13.2.30 Salmonella, Shigella, and Escherichia coli Infections - Andrew T.

Pavia
Rudolph's Pediatrics, Twenty-First Edition Copyright 2002 by The McGraw-Hill INTRODUCTION The family Enterobacteriaceae is a large, heterogeneous group of gram-negative bacteria. Many are normal inhabitants of the GI tract of humans and other animals, but members also frequently cause disease in human beings. Among the Enterobacteriaceae, Salmonella, Shigella, Yersinia, and a number of specific phenotypes of Escherichia coli are important causes of gastroenteritis. In addition to diarrhea, these organisms cause a variety of extraintestinal infections. Each genera includes a heterogenous group of organisms that vary in their epidemiology and clinical characteristics. Enterobacteriaceae possess three major antigenic groups that react with antisera: (a) the O or somatic antigens; (b) the H or flagellar antigens; and (c) the K or capsular antigens. Serotyping has historically been an important means of subtyping these enteric pathogens; this technique is being partially superseded by our increasing ability to identify genotypic and phenotypic markers of virulence. This chapter discusses Salmonella, Shigella, and the diarrheacausing E. coli; Yersinia is discussed in Sec. 13.2.37. SALMONELLA Salmonella are gram-negative, aerobic, nonlactose-fermenting, nonsporulating, flagellated bacilli. Most Salmonella organisms have a single, strongly agglutinating somatic antigen (the major determinant), plus one or more less-strongly reacting minor somatic antigens. Serotyping is performed by State Health Department laboratories after initial isolation of the organism. It is an extraordinarily useful tool for epidemiologic purposes. The nomenclature of Salmonella has been simplified recently. A serotype is now designated S. enterica serotype typhimurium or S. enterica enteritidis, often simplified to S. enteritidis. Because several serotypes represent the majority of isolates, additional epidemiologic subtyping can be useful. Plasmid profile analysis, bacteriophage typing, restriction endonuclease analysis, ribotyping, pulsed-field gel electrophoresis, and antimicrobial susceptibility have all been used as epidemiologic tools. Identification of Salmonella from normally sterile sites such as blood, cerebrospinal fluid (CSF), and joint fluid does not require special media. However, selective media are necessary to identify Salmonella in stool, because of the vast number of other bacteria. Media range from low to high selectivity: MacConkey, deoxycholate agar, and eosin-methylene blue (EMB) agar are low-selectivity media; Salmonella-Shigella (SS), Hektoen enteric (HE), and xylose-lysine-deoxycholate-citrate (XLD) agar are widely used media of medium selectivity; and bismuth sulfite agar is highly selective. Stool specimens

that are placed in enrichment broth prior to plating on agar media will have an increase in the yield of organisms. EPIDEMIOLOGY Reptiles, birds, poultry, cattle, and pigs serve as the major reservoirs for nontyphoidal Salmonella. In contrast, human beings are the only reservoir for S. typhi. The primary animal reservoir varies by serotype, and can serve as a clue to the source of contamination. For example, S. hadar and S. heidelberg are primarily associated with chickens; S. enteritidis with eggs; S. choleraesuis with pigs; and S. marinum and S. urbana with reptiles. In the United States the highest incidence of nontyphoid Salmonella infection is in the first year of life, peaking in the second month at 180 cases/100,000 population per year. Thereafter, rates of isolation decline rapidly by age 5 years and remain constant throughout adulthood. Salmonella infections show a seasonal pattern, with a consistent peak in the summer and fall. Salmonella typhi infection in the United States is uncommon (approximately 400 patients per year) and rarely occurs in children less than 1 year of age. However, typhoid fever remains an important problem in many developing countries. In the United States, two-thirds of S. typhi infections are related to foreign travel. Salmonella infections are acquired through ingesting the organism, most often from food, but waterborne, person-to-person and animal-to-person transmission can occur. The majority of cases are sporadic; recognized outbreaks account for a minority of cases, but provide insight into the epidemiology. Explosive or prolonged common source outbreaks have occurred as a consequence of contaminated milk, cheese, shell eggs, ice cream, and roast beef. Since the mid-1980s, low-level contamination of the yolks of intact shell eggs with S. enteritidis has been an increasing problem. Recently, iguanas and other pet reptiles have emerged as an important source of infection for young children. Sentinel county surveillance demonstrates that Salmonella are becoming increasingly resistant to ampicillin, chloramphenicol, streptomycin, tetracycline, kanamycin, and gentamicin. Some of these agents are rarely used in human disease, but are