Salmonella Infection

Salmonella Infection (Salmonellosis)

DRG Category:	868
Mean LOS:	4.9 days
Description:	MEDICAL: Other Infectious and Parasitic Diseases Diagnoses With CC

Salmonellosis is a bacterial infection caused by gram-negative bacilli of the genus Salmonella. Sometimes classified as food poisoning because it is frequently acquired by ingesting food that has been contaminated with the Salmonella bacterium, salmonella syndromes can be divided into five categories: gastroenteritis, enteric fever, bacteremia, localized infection, and a chronic carrier state (see Table 1). The most severe form of salmonellosis is typhoid, which can cause perforation or hemorrhage of the intestines, pneumonia, toxemia, acute circulatory failure, and cerebral thrombosis. Only about 3% of Salmonella infections are confirmed by laboratory testing, but an estimated 1.4 million people are infected each year in the United States.

Once the Salmonella bacterium is ingested, it multiplies rapidly in the mucosal layers of the stomach and small intestine. The greater the number of organisms ingested, the shorter the incubation period; typically, incubation is 8 to 48 hours after ingestion of contaminated food or liquid, and symptoms usually last for 3 to 5 days. An inflammatory response in the tissues produces gastroenteritis. The infection may stop there or the salmonella organisms may travel via the lymph and vascular system throughout the body. The dissemination of organisms produces lesions in other organs or, possibly, sepsis. Systemic lesions may result in appendicitis, peritonitis, otitis media, pneumonia, osteomyelitis, or endocarditis. Symptoms of intermittent fever, chills, anorexia, and weight loss indicate sepsis.

Types of Salmonella Infections

Table 1. Types of *Salmonella* Infections
Type	Incidence and Incubation	Description
Gastroenteritis	Most common in May through October; incubation is 8–48 hr	Acute onset of fever and chills for 72 hr, nausea and vomiting, cramping, diarrhea for 3–7 days; diarrhea may be bloody
Enteric (typhoid fever)	Transmission from contaminated water or animal by-products; incubation 5–21 days	First 10 days: Headache, cough, anorexia, fatigue, weakness, sore throat, gastrointestinal complaints such as abdominal pain or changes in bowel habits; after 10 days, abdominal distention, abdominal pain, bradycardia, rash, confusion may occur; condition either resolves after 4 wk or complications such as intestinal perforation or endocarditis occur
Bacteremia	Occurs in people who are immunosuppressed	Fever, infection
Local infection	Occurs in 5% of infected people	Infections of heart, brain, lungs, bones, kidneys, muscles
Carrier	Stool or urine for more than 1 yr	< 1% in nontyphoid Salmonella and 4% with untreated Salmonella

Causes

Salmonellosis is caused by any of more than 2,000 serotypes of Salmonella bacteria. Typhoid is transmitted through ingestion of water that has been contaminated with the feces of infected persons. Salmonellosis may also be contracted by eating infected raw eggs or egg products or uncooked meat or poultry, ingesting raw milk, or handling infected animals. Salmonella can survive for an extended period of time in water, sewage, ice, and food. Although cooking food thoroughly can reduce the risk of salmonellosis, it cannot eliminate it.

Genetic considerations

Heritable immune responses could be protective or increase susceptibility. Mutations in the interleukin-12 receptor (IL12RB) appear to increase susceptibility to mycobacteriosis and salmonellosis.

Gender, ethnic/racial, and life span considerations

All people are susceptible. Although the disease is rarely fatal, severity may be pronounced in infants and persons with neoplastic, immunosuppressive, or other debilitating conditions. Enterocolitis and bacteremia are more common among infants. People in hospitals and nursing homes have a higher prevalence of this disease than the general population. Women over age 50 are the most common carriers of typhoid. Patients infected with Salmonella tend to be most commonly either younger than 20 or older than 70. Patients with HIV infection are susceptible to recurrent bacteremia caused by Salmonella bacteria. The disease has no predilection for a particular race, ethnicity, or gender.

Global health considerations

Developed nations have frequencies of salmonella infections resulting in gastroenteritis similar to that of the United States. Estimates of global Salmonella gastritis range widely, from 200 million to 1.4 billion cases each year. Experts estimate that at least 3 million people die annually.

Assessment

History

Establish a history of fever (often 102°F and higher), nausea, abdominal pain, vomiting, anorexia, and diarrhea that has persisted for at least 4 days. Ask about headache or constipation, which are symptoms of typhoid. The first symptoms generally appear between 8 and 48 hours after ingesting the bacteria; ask the patient about possible sources of the infection. Ask if the patient has had recent contact with an infected person or animal. Determine if the patient has ingested uncooked egg or meat products. If so, ask the patient whether the potentially contaminated food was prepared at home or at another location, such as a restaurant or public gathering. Elicit a history of recent travel to other countries that have endemic typhoid.

Physical examination

The patient appears to be weak and pale because of fever, nausea, vomiting, abdominal pain, and diarrhea. Young children and debilitated patients may show signs of dehydration. Fevers range from 101°F to 105°F. Rose spots may appear on the trunk and joints may be painful. Palpation of the abdomen may be difficult because of tenderness. Stools are usually greenish-brown, watery, and foul smelling. They contain mucus, pus, or blood.

