Salmonellosis code for mcb 10 in children. Salmonellosis - description, causes, symptoms (signs), diagnosis, treatment

With a fecal-oral mechanism of transmission of the pathogen, characterized by a predominant lesion of the gastrointestinal tract, the development of intoxication and dehydration.

Non-typhoid Salmonella, predominantly Salmonella Enteritidis, primarily cause gastroenteritis, bacteremia, and focal infection. Symptoms of salmonellosis include diarrhea, high laxative fever, and signs of focal infection. Diagnosis of salmonellosis is based on a culture of blood, feces from the lesions. Treatment of salmonellosis, if indicated, is with trimethoprim-sulfamethoxazole or ciprofloxacin, with surgical treatment of abscesses, vascular lesions, bones and joints.

ICD-10 codes

• A02. Other salmonella infections.
• A02.0. Salmonella enteritis.
• A02.1. Salmonella septicemia.
• A02.2. Localized salmonella infection.
• A02.8. Another specified Salmonella infection.
• A02.9. Salmonella infection, unspecified.

ICD-10 code

A02 Other salmonella infections

A02.0 Salmonella enteritis

A02.1 Salmonella septicemia

A02.2 Localized Salmonella infection

A02.8 Other specified Salmonella infection

A02.9 Salmonella infection, unspecified

Epidemiology of salmonellosis

The reservoir and source of the infectious agent are sick animals: large and small cattle, pigs, horses, poultry. Their disease proceeds acutely or in the form of a bacteriocarrier. A person (patient or carrier) may also be a source of S. typhimurium. The transmission mechanism is fecal-oral. The main route of transmission is food, through animal products. Infection of meat occurs endogenously during the life of the animal, as well as exogenously during transportation, processing, storage. AT last years there was a significant increase in the incidence (S. enteritidis), associated with the spread of the pathogen through poultry meat and eggs. The aquatic route of transmission mainly plays a role in the infection of animals. By contact-household way (through hands and tools), as a rule, the pathogen is transmitted in medical institutions. The greatest risk of infection with salmonellosis is in children of the first year of life and persons with immunodeficiency. Airborne dust plays a large role in the spread of infection among wild birds. The incidence of salmonellosis is high in large cities. Cases of the disease are recorded throughout the year, but more often in the summer months due to the worst storage conditions for food. Observe sporadic and group incidence. The susceptibility of people to the pathogen is high. Post-infection immunity lasts less than a year.

What causes salmonellosis?

The most common cause of salmonellosis is Salmonella enteritidis. These infections are common and a major problem in the US. Many Salmonella enteritydis serotypes have names and are loosely named, as if they were separate species, which they are not. The most common species of Salmonella in the United States are: Salmonella thyphimurium, Salmonella heidelberg, Salmonella newport, Salmonella infantis, Salmonella agona, Salmonella montevidel, Salmonella saint-paul.

Human salmonellosis occurs through direct and indirect contact with infected animals, with products obtained from them, with their secretions. Infected meat, poultry, raw milk, eggs and egg products are the most common sources of Salmonella. Other possible sources of infection are infected domestic turtles and reptiles, carmine red dye, and marijuana.

Diseases such as subtotal gastrectomy, achporhydria (or taking antacids), sickle cell anemia, splenectomy, epidemic relapsing fever, malaria, bartonellosis, liver cirrhosis, leukemia, lymphoma, HIV infection predispose to salmonellosis.

All Salmonella serotypes can cause the clinical syndromes described below, either individually or together, although each serotype is often associated with a specific syndrome. Intestinal fever is caused by Salmonella parathifi types A, B and C.

Asymptomatic carriage may also occur. However, carriers do not play an important role in gastroenteritis outbreaks. The constant excretion of pathogens with stool for a year or more is observed only in 0.2-0.6% of those who have undergone non-typhoid salmonellosis.

What are the symptoms of salmonellosis?

Salmonella infection can present clinically as gastroenteritis, a typhoid-like form, a bacteremic syndrome, and a focal form.
Gastroenteritis begins 12-48 hours after salmonella is ingested. Nausea and spastic pains in the abdomen appear first, then diarrhea, fever, and sometimes vomiting.

The stool is usually watery, but sometimes mushy semi-liquid, occasionally with impurities of mucus and blood. Salmonellosis is not severe and lasts 1-4 days. Sometimes there is a more severe and prolonged course.

The typhoid form is characterized by fever, prostration, and septicemia. Salmonellosis proceeds in the same way as typhoid fever, but more easily.

Bacteremia is not common in patients with gastroenteritis. However, Salmonella choleraesuis, Salmonella thyphimurium heidelberg, among others, can cause a lethal bacteremia syndrome lasting 1 week or more with prolonged fever, headache, weight loss, chills, but rarely diarrhea. Patients may have transient episodes of bacteremia or evidence of focal infection (eg, septic arthritis). And in patients with disseminated Salmonella infection without risk factors, testing for HIV infection should be carried out.

Focal salmonellosis can occur with and without bacteremia. Patients with bacteremia may be affected by the gastrointestinal tract (liver, gallbladder, appendix, etc.), endothelium (atherosclerotic plaques, aneurysms of the iliac or femoral artery or aorta, heart valves), pericardium, meninges, lungs, joints, bones, urinary tract, soft tissues.

Sometimes there are solid tumors with the formation of an abscess, which become a source of Salmonella bacteremia. Salmonella choleraesuis, Salmonella thyphimurium are the most common cause of focal infection.

How is salmonellosis diagnosed?

Diagnosis of salmonellosis is based on the isolation of the pathogen from feces and other materials. In bacteremia and local forms, the blood culture is positive, but the stool culture is negative. Stool samples are stained with methylene blue, and white blood cells are often found, indicating an inflammatory process in the colon - colitis.

Trimethoprim-sulfamethoxazole 5 mg/kg (trimethoprim) every 12 hours for children and ciprofloxacin by mouth every 12 hours for adults. With a normal immune system, treatment for salmonellosis lasts 3-5 days, while patients with AIDS may require longer treatment. Systemic or focal forms of the disease are treated with antibiotics in the same doses as in typhoid fever. With persistent bacteremia, it is usually necessary to continue therapy for 4-6 weeks. Abscesses should be opened. Then antibiotic therapy for 4 weeks. Infections in aneurysms, heart valves, and bones or joints usually require surgery and long-term antibiotic use.

In asymptomatic carriers, the infection usually clears up on its own and antibiotics are rarely needed. In special cases (eg, in food or healthcare workers), carrier elimination can be attempted with ciprofloxacin 500 mg every 12 hours for 1 month. To confirm Salmonella elimination, stool cultures are required within a few weeks of completion of treatment.

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Disease code (ICD-10)

Salmonellosis (salmonellesis) is an acute intestinal zoonotic infection caused by numerous bacteria from the genus Salmonella, characterized by a predominant lesion of the gastrointestinal tract and proceeding most often in the form of gastrointestinal, less often generalized forms.

Historical information

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Diseases that are epidemiologically and clinically similar to salmonellosis have been known to doctors for a long time. In 1885 D.E. Salmon and J. Smith isolated V. suipestifer, the causative agent, as they believed, of swine fever. In 1888, A. Gertner found a microbe similar in properties to B. suipestifer in the organs of a deceased person and meat used for food, thereby substantiating the bacterial etiology of salmonellosis in humans and animals.

