|Electron micrograph showing Salmonella typhimurium (red) invading cultured human cells|
|Symptoms||Diarrhea, fever, abdominal cramps, vomiting|
|Complications||Reactive arthritis, irritable bowel syndrome|
|Usual onset||0.5–3 days post exposure|
|Risk factors||Old, young, weak immune system, bottle feeding, proton pump inhibitors|
|Diagnostic method||Stool test|
|Similar conditions||Other types of gastroenteritis|
|Prevention||Proper preparation and cooking of food|
|Treatment||Fluids by mouth, intravenous fluids, antibiotics|
|Frequency||1.2 million non–typhoidal cases per year (US)|
Salmonellosis is a symptomatic infection caused by bacteria of the Salmonella type. The most common symptoms are diarrhea, fever, abdominal cramps, and vomiting. This typically occurs between 12 hours and 72 hours after exposure with symptoms lasting four to seven days. Occasionally more significant disease can result in dehydration. The old, young, and others with a weak immune systems are more likely to develop severe disease. Specific types of Salmonella can result in typhoid fever or paratyphoid fever.
There are two species of Salmonella: Salmonella bongori and Salmonella enterica with many subtypes. Infection is usually spread via contaminated meat, eggs, or milk. Other foods may spread the disease if they have come into contact with manure. A number of pets may also carry the infection and spread the infection including, cats, dogs, and reptiles. Diagnosis is by a stool test.
Efforts to prevent the disease include proper preparation and cooking of food. Mild disease typically does not require specific treatment. More significant cases may need the treatment of electrolyte problems and the replacement of fluids by intravenous. In those at high risk or in whom the disease has spread outside the intestines, antibiotics are recommended.
Salmonellosis is one of the most common causes of diarrhea globally. In 2015, 90,300 deaths occurred from non-typhoidal and 178,000 deaths from typhoidal salmonellosis. In the United States about 1.2 million cases and 450 deaths occur from non–typhoidal salmonellosis a year. In Europe it is the second most common foodborne disease after campylobacteriosis.
Signs and symptoms
After a short incubation period of a few hours to one day, the bacteria multiply in the intestinal lumen, causing an intestinal inflammation. Most people with salmonellosis develop diarrhea, fever, vomiting, and abdominal cramps 12 to 72 hours after infection. Diarrhea is often mucopurulent (containing mucus or pus) and bloody. In most cases, the illness lasts four to seven days, and most people recover without treatment. In some cases, though, the diarrhea may be so severe that the patient becomes dangerously dehydrated and must be taken to a hospital. At the hospital, the patient may receive intravenous fluids to treat the dehydration, and may be given medications to provide symptomatic relief, such as fever reduction. In severe cases, the Salmonella infection may spread from the intestines to the blood stream, and then to other body sites, and can cause death, unless the person is treated promptly with antibiotics.
In otherwise healthy adults, the symptoms can be mild. Normally, no sepsis occurs, but it can occur exceptionally as a complication in the immunocompromised. However, in people at risk such as infants, small children, and the elderly, Salmonella infections can become very serious, leading to complications. In infants, dehydration can cause a state of severe toxicity. Extraintestinal localizations are possible, especially Salmonella meningitis in children, osteitis, etc. Children with sickle-cell anemia who are infected with Salmonella may develop osteomyelitis. Treatment of osteomyelitis, in this case, will be to use fluoroquinolones (ciprofloxacin, levofloxacin, etc., and nalidixic acid).
Those whose only symptom is diarrhea usually completely recover, but their bowel habits may not return to normal for several months.
Typhoid fever occurs when Salmonella bacteria enter the lymphatic system and cause a systemic form of salmonellosis. Endotoxins first act on the vascular and nervous apparatus, resulting in increased permeability and decreased tone of the vessels, upset thermal regulation, vomiting, and diarrhea. In severe forms of the disease, enough liquid and electrolytes are lost to upset the water-salt metabolism, decrease the circulating blood volume and arterial pressure, and cause hypovolemic shock. Septic shock may also develop. Shock of mixed character (with signs of both hypovolemic and septic shock) are more common in severe salmonellosis. Oliguria and azotemia develop in severe cases as a result of renal involvement due to hypoxia and toxemia.