Psychosocial

The patient with salmonellosis feels ill and may be apprehensive about the diagnosis. The patient feels guilty if he or she has inadvertently exposed others to the disease through food preparation or angry if he or she has been exposed to the illness at a restaurant or other public gathering. Parents of young children are apt to be anxious and afraid for their child’s life.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Cultures of feces, urine, vomitus, pus, or blood	Negative for pathogens	Presence of Salmonella	Determines presence of Salmonella in various samples; stool culture is the definitive diagnostic tool for salmonellosis

Other Tests: Complete blood count to determine the response to infection, liver function tests, bone marrow evaluation (highly sensitive for enteric fever but rarely done)

Primary nursing diagnosis

Diagnosis

Infection related to the presence of the infective organism

Outcomes

Immune status; Knowledge: Infection control; Risk control; Risk detection; Treatment behavior: Illness or injury

Interventions

Infection control; Medication management; Environmental management; Surveillance; Nutrition management; Teaching: Disease process

Planning and implementation

Collaborative

Patients with systemic infections are placed on the antibiotic that is most appropriate for their condition. Symptom management is accomplished by fluid and electrolyte replacement and control of fever. Because antidiarrheal and antispasmodic agents slow intestinal mobility, some experts do not recommend their use because they retard the intestinal transit of the infecting organisms.

The patient with salmonellosis is placed on bedrest during the acute phase and should be on enteric precautions until the diarrhea stops. Observe the patient’s stools for consistency and blood. Bleeding or abdominal pain may indicate the complication of bowel perforation; check for a sudden fall in temperature or blood pressure and a rising pulse rate. Many patients with Salmonella infection are not hospitalized but recover at home. Report Salmonella infection to the local health authority, particularly if the patient is employed in a food-handling occupation.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Antibiotics are reserved for patients with severe disease or who are at a high risk of invasive disease (infants, patients who are elderly or immunocompromised)	Varies with drug	Ciprofloxacin (Cipro), ampicillin, azithromycin (Zithromax), ceftriaxone (Rocephin), chloramphenicol, trimethoprim and sulfamethoxazole (Bactrim DS, Septra)	Kill bacteria and halt infection; treatment with antibiotics for gastroenteritis is controversial; experts suggest that antibiotics do not shorten the disease but prolong the time that the patient is a carrier
Nonsystemic antidiarrheals	60–120 mL after each loose bowel movement PO	Kaolin/pectin (Kaopectate)	Coat the intestinal mucosa, decrease intestinal secretions, and reduce discomfort; use sparingly because may prolong the infection

Independent

Relieve pain and discomfort from diarrhea by using a heating pad on the abdomen and washing and lubricating the anus. Use universal precautions. Employ scrupulous hand-washing techniques before and after working with the patient who has salmonellosis. Wear gloves when you dispose of feces or any objects that have been contaminated by the patient’s feces. Provide regular skin and mouth care and turn the patient often. While the patient is infected, allow her or him as much rest as possible between activities. Provide a restful atmosphere. To help reduce the patient’s temperature, apply tepid wet towels to the patient’s groin and axillae.

Explain to the patient the need to report salmonella infections to the local health authority. To prevent future infections, instruct the patient and family to wash their hands thoroughly after defecation and before handling food. Also, instruct the patient to avoid raw eggs or foods prepared with raw eggs, to cook meat and poultry thoroughly, to refrigerate food below 46°F, and to wash hands after handling animals.

Evidence-Based Practice and Health Policy

Ziehm, D., Dreesman, J., Campe, A., Kreienbrock, L., & Pulz, M. (2013). Risk factors associated with sporadic salmonellosis in adults: A case-control study. Epidemiology and Infection, 141(2), 284–292.

Results of a study comparing 1,017 cases of Salmonella infections to 176 control participants revealed a 2.38 times increased odds that raw ground pork was consumed (95% CI, 1.27 to 4.44), a 3.96 times increased odds that a recent meal was consumed outdoors or at a barbecue (95% CI, 1.41 to 11.12), and a 2.42 times increased odds that gastric acidity inhibitors were used regularly among patients who experienced a Salmonella infection (95% CI, 1.19 to 4.92).
Consumption of raw ground pork was reported by 13.4% of case patients compared to 6.8% of control participants, and eating outdoors or at a barbecue was reported by 9% of case patients compared to 2.3% of control participants. Gastric acidity inhibitor use was reported by 11.8% of case patients compared to 5.1% of control participants.

Documentation guidelines

Physical findings: Vital signs; dehydration; intake of food and fluids; tolerance of food, including instances of vomiting; output; and diarrhea or constipation with description of stool
Notification of the local health authority
Response to treatment: Changes in symptoms, increased comfort, and decrease in body temperature

Discharge and home healthcare guidelines

Instruct the patient and family about the cause, transmission, and symptoms of the disease and preventive measures. Teach the family how to care for the patient at home. Treat mild fever with antipyretics and maintain a good fluid intake. Ice pops and soda may increase fluid intake for young children. Avoid the use of laxatives. Gradually increase the patient’s activity level as tolerated. Explain the need to report complications of bleeding, dehydration, or the return of symptoms to the physician at once. Be sure the patient understands any medications prescribed, including dosage, route, action, and side effects. Stress the importance of completing the antibiotic regimen even after symptoms diminish.