Subsequently, reports began to appear on the isolation of a number of microorganisms similar in morphological and biochemical properties to Salmon and Gertner bacteria. All of them were combined into a group of paratyphoid microbes and in 1934 they were called salmonella.

Etiology

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The causative agent of salmonellosis- Salmonella bacteria

The genus Salmonella
Family – Enterobacteriaceae (intestinal bacteria)

Morphology
Form - sticks measuring (1.0–3.0) x (0.2–0.8) µm with rounded ends.
They have flagella over the entire surface of the cell (peritrichous), due to which they are mobile.
Spores and capsules do not form.
Gram-negative. Grow on normal nutrient media.

Antigenic structure
The antigenic structure of Salmonella is complex. They contain O- and H antigens.
The O antigen is associated with the somatic substance of the cell, it is thermostable, one of its components is the Vi antigen;
The H antigen has a flagellar apparatus and is thermolabile.
The antigenic structure is the basis of the International Serological Classification of Salmonella (Kaufman-White scheme). Differences in the structure of O antigens made it possible to identify serological groups A, B, C, D, E, etc. Based on differences in the structure of H antigens, serological variants were established within each group. More than 2200 serological variants of Salmonella have been described, of which more than 700 are found in humans. The most common Salmonella are: S. typhimurium, S. heidelberg, S. enteritidis, S. anatum, S. derby, S. london, S. panama, S. newport.

toxin formation. Salmonella are able to produce exotoxins. Among them are enterotoxins (thermolabile and thermostable), which enhance the secretion of fluid and salts into the intestinal lumen, and cytotoxin, which disrupts protein synthesis processes in the cells of the intestinal mucosa and affects cytomembranes.
When bacteria are destroyed, endotoxin is released, which leads to the development of an intoxication syndrome.

Stability in the external environment. Salmonella are relatively resistant to various environmental factors, some of them do not die when frozen to –48–82 °C and tolerate drying well. On various objects at room temperature, they persist for 45-90 days, in dry animal feces - up to 3-4 years. In water, especially at low pH, Salmonella survive 40-60 days. In dairy and prepared meat products, Salmonella not only persist for up to 4 months, but also multiply without changing the organoleptic properties and appearance of the products. Salmonella are resistant to salt, smoking and acids. To destroy bacteria, high-quality heat treatment is required. So, for the complete inactivation of Salmonella in a piece of meat weighing 400 g, it is necessary to cook it for at least 2.5 hours.

Pathogenicity for animals. Salmonellosis affects both humans and animals and birds.

Epidemiology

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source of infection there can be animals and people, and the role of animals in epidemiology is the main one. Salmonellosis in animals occurs in the forms of a clinically pronounced disease and bacterial excretion. Being outwardly healthy, they can excrete pathogens with urine, feces, milk, nasal mucus, saliva. The duration of bacterial excretion in animals can be different and is often calculated in months and years. The greatest epidemiological danger is the infection of cattle, pigs, sheep, horses. Salmonella bacterioexcretion was also found in dogs, cats, house rodents (mice and rats), in many species of wild animals: foxes, beavers, wolves, arctic foxes, bears, seals, monkeys, etc.

A significant place in the epidemiology of salmonellosis is occupied by birds (often broiler chickens) and especially waterfowl, which serve as a powerful reservoir of various types of salmonella. Salmonella is found not only in the meat and internal organs of birds, but also in eggs. eggs infected by appearance, smell and taste do not differ from normal. In this regard, it is not recommended to eat raw eggs, especially duck and goose. Salmonella has also been found in foods made from raw eggs (egg powder). Salmonellosis and the isolation of pathogens are also observed among pigeons, sparrows, gulls and other bird species. Salmonella has been reported in lizards, turtles, snakes, frogs, fish, crayfish and crabs.
People with salmonellosis or bacterial excretors can also be sources of salmonellosis, but their epidemiological role should be assessed as secondary. The most important in this case are persons belonging to the category of food workers.
Salmonellosis occurs throughout the year, but more often in the summer months, which can be explained by the deterioration of food storage conditions. Both sporadic and group incidence of this infection is observed.
The most susceptible to salmonellosis are children under the age of 1 year and persons with various types of immunodeficiency. The latter explains the high incidence of salmonellosis in people with severe somatic pathology and serves as a prerequisite for disease outbreaks among hospitalized patients. In this case, salmonellosis is considered as nosocomial infection. Their causative agents are distinguished by some biological features, primarily by high polyresistance to chemotherapeutic agents. Such strains (clones) of Salmonella are called hospital.

Mechanism of infection
The mechanism of transmission of pathogens is fecal-oral.
Feeding Mechanism - Food is the transmission factor for Salmonella. These include the meat of animals or birds. Infection of meat occurs endogenously (during the life of the animal during its illness), as well as exogenously, during transportation, processing, storage. Often, food contamination occurs when they are not properly cooked, cooked on contaminated tables and using infected dishes.
The contact mechanism - the household contact route of transmission can be realized in conditions of close communication with a sick person or animals, if elementary sanitary conditions are not observed. hygiene standards. This pathway is noted, for example, in nosocomial outbreaks of salmonellosis, usually caused by S. typhimurium. The disease is recorded mainly in children under 1 year of age.
Water mechanism - Water and, in rare cases, dust (by ingestion of dust) transmission routes of infection are possible.

Immunity
Immune responses in salmonellosis are presented as a combination of the so-called local (intestinal) immunity, which is manifested primarily by a humoral immune response (IgA secretion) and a mild cellular response. The general humoral reaction is expressed by the production of various classes of immunoglobulins, and the cellular reaction is expressed by an increase in the phagocytic activity of macrophages, which is closely related to the active production of antibodies and the reaction of the latter with bacterial antigens. The formation of antibodies in patients with salmonellosis is often considered as a reaction proceeding according to the type of secondary immune response, since most adults repeatedly contact salmonella during their lives, resulting in sensitization of the body and possible hypersensitivity reactions.
The development of typhoid-like, septic, subclinical and chronic forms of salmonellosis is explained by the emergence of immunological tolerance to Salmonella antigens. The latter is a consequence of either mimicry of antigens, or the result of a temporary decrease in the functional activity of phagocytes and lymphocytes of the macroorganism (development of secondary immunodeficiency).

Pathogenesis and pathological anatomical picture

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When entering the gastrointestinal tract, Salmonella overcome the epithelial barrier of the small intestine and penetrate into the thickness of the tissues, where they are captured by macrophages. Inside macrophages, bacteria not only multiply, but also partially die with the release of endotoxin, which affects the neurovascular apparatus of the intestine and increases the permeability of cell membranes. This contributes to the further spread of salmonella along the lymphatic tract and their penetration into the mesenteric lymph nodes.

