Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:21

1318 Salmonella Infections Other Than Gastroenteritis

positive; localized infection diagnosed by culturing abscess or tis-

sue of involved organ system

differential diagnosis

■In patients with history of foreign travel, enteric fever may be con-

fused with malaria, yellow fever, dengue and amebiasis; other sys-

temic illnesses such as endocarditis, hepatitis, viral infections may

be confused with enteric fever and bacteremia.

management

■Assess possibility of food-borne outbreak and notify public health

officials as indicated.

■Hospitalized patients should be placed on routine barrier precau-

tions if stools positive.

specific therapy

■Gastroenteritis not treated unless associated with bacteremia

■Increasing resistance ofSalmonellato ampicillin and trimethoprim-

sulfamethoxazole limits the use of these drugs until sensitivities

known; empirical therapy with a fluoroquinolone (ciprofloxacin) or

a third-generation cephalosporin (ceftriaxone) indicated

■Enteric fever and bacteremia secondary to gastroenteritis treated for

14 days; endovascular infections (endocarditis, infected aneurysm)

and osteomyelitis treated for 6 weeks; amoxicillin, trimethoprim-

sulfamethoxazole or ciprofloxacin for 4–6 weeks is 80% effective in

eradicating the carrier state; in the presence of biliary stones, chole-

cystectomy in addition to antibiotics often needed to eradicate car-

rier state

follow-up

■Clinical improvement seen within several days of antibiotic therapy

complications and prognosis

■Gastrointestinal hemorrhage most common complication of un-

treated enteric fever; relapses occur in 10–15%

■Mortality rate <5% in treated cases; higher in elderly and immuno-

compromised

■Vaccination with an inactivated preparation given parenterally or

a live attenuated preparation given orally is available for travelers

to high risk areas; efficacy 50–75%; booster doses needed every 2–5

years depending on the preparation used; live attenuated vaccine

should not be used in the immunosuppressed

■Chronic carriers should not be employed as food handlers.