A small number of people afflicted with salmonellosis experience reactive arthritis, which can last months or years and can lead to chronic arthritis. In sickle-cell anemia, osteomyelitis due to Salmonella infection is much more common than in the general population. Though Salmonella infection is frequently the cause of osteomyelitis in sickle-cell anemia patients, it is not the most common cause, which remains to be Staphylococcus infection.
Those infected may become asymptomatic carriers, but it is relatively uncommon, with shedding observed in only 0.2 to 0.6% of cases after a year.
- Contaminated food, often having no unusual look or smell
- Poor kitchen hygiene, especially problematic in institutional kitchens and restaurants because this can lead to a significant outbreak
- Excretions from either sick or infected but apparently clinically healthy people and animals (especially dangerous are caregivers and animals)
- Polluted surface water and standing water (such as in shower hoses or unused water dispensers)
- Unhygienically thawed poultry (the meltwater contains many bacteria)
- An association with reptiles (pet tortoises, snakes, iguanas, and aquatic turtles) is well described.
- Amphibians such as frogs
Salmonella bacteria can survive for some time without a host; thus, they are frequently found in polluted water, with contamination from the excrement of carrier animals being particularly important.
An estimated 142,000 Americans are infected each year with Salmonella Enteritidis from chicken eggs, and about 30 die. The shell of the egg may be contaminated with Salmonella by feces or environment, or its interior (yolk) may be contaminated by penetration of the bacteria through the porous shell or from a hen whose infected ovaries contaminate the egg during egg formation.
Nevertheless, such interior egg yolk contamination is theoretically unlikely. Even under natural conditions, the rate of infection was very small (0.6% in a study of naturally contaminated eggs and 3.0% among artificially and heavily infected hens).
The FDA has published guidelines to help reduce the chance of food-borne salmonellosis. Food must be cooked to 68–72 °C (145–160 °F), and liquids such as soups or gravies must be boiled. Freezing kills some Salmonella, but it is not sufficient to reliably reduce them below infectious levels. While Salmonella is usually heat-sensitive, it does acquire heat resistance in high-fat environments such as peanut butter.
Antibodies against nontyphoidal Salmonella were first found in Malawi children in research published in 2008. The Malawian researchers have identified an antibody that protects children against bacterial infections of the blood caused by nontyphoidal Salmonella. A study at Queen Elizabeth Hospital in Blantyre found that children up to two years old develop antibodies that aid in killing the bacteria. This could lead to a possible Salmonella vaccine for humans.
A recent study has tested a vaccine on chickens which offered efficient protection against salmonellosis.
Vaccination of chickens against Salmonella essentially wiped out the disease in the United Kingdom. A similar approach has been considered in the United States, but the Food and Drug Administration decided not to mandate vaccination of hens.
Since 2011, Denmark has had zero cases of human salmonella poisoning. The country eradicated salmonella without vaccines and antibiotics by focusing on eliminating the infection from "breeder stocks", implementing various measures to prevent infection, and taking a zero-tolerance policy towards salmonella in chickens.
Electrolytes may be replenished with oral rehydration supplements (typically containing salts sodium chloride and potassium chloride).
Appropriate antibiotics, such as ceftriaxone, may be given to kill the bacteria but are not necessary in most cases. Azithromycin has been suggested to be better at treating typhoid in resistant populations than both fluoroquinolone drugs and ceftriaxone. Antibiotic resistance rates are increasing throughout the world, so health care providers should check current recommendations before choosing an antibiotic.
In 2010, an analysis of death certificates in the United States identified a total of 1,316 Salmonella-related deaths from 1990 to 2006. These were predominantly among older adults and those who were immunocompromised. The U.S. government reported as many as 20% of all chickens were contaminated with Salmonella in the late 1990s, and 16.3% were contaminated in 2005.
The United States has struggled to control salmonella infections, with the rate of infection rising from 2001 to 2011. In 1998, the USDA moved to close plants if salmonella was found in excess of 20 percent, which was the industry’s average at the time, for three consecutive tests. Texas-based Supreme Beef Processors, Inc. sued on the argument that Salmonella is naturally occurring and ultimately prevailed when a federal appeals court affirmed a lower court. These issues were highlighted in a proposed Kevin's Law (formally proposed as the Meat and Poultry Pathogen Reduction and Enforcement Act of 2003), of which components were included the Food Safety Modernization Act passed in 2011, but that law applies only to the FDA and not the USDA. The USDA proposed a regulatory initiative in 2011 to Office of Management and Budget.