Along with local action, endotoxin causes the development of symptoms of general intoxication of the body. At this stage, the infectious process, acquiring a localized (gastrointestinal) form, can be completed. However, even with localized forms of infection, the pathogen can enter the blood, although bacteremia is short-lived.
With a deep violation of the barrier function of the lymphatic apparatus of the intestine, the process is generalized and prolonged bacteremia occurs, which clinically corresponds to the development of a generalized form of salmonellosis. As a result of bacteremia, Salmonella are introduced into various internal organs, causing dystrophic changes in them or the formation of secondary purulent foci (septicopyemic variant).
The increase in fluid secretion in the intestine is based on the activation mechanism of adenylcyclase and guanylcyclase of enterocytes by salmonella enterotoxin, followed by an increase in the intracellular concentration of biologically active substances (cAMP, cGMP, etc.). This entails the entry into the intestinal lumen of a large amount of fluid, potassium, sodium and chlorides. Patients experience vomiting and diarrhea. Symptoms of dehydration and demineralization of the body develop, the level of sodium, chlorides and potassium in the blood serum decreases. Dehydration leads to tissue hypoxia with impaired cellular metabolism, which, in combination with electrolyte changes, contributes to the development of acidosis. In severe cases, oliguria and azotemia appear. These pathological phenomena are especially pronounced in the development of dehydration (more often), infectious toxic and mixed shocks.

Pathological picture
Pathological changes in salmonellosis are diverse, depending on the form, severity and duration of the disease. The severity of pathological changes does not always correspond to the severity of the course of the disease.
In the gastrointestinal form of the disease, catarrhal inflammation predominates morphologically in all parts of the gastrointestinal tract. Macroscopically, in the intestine, a sharp plethora with hemorrhages of various sizes, swelling of the mucous membrane, sometimes with superficial necrosis and a tender bran with a visible coating, are found. The lymphatic apparatus of the intestine may not be changed, the spleen is not enlarged. In all other organs, there is a sharp plethora and dystrophic changes. Microscopically, vascular changes with hemorrhages in the mucous membrane and submucosa are revealed in the intestine. In the submucosa, there is a violation of microcirculation with a reactive leukocyte reaction and severe tissue edema.
In the generalized form of the disease with septic manifestations in the gastrointestinal tract, slight plethora and small hemorrhages are observed. In the internal organs there may be multiple metastatic ulcers. Pronounced diffusion and focal proliferation of cells of the reticuloendothelial system. Salmonella are sown from pyemic abscesses, often in association with other microorganisms (staphylococci, proteus).
With a typhoid-like course of salmonellosis, an increase in the spleen and mesenteric lymph nodes is observed. In the intestine - swelling, plethora and hemorrhages in the mucous membrane of the lower part of the small intestine, especially in group lymphatic follicles.

Clinical picture (Symptoms) of salmonellosis

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Incubation period with salmonellosis, on average, 12–24 hours. Sometimes it is shortened to 6 hours or lengthened to 2 days.

Allocate the following forms and course of infection.

I. Gastrointestinal form:
1) gastric variant; 2) gastroenteric variant; 3) gastroenterocolitic variant.
II. Generalized form:
1) typhoid-like variant; 2) septicopyemic variant.
III. Bacterioexcretion:
1) acute; 2) chronic; 3) transitory.

I. Gastrointestinal form

The gastrointestinal form is the most common. With this form, the disease can occur with a clinical picture of gastritis, gastroenteritis and gastroenterocolitis.

Salmonella gastritis develops rarely, clinically accompanied by moderate symptoms of intoxication, pain in the epigastric region, nausea, repeated vomiting. Diarrhea in this variant of the course of the disease does not happen.

Gastroenteric variant is the most common clinical variant of Salmonella infection.

The onset of the disease is acute. Almost simultaneously, symptoms of intoxication and signs of damage to the gastrointestinal tract appear, which quickly, within a few hours, reach their maximum development. Nausea and vomiting are noted in many patients. Vomiting is rarely single, more often repeated, profuse, sometimes indomitable. The stool is loose, copious, usually retains a fecal character, offensive, frothy, brown, dark green or yellow. Sometimes the stools lose their fecal character and may resemble rice water. The abdomen is usually moderately swollen, painful on palpation in the epigastrium, around the navel, in the ileocecal region; rumbling, "transfusion" in the area of ​​the loops of the small intestine can be detected.

Gastroenterocolitic variant salmonellosis can begin as gastroenteritis, but then the symptom complex of colitis appears more and more clearly in the clinical picture. In this case, salmonellosis in its course resembles acute dysentery.

The disease begins acutely, with a rise in body temperature and the appearance of other symptoms of intoxication. From the first days of illness, the stools are frequent, liquid, with an admixture of mucus and sometimes blood. There may be tenesmus and false urges. Sigmoidoscopy in such patients reveals inflammatory changes of varying intensity: catarrhal, catarrhal hemorrhagic, catarrhal erosive.

With the gastrointestinal form of salmonellosis, it is not possible to determine any characteristic type of temperature curve. There is a constant, rarely remitting or intermittent type of fever. Sometimes the disease proceeds at normal or subnormal temperature. The pancreas is often involved in the pathological process in the gastrointestinal form of salmonellosis. Increased activity of amylase in the blood and urine. In some cases, clinical symptoms of pancreatitis appear. With salmonellosis, liver damage occurs early, especially during the period of maximum toxinemia. In some patients, an increase in the liver is detected, sometimes subicteric sclera. Symptoms of damage to the pancreas and liver are usually transient,

Often there is damage to the nervous system, which is due to the action of Salmonella endotoxin, biologically active substances (such as histamine). Headache, dizziness, fainting are noted. Damage to the autonomic nervous system is manifested by symptoms of hypermotor (spastic) dyskinesia of the stomach and intestines.
Cardiovascular disorders develop in most patients. The degree of its defeat depends on the severity of general toxicosis. The frequency, filling and tension of the pulse change, blood pressure decreases. In severe cases, collapse occurs, sometimes very quickly, in the first hours of illness, even before the development of dehydration. As a result of intoxication and vascular insufficiency, dystrophic changes occur in the heart muscle. Heart sounds are muffled or muffled, systolic murmur appears, arrhythmias may occur (most often extrasystole). Especially often these symptoms are expressed in the elderly, which is associated with a decrease in their adaptive ability of the cardiovascular system.
Toxic damage to the renal parenchyma is usually manifested by proteinuria. microhematuria, cylindruria. In very severe cases, in conditions of severe intoxication, a drop in cardiovascular activity, the development of collapse and significant electrolyte disorders, acute renal failure occurs.
The pattern of peripheral blood in the gastrointestinal form of salmonellosis is different. With a large loss of fluid, thickening of the blood develops and erythrocytosis is possible. Occasionally, symptomatic thrombocytopenia develops. The number of leukocytes can be different - normal, reduced, but more often elevated, especially in severe salmonellosis. Leukocytosis is usually moderate, rarely exceeding 20 * 10^9 / l. With great constancy, a shift of the leukocyte formula to the left is detected. ESR is within the normal range or slightly increased. In the midst of the disease, violations of water-salt metabolism are possible, leading to dehydration and demineralization of the body. There are shifts in the acid-base balance, but they are detected only in the most severe cases.

Downstream, the gastrointestinal form of salmonellosis can be mild, moderate and severe.