routinely added to animal feed as growth promoters. Substantial evidence points to antibiotic use in animal husbandry as a major source of antibiotic resistance in human isolates. The dose necessary to cause clinical infection is estimated to be 105 to 1010 organisms, based on volunteer studies in adults. However, the number of organisms necessary to cause illness is substantially lower in other situations, including more virulent organisms, low gastric acidity, prior use of antibiotics, infants, the elderly, and defective cell-mediated immunity. Because of the relatively large number of organisms necessary to produce disease, water and person-to-person spread are less frequent sources of infection than food, which can support multiplication of the organism. Contaminated water may play a larger role in typhoid fever. Spread of Salmonella in childcare centers is unusual. Following infection, nontyphoid Salmonella are excreted in feces for a median of 5 weeks. Excretion is

more prolonged in children less than 5 years of age and for people who have had symptomatic infections. In children younger than 5 years of age, 2.6% continue to excrete nontyphoid Salmonella beyond 1 year, compared to fewer than 1% of patients over 5 years and older. The rate of carriage after infection is higher still in very young infants. Two to 4% of adults infected with S. typhi become chronic carriers, often excreting the organism for the remainder of their lives. Long-standing infection of the gall bladder plays a role in chronic carriage. Despite the large number of chronic excretors of nontyphoid Salmonella, carriers are rarely implicated in outbreaks or sporadic disease. In contrast, chronic carriers play a pivotal role in typhoid fever. The source of Salmonella is less-well understood in salmonellosis among infants. Chronic or transient asymptomatic carriage by the mother and cross-contamination during food preparation are probably important. Nursery outbreaks of salmonellosis occur. Spread of disease has been documented by contaminated medical devices such as rectal thermometers, suction equipment, and baths, but the hands of caregivers may play an important role. PATHOGENESIS The incubation period for gastroenteritis is 6 to 72 hours (mean 36 hours); for enteric fever it is 7 to 21 days (usually 7-14 days). The incubation period is affected by the inoculum size. There are several distinctive steps in Salmonella infection. Upon reaching the small intestine, the bacteria must attach to the epithelium. Chromosomally encoded long, polar fimbriae; thin, aggregative fimbriae; and plasmid-encoded fimbriae are important in this process. Deletion mutations in these genes decrease virulence after oral inoculation but not after intraperitoneal infection. Salmonella invade M cells (mucosal antigen-presenting immune cells) and nonphagocytic epithelial cells. Within macrophages, they may not only survive but multiply. The ability of strains to survive and reproduce in macrophages is correlated with virulence in animal models. The organism directs its own endocytosis through a complex mechanism encoded in a "pathogenicity island," a large collection of contiguous virulence genes. Interestingly, a key component of invasion is a type 3 secretion system, which is similar to systems mediating the invasiveness of Yersinia and enteropathic and enterohemorrhagic E. coli. A second pathogenicity island has been identified in some serotypes. Diarrhea is probably induced by local inflammation, induction of inflammatory mediators, and in some strains, by one or more enterotoxins or cytotoxins. When examined histologically, the organism is prominent in Peyer's patches. In some cases of nontyphoid salmonellosis, and in all cases of typhoid, the organisms reach the regional lymphatics. Bacteremia may result. There are several important barriers to infection. The organism must survive gastric acid, which can rapidly kill Salmonella. Reduced gastric acidity as a result of extremes of age, medications, surgery, or H. pylori infection, and foods that buffer gastric acid, increases the number of organisms that reach the small intestine. Normal intestinal flora are an important barrier. Prior treatment with antibiotics, particularly those that disrupt the predominant intestinal flora, increases the risk of infection with both antibiotic-resistant and antibiotic-sensitive strains. This has been demonstrated experimentally and in outbreak investigations. The third and most complex barrier is the host immune system. Cell-mediated immunity appears to be the primary immunologic defense against Salmonella infections. Susceptibility appears to be highest in the first few months of life, reflecting the developing immune system. Children with HIV infection, transplant recipients and others on immunosuppressive agents, and children with

