitation period. The main method of treating patients with the gastrointestinal form of the disease is pathogenetic therapy, which includes measures aimed at detoxification, restoration of water and electrolyte balance and hemodynamics, elimination of local lesions of the gastrointestinal tract. At the same time, it is necessary to treat concomitant diseases.
Common in these forms of salmonellosis are the need for diet and refusal to use etiotropic therapy. The diet should be mechanically and chemically sparing, which corresponds to table number 4 of clinical nutrition. Whole milk and refractory fats are excluded from the diet, carbohydrates are limited. Recommended oatmeal and rice porridge on the water, boiled fish, steam cutlets, meatballs, fruit jelly, cottage cheese, mild cheeses. The diet is gradually expanded, and with complete clinical recovery, which usually occurs on the 28-30th day from the onset of the disease, they switch to the diet of a healthy person.
The use of antibacterial drugs in these forms is contraindicated, as it leads to a later clinical recovery, a delay in the normalization of the functional activity of the gastrointestinal tract, prolongs the period of sanitation of the body from salmonella and contributes to the formation of dysbacteriosis.
Treatment of patients begins with gastric lavage in order to remove infected products, pathogens and their toxins. For washing, a 2% sodium bicarbonate solution or water in an amount of 2–3 liters with a temperature of 18–20 °C is used. In mild cases of salmonella infection without signs of dehydration, gastric lavage exhausts the entire volume of medical care.
The fight against dehydration in cases of diseases of moderate and mild severity, occurring with dehydration of I-II degree, is carried out with rehydration solutions that are administered orally: glucosolan, oralit, rehydron are used. The volume of oral solutions administered should be determined by the degree of dehydration, the severity of intoxication and the patient's body weight. Usually, patients with salmonellosis of moderate severity with dehydration of the II degree are prescribed solutions in a volume of 40-70 ml / kg, for patients with severe intoxication, but in the absence of dehydration - in a volume of 30-40 ml / kg.
Oral rehydration is carried out in two stages:
- Stage I - primary rehydration in order to eliminate dehydration, loss of salts, intoxication. Its duration is usually 2-4 hours;
- Stage II - maintenance therapy aimed at eliminating the ongoing loss of fluid and salts, as well as the remaining intoxication syndrome. It is carried out over the next 2-3 days.
In most cases, oral rehydration therapy has a good therapeutic effect.
With repeated vomiting, increasing dehydration, treatment of patients begins with intravenous administration of polyionic solutions, such as Quartasol, Chlosol, Acesol, Trisol, etc., heated to a temperature of 38–40 ° C. The volume of fluid administered for the purpose of rehydration depends on the degree of dehydration and the patient's body weight. After compensating for initial fluid losses, they switch to oral fluid intake.
In order to detoxify and restore hemodynamics, synthetic colloidal solutions are used: hemodez, polyglucin, reopoliglyukin. However, their use is permissible only in the absence or after the elimination of dehydration.
In severe course of the disease with III-IV degree dehydration, treatment should begin with intravenous jet (80-120 ml / min) administration of the indicated polyionic solutions. The volume of solutions administered for the purpose of rehydration is determined by the degree of dehydration and the patient's body weight. Switching to oral fluid intake may be recommended after stabilization of hemodynamic parameters, cessation of vomiting and restoration of renal excretory function. In cases of development of metabolic acidosis, the introduction of a calculated dose of 4% sodium bicarbonate solution is recommended.
In the presence of toxic-infectious shock, therapeutic measures begin with an intravenous infusion of polyionic solutions (at a rate of 100–120 ml/min). The volume of injected solutions is determined by the state of hemodynamics and biochemical parameters of the blood. For the purpose of detoxification with slight dehydration, together with saline solutions, synthetic colloidal solutions (hemodez, polyglucin, reopoliglyukin) in a volume of 400-1000 ml can be used.
With the development of adrenal insufficiency, the introduction of glucocorticoids is indicated. The initial dose (60–90 mg of prednisolone, 125–250 mg of hydrocortisone) is administered intravenously by stream, the subsequent dose is intravenously dripped after 4–6 hours. At the same time, deoxycorticosterone acetate is administered intramuscularly, 5–10 mg every 12 hours. normalization of hemodynamic parameters and restoration of urination. The appointment of patients with the gastrointestinal form of drugs such as mezaton, norepinephrine, ephedrine is contraindicated due to their ability to cause spasm of the kidney vessels. With the development of acute renal failure, pulmonary or cerebral edema, targeted therapy is carried out with the inclusion of diuretics (mannitol, furosemide). In order to restore the functional activity of the gastrointestinal tract, enzyme preparations (panzinorm, festal, mezim-forte, abomin, cholenzim) should be used. To bind infectious aggressors, it is possible to use enterosorbents - smecta, enterodesis, etc. In order to normalize the motor-evacuation activity of the intestine, the appointment of antispasmodic and astringent agents (papaverine, noshpa, belladonna, atropine, bismuth, tanalbin, decoction of oak bark, blueberries, bark pomegranate, bird cherry).
In generalized forms of salmonellosis, along with pathogenetic therapy, it is necessary to prescribe antibacterial agents - chloramphenicol, ampicillin. With a typhoid-like variant, chloramphenicol is prescribed 0.5 g 4 times a day for 10-12 days. It is preferable to administer chloramphenicol succinate at the rate of 30–50 mg/kg per day. Ampicillin is prescribed for the same period of 0.5-1.0 g 3 times a day orally or 500-1000 mg 4 times a day intravenously. In the septic-pyemic variant, ampicillin is prescribed at the rate of 200–300 mg/kg per day, and the dose of levomycetin succinate is increased to 70–100 mg/kg.
Sanitation of chronic salmonella bacteria should be comprehensive. Of paramount importance is the use of drugs that affect the overall reactivity of the body: the use of pyrimidine drugs (pentoxyl and methyluracil), the treatment of concomitant diseases of the gastrointestinal tract, intestinal dysbacteriosis. It is advisable to prescribe a salmonella bacteriophage.
An extract from the hospital is made after clinical recovery in the presence of a negative result of bacteriological examination of feces. The control examination of persons from the decreed population group is carried out three times. Persons who do not emit salmonella after discharge from the hospital are allowed to work and are not subject to dispensary observation.
Prevention and measures in the outbreak .
Veterinary and sanitary control over the slaughter of livestock, over the technology of processing carcasses, over the preparation and storage of meat and fish dishes. After hospitalization of the patient, the focus is monitored for a week. Employees of food enterprises are subjected to a single bacteriological examination. After discharge from the hospital, employees of food enterprises and children attending a nursery are observed for 3 months with bacteriological examination of feces (1 time per month). Bacteriocarriers are not allowed to work in food and equivalent enterprises.
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