With mild flow intoxication is moderate, malaise, slight weakness, chilling are noted. Body temperature briefly rises to subfebrile figures. Vomiting may not be or it is single, abdominal pain is slight or absent, stools are mushy or liquid 1-3 times a day, quickly normalize.
Moderate course accompanied by intoxication, body temperature rises to 39-40 °C. Weakness, headache, dizziness, fainting, cramps in the extremities are noted. Patients complain of abdominal pain, localization of which depends on the severity of gastritis, enteritis or colitis. Vomiting is painful, repeated, at first eaten food, then bile or cloudy liquid. Stool up to 10 times a day, plentiful, with a gastroenterocolitis variant - mucous. After 2-4 days, the patient's condition improves, abdominal pain disappears, body temperature and functions of the gastrointestinal tract return to normal.
In case of severe symptoms of intoxication reach their maximum development in the first hours of the disease. Body temperature quickly rises to 39-40 ° C and is accompanied by chills. Fever is most often permanent in nature with slight daily fluctuations; less often it takes on a remitting character. In very severe cases, hyper- or hypothermia develops, which is especially unfavorable in terms of prognosis, as it indicates the occurrence of pronounced neurotoxicosis or acute vascular insufficiency. Simultaneously with the development of symptoms of intoxication, or somewhat later, severe cutting pains in the abdomen, excruciating nausea, then profuse, repeated, sometimes indomitable vomiting appear. Stool 10-20 times a day, profuse, watery, fetid, sometimes reminiscent of rice water. When the colon is involved in the process, the stool can be with mucus, rarely with blood. Symptoms of dehydration, demineralization and associated acidosis develop. The patients look exhausted. The skin is pale, with a bluish tinge, dry, the face is haggard, the voice is weak, there are convulsions (from pulling pains in large muscles to total clonic), oliguria and anuria are possible. In this condition, resuscitation detoxification therapy, rapid rehydration and remineralization are necessary.

II. Generalized form

Typhoid variant salmonellosis usually begins with lesions of the gastrointestinal tract, but may occur without intestinal dysfunction from the very beginning.

Clinically, it is very similar to typhoid fever and especially paratyphoid. The intoxication syndrome is pronounced and is accompanied by depression of the neutral nervous system. Patients complain of headache, sleep disturbance (drowsiness during the day and insomnia at night), lethargy, severe weakness. In severe cases, they become indifferent, adynamic, consciousness is clouded, delirium and hallucinatory syndrome are possible. Fever with a temperature reaching 39–40 ° C is often permanent. The duration of the febrile period ranges from 6–10 days to 3–4 weeks.
The skin of patients is usually pale, a rash may appear. It is usually poorly visible and is represented by single small pale roseolas on the skin of the abdomen and trunk. The pulse is often slower. Arterial pressure is reduced. In some cases, a cough appears, occasionally bronchitis and pneumonia develop. By the end of the 1st week of the disease, an increase in the liver and spleen is noticeable. In the peripheral blood, leukopenia, aneosinophilia with a neutrophilic shift to the left are found, but moderate leukocytosis can also be observed.

Septicopyemic variant salmonellosis from the very beginning develops as salmonella sepsis. But sometimes in a patient with a gastrointestinal form of salmonellosis, intestinal dysfunction stops, but intoxication increases.

The disease loses its cycles, the temperature curve takes on an irregular, relapsing character, stunning chills and profuse sweat appear - salmonellosis takes on a septic course. The clinical picture depends on the localization of metastatic purulent foci, which can occur in all organs. An enlargement of the liver and spleen is always detected. Typically a long severe course. Treatment presents considerable difficulties, an unfavorable outcome is possible.

III. Bacterioexcretion

Bacterial excretion as a result of salmonellosis can be acute or chronic.

Acute bacterial excretion, in which the pathogen continues to be isolated up to 3 months after clinical recovery, is much more common than chronic.

Chronic bacterial excretion, in which the pathogen is found in the feces for more than 3 months after clinical recovery.

Transient bacterial excretion It is diagnosed in cases where there is only one double isolation of Salmonella followed by multiple negative results of bacteriological examination of feces and urine. In addition, the conditions necessary for the diagnosis of transient bacterial excretion are the absence of any clinical manifestations of the disease at the time of examination and over the previous 3 months, as well as negative results of a serological study performed in dynamics.

Complications. Numerous and varied. With the gastrointestinal form of the disease, the development of vascular collapse, hypovolemic shock, acute heart and kidney failure is possible. In patients with salmonellosis, there is a tendency to septic complications, of which there are purulent arthritis, osteomyelitis, endocarditis, abscesses of the brain, spleen, liver and kidneys, meningitis, peritonitis, appendicitis. In addition, pneumonia, ascending urinary tract infection (cystitis, pyelitis), toxic infectious shock may occur. In all clinical forms of the disease, relapses are possible.

Forecast

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With the gastrointestinal form and the typhoid-like variant of salmonellosis, the prognosis is favorable, especially in cases of early diagnosis and proper treatment. The prognosis for the septicopyemic variant is always serious, the mortality rate is 0.2-0.3%.

Diagnosis of salmonellosis

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Diagnosis of salmonellosis is carried out on the basis of epidemiological, clinical and laboratory data. Laboratory examination of patients is an important link in the diagnosis, especially if we take into account the polymorphism of clinical manifestations. Bacteriological and serological research methods are used. For bacteriological examination, vomit, gastric lavage, feces, duodenal contents, blood, urine, and in rare cases pus from inflammatory foci and cerebrospinal fluid are sent to the laboratory for bacteriological examination. Material from the patient should be taken as soon as possible early dates and before the start of treatment.

In serological studies (7–8 days of illness), agglutination reactions (RA) and more often indirect hemagglutination (RIHA) are used. RA is considered positive when the serum dilution is not less than 1:200. Especially important diagnostic value is the increase in antibody titer in the dynamics of the disease. RNGA is more sensitive and gives positive results from the 5th day of illness. For diagnostic take antibody titer in RNGA 1:200.
In case of group diseases with salmonellosis, express diagnostic methods are used: MFA, RNGA with antibody diagnosticums, etc.
In recent years, ELISA methods have been used to determine antibodies belonging to various classes of immunoglobulins (M, G). Methods (haemagglutination aggregate and enzyme immunoassay) have been developed for the detection of Salmonella antigens in the blood and an enzyme immunoassay method for the detection of antigens of these pathogens in the urine.

Differential Diagnosis

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Depends on the clinical form of the disease. Most often, the gastrointestinal form has to be differentiated from other acute intestinal infections - dysentery, food poisoning, escherichiosis, cholera. Often there is a need to differentiate this form from acute surgical diseases - acute appendicitis, pancreatitis, cholecystitis, thrombosis of mesenteric vessels and acute gynecological pathology - ectopic pregnancy and adnexitis; from therapeutic pathology - from a heart attack, exacerbations of chronic gastritis, enterocolitis, peptic ulcer. There are also difficulties in the differential diagnosis of the gastrointestinal form of salmonellosis and poisoning with inorganic poisons, pesticides, fungi, and some plants.

The generalized form of salmonellosis should be differentiated from other bacteremic infections, sepsis of various nature, influenza, pneumonia, malaria, acute pyelonephritis, tuberculosis, lymphogranulomatosis.

Treatment of salmonellosis

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The complexity of pathogenetic mechanisms in salmonellosis, the variety of clinical forms of the disease dictate the need for an individual approach to treatment.