advanced malignancies are at increased risk. Reticuloendothelial dysfunction is also associated with increased risk of Salmonella infection, including sickle cell disease, hemolytic anemias, and malaria. The available evidence suggests that humoral immunity is less important. Bacteremia and mesenteric adenitis are the rule with S. typhi, and much less common with other nontyphoid Salmonella. However, the rate of bacteremia and extraintestinal infection varies by serotype, reflecting distinct but incompletely understood differences in virulence. CLINICAL MANIFESTATIONS The range of clinical manifestations of Salmonella infection includes asymptomatic infection, gastroenteritis, bacteremia, focal infection, urinary tract infection, and enteric fever. These symptom complexes may overlap. GastroenteritisDiarrhea is the most common manifestation of salmonellosis. The diarrhea may be profuse and watery, reflecting predominant small-bowel involvement, or may involve smaller volume stools associated with mucous and fecal leukocytes, reflecting colonic involvement. Bloody diarrhea occurs in approximately 25% of cases. Fever, when present, tends to be highest within the initial day of onset. Headache, chills, anorexia, nausea, vomiting, and malaise may be present. Symptoms usually last 2 to 5 days, although diarrhea may be prolonged. The most common complication of Salmonella gastroenteritis is dehydration and metabolic acidosis, occasionally progressing to hypovolemic shock. Infected children also may have concurrent bacteremia, may develop prolonged secretory diarrhea, or may manifest failure to thrive after acute infection. BacteremiaBacteremia may occur during acute Salmonella gastroenteritis. Factors that increase the risk include age, underlying systemic illness, hemoglobinopathy, immunosuppression, and serotype of the infecting organism. In children with uncomplicated gastroenteritis, "silent" bacteremia occurs in 5 to 10%. The risk of bacteremia is markedly increased in infants less than 3 months of age, most likely because of the immaturity of their cell-mediated immune response. Other conditions associated with increased risk of bacteremia include malnutrition; hemolytic anemias, especially sickle-cell anemia; collagen vascular disease; schistosomiasis; bartonellosis; hematogenous or gastrointestinal tract malignancy; diabetes mellitus; previous therapy with antimicrobial agents; corticosteroids; and HIV infection. Salmonella bacteremia is common among adults and children with AIDS. Frequently, Salmonella bacteremia in AIDS patients presents with fever and a paucity of gastrointestinal symptoms. The illness is often prolonged, and relapses after therapy are common. After relapse, lifetime secondary prophylaxis may be necessary. Patients with Salmonella bacteremia during acute gastroenteritis cannot be readily recognized by clinical examination. Although fever usually is present and the patient appears acutely toxic, these signs may be indistinguishable from those of acute gastroenteritis without bacteremia. Focal InfectionFocal suppurative infections occur in about 10% of patients with bacteremia. Salmonella

bacteremia can result in suppurative complication of almost any organ or tissue. Infection can result in pneumonia; empyema; pyelonephritis; abscesses of brain, liver, spleen, muscle, or other soft tissue; or endovascular infection. Endocarditis most often involves abnormal or prosthetic valves, but infection of normal valves can occur. Endovascular infections can also involve arteriovenous fistulas, preexisting aneurysms (classically atherosclerotic aneurysms), or endarteritis. Salmonella choleraesuis has a propensity for causing endovascular infections. Osteomyelitis caused by Salmonella tends to occur in injured or infarcted bone. This probably explains the predisposition of children with hemoglobinopathies, especially sickle-cell disease, to develop this complication. Meningitis is rare, occurring most often in neonates or young infants and in AIDS patients. Mortality is high, even since the advent of third-generation cephalosporins. Enteric FeverThe prototypic enteric fever is typhoid fever caused by S. typhi, although clinically indistinguishable enteric fever has been reported with infections by S. paratyphi A, S. schottmuelleri, S. hirschfeldii, and S. choleraesuis and less commonly by other serotypes. The enteric fever caused by nontyphoid Salmonella is called paratyphoid fever, and generally has less morbidity than typhoid, in that the duration of fever is briefer, patients do not appear to be as ill, and complications and relapses occur less frequently. An average of 245 S. typhi isolates are reported yearly to the CDC. Three quarters of patients report international travel within the 30 days before onset of illness. The onset of enteric fever is insidious in contrast to bacteremia due to other gram-negative bacteria. The number of bacteria ingested influence attack rate and the length of the incubation period. The initial signs of infection are malaise, anorexia, headache, myalgias, and fever. The fever begins insidiously, is hectic, and gradually rises over the initial week to as high as 40C (104F). A