Non-typhoidal Salmonellosis, is one of the most common and widely distributed foodborne diseases, with tens of millions of human cases occurring worldwide every year. In the United States, the incidence of NTS infection has doubled in the past 2 decades. In 2009 there were 14 million cases of NTS.

1. Non-TyphoidalNon-Typhoidal
SalmonellosisSalmonellosis
Infectious Diseases, AIDS & ClinicalInfectious Diseases, AIDS & Clinical
Immunology Research Center TbilisiImmunology Research Center Tbilisi

2.  Non-typhoidal Salmonellosis, is one of the most
common and widely distributed foodborne
diseases, with tens of millions of human cases
occurring worldwide every year.
 In the United States, the incidence of NTSIn the United States, the incidence of NTS
infection has doubled in the past 2 decades.infection has doubled in the past 2 decades.
 In 2009 there were 14 million cases of NTS.In 2009 there were 14 million cases of NTS.

3. EtiologyEtiology
 Salmonellae are gram negative, non-sporeSalmonellae are gram negative, non-spore
forming, facultatively anaerobic bacilli.forming, facultatively anaerobic bacilli.
 Most commonly non-typhoidal salmonellosisMost commonly non-typhoidal salmonellosis
caused bycaused by S. typhimuriumS. typhimurium oror S. enteritidis.S. enteritidis.
 SalmonellaSalmonella was first discovered in 1884 bywas first discovered in 1884 by
Dr. DE Salmon.Dr. DE Salmon.

4. EpidemiologyEpidemiology
 The incidence of nontyphoidal salmonellosisThe incidence of nontyphoidal salmonellosis
(NTS) is highest during the rainy season in(NTS) is highest during the rainy season in
tropical climates and during the warmertropical climates and during the warmer
months in temperate climates, coinciding withmonths in temperate climates, coinciding with
the peak in food-borne outbreaks.the peak in food-borne outbreaks.
 Rates of morbidity and mortality associatedRates of morbidity and mortality associated
with NTS are highest among the elderly,with NTS are highest among the elderly,
infants, and immunocompromised individuals.infants, and immunocompromised individuals.

5. EpidemiologyEpidemiology
 Unlike S. typhi and S. paratyphi, whose onlyUnlike S. typhi and S. paratyphi, whose only
reservoir is humans, NTS can be acquiredreservoir is humans, NTS can be acquired
from multiple animal reservoirs.from multiple animal reservoirs.
 Transmission is most commonly associatedTransmission is most commonly associated
with animal food products, especially eggs,with animal food products, especially eggs,
poultry, undercooked ground meat, dairypoultry, undercooked ground meat, dairy
products and fresh produce contaminatedproducts and fresh produce contaminated
with animal waste.with animal waste.

6. Prevalence in AnimalsPrevalence in Animals
86%
50%
1-36%
2-20%
6%
Center for Food Security and Public Health,Center for Food Security and Public Health,
Iowa State University, 2011Iowa State University, 2011

7.  In animals, asymptomaticIn animals, asymptomatic SalmonellaSalmonella infectionsinfections
are common.are common.
 Overall, approximately 1-3% of domestic animalsOverall, approximately 1-3% of domestic animals
are thought to carryare thought to carry SalmonellaSalmonella spp. but thespp. but the
prevalence can be much higher in some species.prevalence can be much higher in some species.
 Reptile-associated Salmonella infection moreReptile-associated Salmonella infection more
commonly leads to hospitalization and morecommonly leads to hospitalization and more
frequently involves infants than do otherfrequently involves infants than do other
Salmonella infections.Salmonella infections.

8.  Increasing antibiotic resistance in NTSIncreasing antibiotic resistance in NTS
species is a global problem and hasspecies is a global problem and has
been linked to the widespread use ofbeen linked to the widespread use of
antimicrobial agents in food animals.antimicrobial agents in food animals.

9. Clinical ManifestationsClinical Manifestations
In humans, salmonellosis varies from aIn humans, salmonellosis varies from a
self-limiting gastroenteritis toself-limiting gastroenteritis to
septicemia.septicemia.
– GastroenteritisGastroenteritis
– Bacteremia and endovascularBacteremia and endovascular
infectionsinfections
– Localized infectionsLocalized infections

10. GastroenteritisGastroenteritis
 Infection with NTS most often results in gastroenteritisInfection with NTS most often results in gastroenteritis
indistinguishable from that caused by other entericindistinguishable from that caused by other enteric
pathogens.pathogens.
 Nausea, vomiting and diarrhea occur 6–48 h after theNausea, vomiting and diarrhea occur 6–48 h after the
ingestion of contaminated food or water.ingestion of contaminated food or water.
 Patients often experience abdominal cramping and feverPatients often experience abdominal cramping and fever
(38–39°C).(38–39°C).
 Diarrheal stools are usually loose, nonbloodyDiarrheal stools are usually loose, nonbloody
and of moderate volume.and of moderate volume.
 Rarely, NTS causes pseudoappendicitis or an illness thatRarely, NTS causes pseudoappendicitis or an illness that
mimics inflammatory bowel disease.mimics inflammatory bowel disease.