Currently, there are no sufficiently effective chemotherapeutic drugs (including antibiotics) for the treatment of the gastrointestinal form of Salmonella infection. With this form of the disease, the main methods are pathogenetic therapy.

The main directions of pathogenetic therapy of salmonellosis are the following:

1. detoxification;
2. normalization of water and electrolyte metabolism;
3. fight against hypoxemia, hypoxia, metabolic acidosis;
4. maintaining at the physiological level of hemodynamics, as well as the functions of the cardiovascular system and kidneys.

All patients with gastrointestinal form of salmonellosis in the first hours of the disease, gastric lavage is indicated. For the fastest relief of diarrhea, calcium preparations (calcium gluconate, lactate, glycerophosphate) are used as an activator of phosphodiesterase, an enzyme that prevents the formation of cAMP. The dose of calcium gluconate (lactate, glycerophosphate) - up to 5 g per day - is taken at one time. Of the other drugs that stop secretory diarrhea, non-steroidal anti-inflammatory drugs are used, for example, indomethacin 50 mg 3 times for 12 hours. At the same time, cytoprotectors such as polysorb MP are prescribed to protect the intestinal mucosa.

Patients with mild disease do not need a wide range of therapeutic measures. It should be limited to giving them a diet (No. 4) and drinking plenty of water. For oral rehydration, glucose-electrolyte solutions Oralit, Citraglucosolan, Regidron can be used. They are given to drink in small portions in an amount corresponding to the loss of fluid.

With moderate severity gastrointestinal form of salmonellosis, but without severe hemodynamic disturbances and rare vomiting, oral rehydration is also performed. However, with increasing dehydration, severe hemodynamic disturbances, frequent (indomitable) vomiting, polyionic solutions are administered intravenously. After replacement of initial fluid losses and absence of vomiting, oral rehydration can be continued.

In severe illness treatment is carried out in the mode of intensive care and resuscitation. To implement the above principles of pathogenetic therapy, intravenous administration of polyionic solutions is mandatory. Their volume depends on the amount of fluid lost with feces, vomit and urine, as well as on the degree of intoxication, amounting to 4 to 8 liters per day. In infusion therapy, solutions "Trisol", "Atsesol", "Laktasol", "Kvartasol", "Chlosol" and others are used.

In cases of dehydration shock, resuscitation therapy is carried out, as in severe forms of cholera; in infectious toxic shock, in addition to polyionic, colloidal solutions (hemodez, reopoliglyukin) and glucocorticoids are administered.

In the complex of pathogenetic measures, especially with a protracted course of the disease, stimulating therapy is of great importance. Drugs such as multivitamins, methyluracil, potassium orotate increase the body's resistance to infection, promote tissue regeneration, and stimulate the production of immunity.

Antibacterial therapy, including antibiotics, sulfanilamide and other chemotherapy drugs, is ineffective. One of the main reasons for this is the predominantly intracellular location of microorganisms, characteristic of the gastrointestinal form of salmonellosis.

With a generalized form along with pathogenetic therapy, etiotropic treatment, including antibiotics, is indicated. The course of treatment is prescribed individually, depending on the form and severity of the disease. Combinations of antibiotics of the aminoglycoside group (gentamicin sulfate, sisomycin sulfate, amikacin sulfate, tobramycin, etc.) and quinolones (ciprofloxacin, ofloxacin, etc.), cephalosporins, chloramphenicol, ampicillic, amoxicillin are used.

An unresolved problem is the treatment of patients with prolonged exposure to Salmonella. As a rule, strains of the pathogen that caused bacterial excretion are resistant to many antibiotics. In some cases, it is possible to obtain an effect in the treatment of patients with ampicillin, amoxicillin or quinolone drugs, especially in combination with injections of prodigiosan or other bacterial lipopolysaccharide (3-5 injections per course).

In the complex treatment of patients with salmonellosis, a polyvalent salmonella bacteriophage is also used.
Particular attention in the treatment should be given to concomitant pathology, as well as the rehabilitation of chronic foci of infection.

Prevention

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Prevention of salmonellosis includes veterinary, sanitary, sanitary and anti-epidemic measures. Veterinary sanitary measures are aimed at preventing the spread of salmonellosis among domestic mammals and birds, as well as at organizing a sanitary regime at meat processing plants and dairy enterprises. The purpose of sanitary and hygienic measures is to prevent the contamination of food products with Salmonella during their processing, transportation and sale. Of great importance in the fight against salmonellosis is the correct culinary and optimal thermal processing of food products. Anti-epidemic measures are aimed at preventing the spread of the disease in the team. In the event of sporadic diseases and epidemic outbreaks, it is necessary to identify the ways of transmission of infection and subject suspicious foodstuffs, vomit, washings, blood and feces of the diseased to bacteriological examination. In the foci of the disease, current and final disinfection is carried out. Patients are hospitalized according to clinical and epidemiological indications.

Those who have been ill are discharged after clinical recovery and negative control bacteriological studies of feces.
In the event of a nosocomial outbreak of salmonellosis, a special mode of operation of the medical institution is established, which is regulated by the relevant instructions. The most important role in overcoming nosocomial salmonellosis is played by the coordinated actions of the epidemiological service, the hospital administration, doctors, all medical personnel and the bacteriological laboratory.

Under the diagnosis of salmonellosis, they unite a group of infectious diseases of humans and animals caused by bacteria of the genus Salmonella, which enter the body through the digestive tract. In our country, among acute intestinal infections, salmonellosis ranks second after dysentery and is observed in the form of limited outbreaks or scattered sporadic diseases. They are especially unfavorable in early childhood.

Salmonellosis is caused by a large group of bacteria of the genus Salmonella, a family of intestinal bacteria, which are gram-negative rods that are facultative aerobes that secrete endotoxin. Salmonella have a fairly pronounced resistance in the external environment. In our country, more than 500 different serotypes have been isolated from people with salmonellosis, the leading ones are group B salmonella (S. typhi murium, derbi, heidelberg), C (S. cholerae suis, newport), D (S. enteritidis, dublin), E ( S. anatum) and others.

Salmonella is highly resistant to physical and chemical factors. They remain in water for up to 5 months, in soil - 9 months, in dried feces - 4 years, in eggs - 3 months, in milk - 20 days, in butter - 9 months. At a temperature of 56 0 C they die in 1-3 minutes, boiling kills them instantly. In food products, they are not only preserved, but also multiply.

Epidemiology

The source of infection are animals and humans (patients and carriers). The main role in the spread of salmonellosis belongs to animals in which the infection occurs in the form of manifest forms and bacteriocarrier. The most important source of infection is poultry (chickens, turkeys, geese, ducks), cattle, pigs, less often sheep and goats. The reservoir of infection is also rodents, wild birds, waterfowl, etc.

Transfer mechanism - fecal-oral. The leading route of transmission is food, the transmission factors are mainly animal meat, meat products, eggs massively infected with pathogens, a smaller role belongs to dairy products. Water outbreaks associated with the consumption of contaminated water are described. A contact-household transmission route is possible, which is observed more often in premature babies, children of the first year of life with a burdened premorbid background. Infection occurs through towels, toys, changing tables, hands of medical personnel.