Since July 2012, an outbreak of salmonellosis occurred in Northern Europe caused by Salmonella thompson. The infections were linked to smoked salmon from the manufacturer Foppen, where the contamination had occurred. Most infections were reported in the Netherlands, over 1060 infections with this subspecies have been confirmed, as well as four mortalities.
A case of widespread infection was detected mid-2012 in seven EU countries. Over 400 people had been infected with Salmonella enterica serovar Stanley (S. Stanley) that usually appears in the regions of Southeast Asia. After several DNA analyses seemed to point to a specific Belgian strain, the "Joint ECDC/E FSA Rapid Risk Assessment" report detected turkey production as the source of infection.
In Germany, food poisoning infections must be reported. Between 1990 and 2005, the number of officially recorded cases decreased from about 200,000 to about 50,000 cases.
In March 2007, around 150 people were diagnosed with salmonellosis after eating tainted food at a governor's reception in Krasnoyarsk, Russia. Over 1,500 people attended the ball on March 1 and fell ill as a consequence of ingesting Salmonella-tainted sandwiches.
About 150 people were sickened by Salmonella-tainted chocolate cake produced by a major bakery chain in Singapore in December 2007.
Both salmonellosis and the Salmonella genus of microorganisms derive their names from a modern Latin coining after Daniel E. Salmon (1850–1914), an American veterinary surgeon. He had help from Theobald Smith, and together they found the bacterium in pigs.
The "Four-inch regulation" or "Four-inch law" is a colloquial name for a regulation issued by the U.S. FDA in 1975, restricting the sale of turtles with a carapace length less than four inches (10 cm).
The regulation was introduced, according to the FDA, "because of the public health impact of turtle-associated salmonellosis". Cases had been reported of young children placing small turtles in their mouths, which led to the size-based restriction.
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Among them is a final rule, issued by the FDA, to reduce the contamination in eggs. About 142,000 Americans are infected each year with Salmonella enteritidis from eggs, the result of an infected hen passing along the bacterium. About 30 die.
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Eggs can be contaminated on the outer shell surface and internally. Internal contamination can be the result of penetration through the eggshell or by direct contamination of egg contents before oviposition, originating from infection of the reproductive organs. Once inside the egg, the bacteria need to cope with antimicrobial factors in the albumen and vitelline membrane before migration to the yolk can occur
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Normally, the oviduct of the hen is sterile and therefore the shell and internal contents of the egg are also free of microorganisms (10,16). In some instances, however, the ovaries and oviduct may be infected with Salmonella and these may be deposited inside the egg (12). More frequently, however, the egg becomes contaminated after it is laid.
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when hens were artificially infected to test for transmission rate to yolks: "Mature laying hens were inoculated intravenously with 106 colony-forming units of Salmonella enteritidis, Salmonella typhimurium, Salmonella infantis, Salmonella hadar, Salmonella heidelberg, or Salmonella montevideo to cause the systemic infection. Salmonella Enteritidis was recovered from three yolks of the laid eggs (7.0%), suggesting egg contamination from the transovarian transmission of S. enteritidis."
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The migration of the bacterium into the nutritionally rich yolk is constrained by the lysozyme loaded vitelline membrane, and would need warm enough storage conditions within days and weeks. The high concentration on of antibodies of the yolk does not inhibit the Salmonella multiplication. Only seldom does transovarian contamination of the developing eggs with S. enteritidis make this bacterium occur in laid eggs, because of the bactericidal efficacy of the antimicrobial peptides
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when hens are artificially infected with unrealistically large doses (according to the author): In the present study, groups of laying hens were experimentally infected with large oral doses of Salmonella Heidelberg, Salmonella Enteritidis phage type 13a, or Salmonella Enteritidis phage type 14b. For all of these isolates, the overall frequency of ovarian colonization (34.0%) was significantly higher than the frequency of recovery from either the upper (22.9%) or lower (18.1%) regions of the oviduct. No significant differences were observed between the frequencies of Salmonella isolation from egg yolk and albumen (4.0% and 3.3%, respectively).
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