11. GastroenteritisGastroenteritis
 Gastroenteritis caused by NTS is usually self-Gastroenteritis caused by NTS is usually self-
limited.limited.
 Diarrhea resolves within 3–7 days and feverDiarrhea resolves within 3–7 days and fever
within 72 h.within 72 h.
 Stool cultures remain positive for 4–5 weeksStool cultures remain positive for 4–5 weeks
after infection and—in rare cases of chronicafter infection and—in rare cases of chronic
carriage (<1%)—for >1 year.carriage (<1%)—for >1 year.

12. GastroenteritisGastroenteritis
TreatmentTreatment
Antibiotic treatment usually is not recommendedAntibiotic treatment usually is not recommended
and may prolong fecal carriage.and may prolong fecal carriage.
Neonates, the elderly, and immunosuppressedNeonates, the elderly, and immunosuppressed
patients (e.g., transplant recipients, HIV-infectedpatients (e.g., transplant recipients, HIV-infected
persons) with NTS gastroenteritis are especiallypersons) with NTS gastroenteritis are especially
susceptible to dehydration and dissemination andsusceptible to dehydration and dissemination and
may require hospitalization and antibiotic therapy.may require hospitalization and antibiotic therapy.

13. Bacteremia and endovascularBacteremia and endovascular
infectionsinfections
 Up to 8% of patients with NTS gastroenteritisUp to 8% of patients with NTS gastroenteritis
develop bacteremia.develop bacteremia.
 of these, 5–10% develop localized infections.of these, 5–10% develop localized infections.
 Bacteremia is most common with S.Bacteremia is most common with S.
choleraesuis and S. Dublin and among infants,choleraesuis and S. Dublin and among infants,
the elderly, and immunocompromised patients.the elderly, and immunocompromised patients.

14. Bacteremia and endovascularBacteremia and endovascular
infectionsinfections
 NTS endovascular infection should be suspectedNTS endovascular infection should be suspected
in high-grade or persistent bacteremia, especiallyin high-grade or persistent bacteremia, especially
with preexisting valvular heart disease,with preexisting valvular heart disease,
atherosclerotic vascular disease or aorticatherosclerotic vascular disease or aortic
aneurysm.aneurysm.
 Arteritis should be suspected in elderly patientsArteritis should be suspected in elderly patients
with prolonged fever and back, chest, orwith prolonged fever and back, chest, or
abdominal pain developing after an episode ofabdominal pain developing after an episode of
gastroenteritis.gastroenteritis.

15. Bacteremia and endovascularBacteremia and endovascular
infectionsinfections
 Endocarditis and arteritis are rare (<1% of cases)Endocarditis and arteritis are rare (<1% of cases)
but are associated with potentially fatalbut are associated with potentially fatal
complications, including valve perforation,complications, including valve perforation,
endomyocardial abscess, pericarditis, aneurysmendomyocardial abscess, pericarditis, aneurysm
rupture, aortoenteric fistula and vertebralrupture, aortoenteric fistula and vertebral
osteomyelitis.osteomyelitis.

16. Bacteremia and endovascularBacteremia and endovascular
infectionsinfections
 In some areas of sub-Saharan Africa, NTS mayIn some areas of sub-Saharan Africa, NTS may
be among the most common causes—or evenbe among the most common causes—or even
the most common cause—of bacteremia inthe most common cause—of bacteremia in
children.children.
 NTS bacteremia among these children is notNTS bacteremia among these children is not
associated with diarrhea and has beenassociated with diarrhea and has been
associated with nutritional status and HIVassociated with nutritional status and HIV
infection.infection.

17. Localized infectionsLocalized infections
Intraabdominal infectionsIntraabdominal infections
Intraabdominal infections due to NTS are rare andIntraabdominal infections due to NTS are rare and
usually manifest as hepatic or splenic abscesses or asusually manifest as hepatic or splenic abscesses or as
cholecystitis.cholecystitis.
Central nervous system infectionsCentral nervous system infections
NTS meningitis most commonly develops in infantsNTS meningitis most commonly develops in infants
1–4 months of age.1–4 months of age.
Pulmonary infectionsPulmonary infections
NTS pulmonary infections usually present as lobarNTS pulmonary infections usually present as lobar
pneumonia, and complications include lung bscess,pneumonia, and complications include lung bscess,
empyema, and bronchopleural fistula formation.empyema, and bronchopleural fistula formation.