With hospital salmonellosis, the source of infection is a sick child, the route of transmission is contact-household, less often food. Characterized by high contagiousness, sluggish, torpid course, the prevalence of severe forms, high mortality, an increase in the incidence in the cold season, which is due to the concentration of children in hospitals.

Immunity - type-specific, short (5-6 years).

Pathogenesis

The entrance gate of infection is the gastrointestinal tract. A massive intake of live bacteria is accompanied by their destruction in the upper digestive tract, resulting in the release of a large amount of endotoxins, which, being absorbed into the blood, cause the onset of a toxic syndrome (“toxemia phase”), which determines the clinical picture of the initial period of the disease.

If the factors of nonspecific protection of the gastrointestinal tract are imperfect, then Salmonella freely enters first into the small intestine, then into the large intestine, where the primary localization of the pathological process (“enteral phase”) occurs.

Depending on the state of the body's immune system and, first of all, the cellular link of immunity, factors of nonspecific protection, either only a local inflammatory process is noted, or a breakthrough of the intestinal and lymphatic barriers, and the next stage of the infectious process occurs - the "bacteremia phase". With the blood flow, Salmonella enter various organs and tissues, where it can also occur from reproduction (“secondary localization”) with the development of lymphohistiocytic and epithelioid granulomas in cells with the formation of septic foci (meningitis, endocarditis, osteomyelitis, peritonitis, etc.) - septic form salmonellosis.

Classification of salmonellosis

By type, there are: 1. Typical - gastrointestinal (gastritis, enteritis, gastroenteritis, enterocolitis, gastroenterocolitis).

2. Atypical - typhoid-like, septic, toxic-septic, erased, asymptomatic (inapparent), transient bacteriocarrier.

By gravity: light, medium, heavy

According to the course, they are distinguished: acute up to 1.5 months, protracted - up to 3 months, chronic over 3 months.

Clinic

The nature of clinical manifestations and the severity of the disease are determined by the massiveness of infection, by infection, the age of children, their premorbid background at the time of the disease, the type and properties of Salmonella.

Incubation period ranges from several hours to 2-3 days with the food way of infection and can be extended up to 6 days with contact-household infection.

Typical- the gastrointestinal (gastrointestinal) form is most common. The disease begins acutely with a rise in body temperature, the development of symptoms of intoxication and intestinal dysfunction. The clinical picture is determined by the level of damage to the gastrointestinal tract.

gastric form observed in older children and proceeds according to the type of food poisoning. The disease begins acutely, sometimes violently, there is repeated vomiting, abdominal pain, fever, weakness, headache, loss of appetite to anorexia. The tongue is covered with a white coating, the abdomen is swollen, the nature of the stool does not change. After adequate therapy, recovery occurs in 2-4 days.

Enteric form develops more often in young children with burdened premorbid background. The disease begins gradually with a decrease in appetite, regurgitation, subfebrile temperature, duration 5-7 days. Enteritic stool (copious, watery, frothy, mixed with greenery) up to 5-10 times a day. The disease is characterized by unstable stools and prolonged bacterial excretion.

Gastroenteritis form characterized by prolonged fever, severe symptoms of intoxication, vomiting, frequent stools up to 3-8 times a day. Stools are profuse, liquid, frothy, mixed with mucus and greenery. The tongue is dry, lined with a white coating, the abdomen is swollen, there is rumbling, splashing noise along the colon. A number of patients develop dehydration of I-II degree.

Children are more likely to have symptoms gastroenterocolitis or enterocolitis, characterized by an acute onset, the body temperature rises to 38.5 - 39.5 0 C, which persists for 5-7 days. Vomiting is noted, infrequent, but persistent. From the first days of the disease, stools are frequent, profuse, liquid, fecal with an unpleasant odor, brown-green in color (in the form of "swamp mud"), with a lot of mucus and blood. The frequency of stools is 5-12 times a day, defecation is painful, the abdomen is swollen, on palpation - diffuse soreness. From the first days of the disease, there is an increase in the size of the liver, spleen - from 5-7 days.

In all variants of the gastrointestinal form of salmonellosis, damage to the cardiovascular system (transient infectious-toxic cardiopathy), kidneys (infectious-toxic nephropathy) is detected.

According to the severity of the phenomena of intoxication and gastrointestinal disorders, the disease is regarded as mild, moderate and severe.

At mild forms salmonellosis, which are more common in older children, general state slightly disturbed, vomiting does not exceed 1-2 times a day, there is no temperature, or a short-term rise to 38 0 is possible, the stool retains a fecal character and is accelerated up to 3-6 times.

At medium-heavy forms, the phenomena of intoxication are more pronounced, the temperature rises to 38.5 0, sleep is disturbed, lethargy, pallor of the skin, cardiovascular disorders, persistent vomiting, stools more than 6 times a day with blood, greens and mucus are noted.

At severe forms diseases are observed repeated, sometimes indomitable vomiting, stool 12-15 times a day, there may be intestinal bleeding. With massive food contamination, endotoxin shock may develop, more often in adults and older children. Increasing lethargy, lethargy, circulatory disorders (cyanosis, cold extremities, drop in blood pressure, deafness of heart tones) are noted.

Atypical forms:

typhoid form occurs more frequently in school-age children. The onset is acute, body temperature rises to febrile numbers, fever of a wave-like or constant type within 10-14 days. Changes in the nervous system are expressed: headache, lethargy, stupor, often delirium and hallucinations. The skin is pale, the tongue is thickly coated, with imprints of teeth. The abdomen is swollen, the liver and spleen are enlarged. The chair is liquid, undigested green color. A scanty roseolous rash is noted on the skin of the chest and abdomen.

septic form- observed more often in newborns and young children with a burdened premorbid background. It begins acutely or gradually, accompanied by a febrile temperature with significant fluctuations during the day. Symptoms of intoxication are expressed (waxy pallor, marbling of the skin, subicteria, perioral, periorbital cyanosis, acrocyanosis, decreased tissue turgor, tachypnea, tachycardia. All patients have hepatosplenomegaly, thrombohemorrhagic syndrome. Purulent metastatic foci are often formed in the soft meninges, bones, kidneys, lungs and other organs.The majority have rapid stools of enterocolitis nature.Lethality in this form is high.

Laboratory diagnostics

Clinical symptoms and epidemiological data suggest salmonellosis, but the final diagnosis is established with bacteriological and serological confirmation.

The leading role in laboratory diagnostics belongs to bacteriological method, the material for the study is feces, vomit, washings, if necessary, blood, urine, cerebrospinal fluid and pus from the foci.

An important diagnostic tool is passive hemagglutination reaction using standard erythrocyte diagnosticums. The diagnostic titer of total antibodies is 1:100 (in children under 1 year old) and 1:200 (over 1 year old).

A blood test should be repeated in dynamics, after 7-10 days. An increase in antibody titers by 4 times or more is of diagnostic significance, the highest intensity of the serological response is observed on the 3rd week.

For the purpose of express diagnostics, the coagglutination reaction (RCA) and ELISA are used.

Coprocytogram has no specific features. Involvement in the pathological process of the colon is accompanied by the appearance of erythrocytes and leukocytes. In the peripheral blood, leukocytosis, neutrophilia with a stab shift, and an increase in ESR are noted.