relative bradycardia disproportionate to the temperature elevation is characteristic. Although diarrhea may be present during the initial stages, constipation becomes a more prominent symptom as the illness progresses. Hepatomegaly and splenomegaly, often with diffuse abdominal tenderness, are common. The abdomen may be mildly tender; but marked distension, dilated loops, or significant tenderness may indicate ileus. Leukopenia is not uncommon. Rose spots occur in a small proportion of patients toward the second week. They are discrete (2-4 mm), palpable, erythematous lesions on the trunk. Biopsy of a rose spot reveals nests of mononuclear cells and usually yields S. typhi. However, rose spots are often sparse, transient, and difficult to spot on darkskinned children. The natural course of illness is persistence of fever for 2 to 3 weeks, with slow recovery. Signs and symptoms of a chronic inflammatory process are often apparent by this time. Complications are common. Most fatalities are the result of intestinal hemorrhage or perforation, resulting from necrosis of infected Peyer's patches. The overall mortality is 3 to 6% with treatment. Predictors of mortality include intestinal perforation, seizures, septic shock, pneumonia, delirium, and coma. Late focal infections, such as meningitis, endocarditis, osteomyelitis, and pneumonia, are rare. Relapse, a recurrence of the manifestations of typhoid fever after initial clinical response, occurred in 8 to 12% of patients who did not receive antimicrobial therapy, but may be higher in the antibiotic era. Of patients with typhoid fever, 2 to 5% become chronic carriers. The risk of becoming a chronic carrier

increases with increasing age and with the presence of gall bladder disease. Children younger than 2 years of age often have mild illness, often resembling a mild, nonspecific febrile illness. Classic typhoid fever can occur in this age group, although it is the exception. DIAGNOSIS Salmonella should always be considered in a child with gastroenteritis. More severe disease; fever; headache; evidence of dysentery; immune deficiency; recent immigration from endemic areas; exposure to reptiles; undercooked meat or eggs; or an ongoing common source outbreak should increase suspicion. The diagnosis is made by stool culture. If fresh stool cannot be obtained, a rectal swab can be cultured. The yield is higher from fresh stool, and the use of enrichment broths in the microbiology lab also improves sensitivity. Blood cultures are negative in the majority of children with Salmonella gastroenteritis, and agglutination tests are of no value in diagnosis. Gastroenteritis with fever, especially in a child under 2 years old, is usually an indication for obtaining a blood culture. CSF cultures should be obtained when the diagnosis is suspected in infants less than 3 months of age, even in the absence of elevated temperature, because of the increased risk in this age group. For suspected enteric fever, serial blood cultures should be obtained. Because the concentration of organisms is low, the yield is increased by culturing larger volumes of blood and up to three specimens. In untreated patients with typhoid fever, three blood cultures during the first week have approximately a 90% yield. The yield decreases over time with a concomitant increase in positive stool cultures. Bonemarrow culture is the most sensitive procedure for recovery of S. typhi. Culture of bile obtained by a swallowed capsule (string test) is also sensitive, but not as sensitive as the combination of blood and bone marrow cultures. The Widal test is problematic. It measures the titer of agglutinating serum antibodies against the O and H antigens of S. typhi. In untreated disease, only one-half to two-thirds of patients have a four-fold or greater increase in titer of agglutinins against typhoid O antigen. Antimicrobial therapy interferes with immunologic response. Moreover, the Widal test is not specific. In endemic areas, antibody may represent past infection, and there is cross-reactivity with antibody from nontyphoid Salmonella infections. In the future, PCR may increase the sensitivity and turnaround time for detection of bacteremia. Stool antigen assays are potentially attractive, but have yet to prove useful. TREATMENT The type of illness caused by Salmonella directs the selection and duration of antimicrobial therapy. Uncomplicated Salmonella gastroenteritis requires no antimicrobial therapy; antibiotics do not shorten the clinical illness, as demonstrated in carefully conducted trials. In addition, antimicrobials may select for resistant strains and prolong Salmonella carriage. Antimicrobial therapy should be given to patients with enteric fever, bacteremia from nontyphoid strains, and disseminated infection with localized suppuration. Antimicrobial therapy also should be considered in infants younger than 3 to 6 months, and in patients with enterocolitis who have HIV disease or other underlying conditions that impair host resistance.