18. Localized infectionsLocalized infections
Urinary and genital tract infectionsUrinary and genital tract infections
Urinary tract infections caused by NTS present as eitherUrinary tract infections caused by NTS present as either
cystitis or pyelonephritis.cystitis or pyelonephritis.
NTS genital infections are rare and include ovarian andNTS genital infections are rare and include ovarian and
testicular abscesses, prostatitis and epididymitis.testicular abscesses, prostatitis and epididymitis.
Bone, joint, and soft tissue infectionsBone, joint, and soft tissue infections
Salmonella osteomyelitis most commonly affects theSalmonella osteomyelitis most commonly affects the
femur, tibia, humerus, or lumbar vertebrae and is mostfemur, tibia, humerus, or lumbar vertebrae and is most
often seen in association with sickle cell disease,often seen in association with sickle cell disease,
hemoglobinopathies, or preexisting bone disease (e.g.,hemoglobinopathies, or preexisting bone disease (e.g.,
fractures).fractures).

19. DiagnosisDiagnosis
 The diagnosis of NTS infection is based onThe diagnosis of NTS infection is based on
isolation of the organism from freshlyisolation of the organism from freshly
passed stool or from blood or anotherpassed stool or from blood or another
ordinarily sterile body fluid.ordinarily sterile body fluid.
 Positive cultures of blood, stool or otherPositive cultures of blood, stool or other
specimens are required for diagnosis.specimens are required for diagnosis.

20. TreatmentTreatment
 Antibiotics should not be used routinely to treatAntibiotics should not be used routinely to treat
uncomplicated NTS gastroenteritis.uncomplicated NTS gastroenteritis.
 The symptoms are usually self-limited and the duration ofThe symptoms are usually self-limited and the duration of
fever and diarrhea is not significantly decreased byfever and diarrhea is not significantly decreased by
antibiotic therapy.antibiotic therapy.
 Antibiotic treatment has been associated with increasedAntibiotic treatment has been associated with increased
rates of relapse, prolonged gastrointestinal carriage andrates of relapse, prolonged gastrointestinal carriage and
adverse drug reactions.adverse drug reactions.
 Dehydration should be treated with fluid and electrolyteDehydration should be treated with fluid and electrolyte
replacement.replacement.

21. Preemptive antibiotic treatmentPreemptive antibiotic treatment
Preemptive antibiotic treatment should bePreemptive antibiotic treatment should be
considered for patients at increased risk forconsidered for patients at increased risk for
invasive NTS infection, includinginvasive NTS infection, including
neonates (probably up to 3 months of age);neonates (probably up to 3 months of age);
Persons >50 years of age with suspectedPersons >50 years of age with suspected
atherosclerosis;atherosclerosis;
patients with immunosuppression, cardiac valvularpatients with immunosuppression, cardiac valvular
or endovascular abnormalities or significant jointor endovascular abnormalities or significant joint
disease.disease.

22. Antibiotic Therapy for NontyphoidalAntibiotic Therapy for Nontyphoidal
Salmonella Infection in AdultsSalmonella Infection in Adults
Indication Agent Dosage (route) Duration,
days
Preemptive Treatment
Ciprofloxacin 500 mg bid (PO) 2–3
Severe Gastroenteritis
Ciprofloxacin
Trimethoprim-
sulfamethoxazole
Amoxicillin
Ceftriaxone
500 mg bid (PO) or 400
mg q12h (IV)
160/800 mg bid (PO)
1 g tid (PO)
1–2 g/d (IV)
3–7

23. Indication Agent Dosage (route) Duration,
days
Bacteremia
Ceftriaxone
Ciprofloxacin
2 g/d (IV)
400 mg q12h (IV),
then 500 mg bid (PO)
7–14
Endocarditis or Arteritis
Ceftriaxone
Ciprofloxacin
Ampicillin
2 g/d (IV)
400 mg q8h (IV), then
750 mg bid (PO)
2 g q4h (IV)
42

24. Indication Agent Dosage (route) Duration,
days
Meningitis
Ceftriaxone
Ampicillin
2 g q12 h (IV)
2 g q4h (IV)
14–21
Other Localized Infection
Ceftriaxone
Ciprofloxacin
Ampicillin
2 g/d (IV)
500 mg bid (PO) or
400 mg q12h (IV)
2 g q6h (IV)
14–28

25. PREVENTION AND CONTROLPREVENTION AND CONTROL
 monitoring of every step of food production, from handlingmonitoring of every step of food production, from handling
of raw animal or plant products to preparation of finishedof raw animal or plant products to preparation of finished
foods.foods.
 Contaminated food can be made safe for consumption byContaminated food can be made safe for consumption by
pasteurization, irradiation, or proper cooking.pasteurization, irradiation, or proper cooking.
 All cases of NTS infection should be reported to localAll cases of NTS infection should be reported to local
public health departments.public health departments.
 Lastly, the prudent use of antimicrobial agents in bothLastly, the prudent use of antimicrobial agents in both
humans and animals is needed to limit the emergence ofhumans and animals is needed to limit the emergence of
MDR Salmonella.MDR Salmonella.