Differential diagnosis carried out with diseases accompanied by symptoms of colitis or hemocolitis.

Dysentery, unlike salmonellosis, is characterized by a short-term temperature reaction, a pronounced colitis syndrome (tenesmus or their equivalents, spasm of the sigmoid colon, anus compliance), scanty stools with mucus, greenery, pus, streaks of blood ("rectal spit"), the development of all symptoms from the first day of illness. Salmonellosis is characterized by a longer rise in temperature, often its undulating nature, the stool is more liquid, plentiful, fetid, the color of marsh mud, brown, pain in the epigastric and right iliac region, intoxication with salmonellosis is longer.

Intussusception, unlike salmonellosis, in young children begins with paroxysmal pain in the abdomen, accompanied by a cry and anxiety of the child at normal temperature. From the first hours of the disease there is bloating, increased peristalsis above the intussusceptum. The stool is initially fecal, then consists of liquid scarlet blood and mucus - "raspberry jelly". On palpation of the abdomen and digital rectal examination, it is possible to palpate the intussusceptum; scarlet blood appears on the finger after the examination. An x-ray examination reveals a local shadow, then a horizontal level of fluid in the intestine.

Acute appendicitis in children is accompanied not only by vomiting, but also by the appearance of loose stools with mucus and greens. With appendicitis, pain in the abdomen is cramping, not associated with the act of defecation, there is a forced position on the right side with legs brought to the stomach, tension in the muscles of the abdominal wall, dryness and furry tongue are characteristic. There is tachycardia that does not correspond to temperature.

Difficulties arise in the differential diagnosis of salmonellosis with escherichiosis caused by enteroinvasive Escherichia coli, with staphylococcal enterocolitis. Decisive in the diagnosis are epidemiological and laboratory data.

Treatment of a patient with salmonellosis should be complex (pathogenetically substantiated, etiotropic and symptomatic), individualized taking into account the severity, age and premorbid background.

Patients are subject to hospitalization according to clinical indications: (severe, moderate, protracted forms, children with a burdened premorbid background and in the presence of concomitant diseases).

According to epidemiological indications: children from closed children's institutions (children's homes, orphanages), hostels and from families of decreed population groups.

A ward regime is assigned.

In nutrition, preference is given to dairy products. With the normalization of the stool, cottage cheese, cereals, mashed potatoes are introduced into the diet. Older children - vegetable and fruit puree, cereals, cottage cheese, vegetable soup, meat broth, meat soufflé, crackers, apples, bananas.

Pathogenetic therapy is reduced to the introduction of a sufficient amount of liquid both inside and parenterally. Detoxification drugs, glucose-salt, etc. are administered in doses appropriate for age. Of the etiotropic drugs in the treatment of patients with mild and moderate forms of salmonellosis, the drugs of choice are nitrofuran (enterofuril, ercefuril) and polyvalent salmonella bacteriophage.

Antibiotics are prescribed for children under 1 year of age due to the real danger of generalization, as well as for older children with severe, sometimes moderate forms, mixed infections, with an unfavorable premorbid background, the presence of concomitant inflammatory foci and complications. It is advisable to use kanamycin, gentamicin by mouth. In severe forms, parenteral administration of antibiotics is acceptable, followed by the transition to enteral: amikacin, carbenicillin, ceftazidime (fortum), cefotaxime (claforan), levomycetin-succinate. The course of treatment is 7-10 days.

It is inappropriate to prescribe repeated courses of antibiotic therapy, as well as the use of antibiotics in case of bacteriocarrier.

Prevention of salmonellosis is based on the implementation of veterinary and sanitary measures aimed at preventing diseases among farm animals and birds, as well as ensuring proper sanitary conditions at meat processing and meat and dairy enterprises. It is important to observe sanitary and hygienic standards, rules for storage, transportation and culinary processing of food products.

In order to prevent nosocomial morbidity, all children's hospitals should work according to the regime of infectious diseases hospitals.

Salmonellosis occupies one of the first places in the structure of AII (acute intestinal infections). Due to the wide spread of salmonellosis throughout the world, the emerging trend of increasing incidence among residents of developed countries and the high percentage of deaths in young children, this disease is one of the most important and urgent health problems.

Salmonellosis is most severe in children. Most cases of death from salmonellosis occur in babies in the first year of life. In addition to the severe course, salmonellosis in children is characterized by high risks of developing a protracted recurrent course.

Salmonellosis is a group of infectious diseases caused by bacteria of the genus Salmonella, represented by 2 species of Salmonella enterica and bongori, divided into seven main serovars that cause salmonellosis in humans: typhimurium, enteritidis, panama, infantis, newport, agona, london. Other pathogens of salmonellosis are found mainly in birds and animals.

Salmonellosis is distinguished by a large number of clinical forms, which greatly complicates its clinical diagnosis. However, common to all forms of the disease will be damage to the gastrointestinal tract and severe intoxication.

Salmonellosis ICD code 10– A02.0 for Salmonella enteritis, A02.1 for Salmonella septicemia, A02.2 for localized forms, A02.8 for specified Salmonella infections and A02.9 for unspecified.

Epidemiology of salmonellosis

The epidemic situation varies depending on the geographical area, climatic features, population density, etc. However, in recent years there has been a significant increase in the incidence of the disease in all countries. At the same time, salmonellosis caused by Salmonella Enteritidis has become much more common in Russia. The peculiarity of this salmonella serovar is that it can lead to an outbreak of salmonellosis even at minimal concentrations in products.

The high ubiquitous prevalence of salmonellosis is also facilitated by the variety of ways of infection and the fact that, in addition to humans, warm-blooded animals (livestock, poultry) can suffer from salmonellosis.

It should also be noted that many salmonellosis serovars have acquired resistance to antibacterial drugs previously used against them, which greatly complicates the treatment process.

Over the past decade, the prevalence of salmonellosis has increased more than eightfold, with a significant increase in the number of cases in large cities with a centralized water supply system.

Susceptibility to the causative agent of salmonellosis is high, however, the greatest risk of infection is observed in children under three years of age and the elderly.

In the structure of the disease, there is a pronounced seasonality summer-autumn. The prevalence of salmonellosis bacteria is ubiquitous. Most often, the disease is recorded in the form of sporadic outbreaks. Large outbreaks of salmonellosis (food or water), as a rule, are registered in closed institutions (nursing home, boarding school, etc.). The least frequent outbreaks of nosocomial infection in maternity hospitals and intensive care units.

Specific methods for the prevention of salmonellosis have not yet been developed. After an infection, a strictly serospecific unstable (lasting up to a year) immunity is formed.

How is salmonella infection most likely to occur?

Infection occurs when eating water or food contaminated with salmonellosis bacteria. In most cases, the pathogen is found in:

• raw eggs (chickens, ducks, turkeys, etc.);
• poultry meat, pork, beef;
• in fish (salmonellosis bacteria can persist when hot smoked or spicy salted fish);
• unwashed fruits, vegetables;
• confectionery (the maximum danger is sweets with a lot of cream).

A rarer variant of infection is the contact-household transmission of the pathogen through dishes, linen, toys, towels, etc.

Is salmonellosis contagious?