Ampicillin, chloramphenicol, and trimethoprim-sulfasoxazole (TMP-SMX) have in vitro activity and historically have been successful in treating patients with nontyphoid Salmonella infections (Table 1341). Resistance to these agents has increased in recent years. A highly drug-resistant clone, Salmonella typhimurium DT (definitive type) 104, has spread explosively in the United States and Europe. Therefore, all isolates should be tested for susceptibility. Cefotaxime is useful for ampicillin-resistant strains and is the drug of choice for Salmonella meningitis. Therapy for uncomplicated bacteremia is usually given for 10 to 14 days; at least 7 days of therapy should be intravenous. Meningitis should be treated for at least 3 weeks. Fluoroquinolones have been very effective in the treatment of adults. Because fluoroquinolones are not approved for use in patients less than 17 years of age, they should be considered only as alternative agents when ampicillin, third-generation cephalosporins, and TMP-SMX cannot be used. Ampicillin, amoxicillin, and TMP-SMX are effective therapy for typhoid fever caused by susceptible Salmonella. Although therapy with chloramphenicol is associated with a more rapid sterilization of blood, the rate of recurrence is somewhat higher. Multidrug-resistant S. typhi is a rapidly emerging problem worldwide. Ampicillin, chloramphenicol, and TMP-SMX may no longer be reasonable choices for empiric therapy, before susceptibility tests are available. Antimicrobial agents that have been used successfully in the treatment of resistant Salmonella typhi strains are cefotaxime, ceftriaxone, cefixime, aztreonam, ofloxacin, and ciprofloxacin. These might be predicted to work for bacteremia with resistant nontyphoid Salmonella as well. Short courses of oral cefixime demonstrate acceptable success rates, but the time to clinical improvement is slower than with ceftriaxone or fluoroquinolones. Survival of patients with delirium, stupor, or coma associated with typhoid fever is improved by brief, high-dose corticosteroid therapy administered concurrently with antibiotics. Dexamethasone has been used at an initial dose of 3 mg/kg followed by eight doses of 1 mg/kg every 6 hours. Aggressive surgical intervention, together with broad-spectrum antibiotics (including anti-Salmonella therapy), has improved survival in typhoid fever complicated by intestinal perforation with peritonitis. The chronic asymptomatic carriage of S. typhi can be extremely difficult to eradicate, especially if there is obstructive hepatobiliary disease such as gallstones. Success has been achieved with a combination of 6 weeks of ampicillin or amoxicillin with probenecid in patients who have normally functioning gallbladders without evidence of cholelithiasis. In adults, ciprofloxacin has been reasonably successful in eradicating the organism in chronic carriers. Cholecystectomy is recommended for carriers who have relapsed after therapy or who cannot tolerate antimicrobial therapy. Patients who excrete nontyphoid Salmonella usually do not need antimicrobial therapy. One trial of 14 days of ciprofloxacin showed disappointing results in house officers and nurses with prolonged shedding of S. enteritidis after a hospital outbreak. The mortality of Salmonella infections ranges from 0.5 to 1.4%. Most deaths are associated with bacteremia, sepsis, or meningitis. Malnutrition, extremes of age, and underlying disease strongly influence mortality. The fatality rate for typhoid fever is less than 2% for industrialized nations, but

approaches 35% for developing countries. Coma, shock, or abdominal perforation are predictors of mortality. PREVENTION Improvements in sanitation, waste disposal, and safe drinking water led to a dramatic decrease in Salmonella typhi infections, but has had little impact on the control of nontyphoid Salmonella. Prevention of nontyphoid Salmonella involves many fronts. The amount of Salmonella, particularly antimicrobial-resistant Salmonella, reaching the consumer depends on practices in agriculture. Three vaccines against typhoid fever are available for civilian use in the United States: a parenteral heatphenol-inactivated vaccine; an orally administered, live-attenuated oral vaccine prepared from the Ty21a strain of S. typhi; and an injectable vaccine made from purified Vi polysaccharide. The vaccines are of roughly equal efficacy, although a published meta-analysis concluded that the efficacy of the heat-phenol-inactivated vaccine was slightly higher. However, the oral vaccine and the Vi polysaccharide cause significantly fewer side effects and are preferred. The oral Ty21a vaccine is licensed for children 6 years and older, although it is immunogenic in children 2 years and older. It requires four oral doses and must be repeated every 5 years. The Vi polysaccharide vaccine is licensed for children older than 2 years. It requires a single injection, but must be repeated every 2 years. Vaccination against typhoid fever is recommended for persons with intimate contact with a known carrier, for microbiologists, and for travelers staying in endemic areas for prolonged periods or if safe food and water cannot be assured.