The source of infection for salmonellosis are sick people (including bacteria carriers), as well as farm animals (cows, pigs), poultry (goose, duck, chicken, turkey), freshwater fish and cats.

Infection of products (meat, eggs) is possible both endogenous (infection of an animal, birds, fish, etc., is carried out in vivo), and exogenous infection.

How does salmonella infection occur?

Exogenous contamination of products is carried out in the process of their preparation. It can occur due to washing food in water contaminated with salmonella, non-compliance with sanitary and hygienic standards during food preparation.

How is salmonella transmitted from person to person?

The pathogen is transmitted by the fecal-oral route. Patients with salmonellosis and bacteria carriers pose an epidemic danger.

Infection is carried out by food (eating food prepared by a bacteriocarrier) or contact-household method (dirty hands, shared utensils).

Features of the causative agent of salmonellosis

The causative agents of salmonellosis are gram-negative rods that are highly resistant to environmental factors. Salmonella are capable of:

• withstand low temperatures for several months;
• half an hour to remain active at a temperature of 60 degrees.

On linen, the pathogen remains viable from several weeks to several months, in feces - up to a month. Running water retains salmonella for 10 days, tap water for five months. In dust and dirt, Salmonella remain viable for up to six months.

In food products, the causative agent of salmonellosis can not only persist for an extremely long time, but also actively multiply. Frozen meat can store salmonella for up to six months, frozen bird carcasses for up to a year, sausages or sausages for up to three months, and butter and cheeses for up to a year.

The main feature of the pathogen is its ability to quickly develop resistance to antibacterial drugs.

At what temperature does salmonellosis die? ?

The causative agent of salmonellosis instantly dies at a temperature of one hundred degrees. At the same time, in order to destroy the pathogen in the eggs, they must be hard-boiled or fried on both sides (undercooked or undercooked eggs can retain the pathogen).

The pathogenesis of salmonellosis

The incubation period for salmonellosis is six hours to three days (usually twelve to 24 hours). In adults and children, the first signs of salmonellosis, in most cases, are acute - vomiting, abdominal pain, diarrhea (gastroenteric variant of the course of the disease).

The incubation period for salmonellosis in children is similar to that in adults, but younger children tend to develop symptoms more quickly than adults (six to ten hours).

Signs of salmonellosis in children and adults develop after bacteria and their toxins enter the gastrointestinal tract. The site of primary colonization of bacteria is the small intestine. In severe cases, the colon may also be affected.

After the pathogen enters the intestine, it begins to actively fix itself on the cell membranes of enterocytes, leading to the appearance of degenerative changes in them and the development of enteritis (inflammation of the small intestine). Due to their high adhesive properties, Salmonella are able to quickly overcome the protective layer of mucus in the intestine and quickly colonize the intestinal mucosa.

An important role in the pathogenesis of the disease also has the ability of the pathogen to invade. Salmonella are able to penetrate into the M-cells of the intestinal mucosa and destroy them, while invading the lymphoid intestinal formations.

Due to its invasive properties, the bacteria penetrate the mesenteric lymph nodes, the thoracic lymphatic duct and the general circulation.

As a rule, the entry of the causative agent of salmonellosis into the blood is not accompanied by clinical signs of bacteremia and does not lead to a generalization of the infectious process. This is due to the fact that most of the pathogen is quickly destroyed by bactericidal factors in the blood serum. However, in the presence of immunodeficiency states, Salmonella can be fixed in the MHS (macrophage-histiocytic system) and form purulent inflammatory foci.

In the intestine, active reproduction and production of enterotoxin by Salmonella activates adenylate cyclase and contributes to the development of secretory type diarrhea. Against the background of the fact that the pathogen continues to invade the submucosal layer of the small intestine, the neutrophilic and lympho-macrophage link of immunity is activated. The death of a part of the pathogen is accompanied by a massive release of endotoxins and the development of an intoxication syndrome (cramping abdominal pain, vomiting, exudative diarrhea).

The entry of endotoxins into the blood is accompanied by the occurrence of general intoxication and febrile syndromes, due to the systemic immune response to bacteremia and toxinemia.

The development of diarrhea occurs due to inhibition of the secretion of chlorine and stimulation of excessive fluid loss by cells. Also, salmonella toxins trigger the active production of prostaglandins by organisms, which can increase intestinal motility and fluid secretion into the intestinal lumen.

Intoxication, as well as dehydration developing against the background of diarrhea, lead to an imbalance of electrolytes and cardiac activity. Salmonellosis poses the greatest danger for children in the first years of life, as they develop life-threatening dehydration, neurotoxicosis, arterial hypotension, cardiac arrhythmias, etc. very quickly.

Why is salmonellosis dangerous for humans?

Complications of salmonellosis can be the development of:

• neurotoxicosis;
• septic shock;
• hypovolemic shock;
• life-threatening dehydration;
• severe electrolyte imbalance;
• acute renal failure;
• disseminated intravascular coagulation;
• life-threatening cardiac arrhythmias
• intestinal bleeding;
• circulatory disorders in the vessels of the intestines, heart and brain;
• perforation or invagination of the intestine;
• prolapse of the rectal mucosa.

The transition of salmonellosis to a chronic form is also possible.

Classification of salmonellosis

The disease can occur in a localized or generalized form. The localized type includes gastritis, gastroenterocolitis or gastroenteritis.

Generalized forms of the disease can occur in a typhoid-like or septic variant.

Bacterial excretion in salmonellosis can be acute, transient or chronic.

Symptoms and signs of salmonellosis in adults and children

In almost 90% of patients, the disease occurs in a gastroenteric form. In two to three percent of patients, the disease can proceed in a generalized form (typhoid-like or septic course).

With a mild gastric course, salmonellosis is manifested by an acute onset, vomiting, pain in the epigastric region and a mild intoxication syndrome.

The gastroenteric course is characterized by spastic abdominal pain, vomiting, nausea, and loss of appetite. Diarrhea and fever, as a rule, join on the second or third day of illness. At the beginning, the feces are formed, later they liquefy, becoming fetid, frothy-watery and acquire the color of swamp mud. The abdomen is painful and swollen.

With the development of dehydration, against the background of vomiting and diarrhea, the patient develops:

• pallor and cyanosis of the skin;
• dry mucous membranes (dry, rough, coated tongue);
• decrease in diuresis;
• pronounced weakness;
• decrease in skin turgor;
• lethargy;
• tachycardia, cardiac arrhythmias, muffled heart sounds;
• tremor and convulsions.

With the gastroenterocolitis form of the disease, mucous and bloody impurities appear in the stool.

The generalized course develops against the background of the clinical picture of gastroenteric or gastroenterocolitic salmonellosis. With typhoid-like salmonellosis, high undulating fever, headaches, roseolous rashes on the abdomen are noted (on the sixth or seventh day of illness). The appearance of dry rales in the lungs, cardiac arrhythmias, bradyarrhythmias, enlargement of the liver and spleen are also noted.

The septic course is characterized by high fever and pronounced intoxication. This variant of salmonellosis, as a rule, develops in debilitated patients or patients with immunodeficiency states. In a septic course, the pathogen, after entering the blood, is not destroyed by bactericidal blood factors, but leads to the formation of purulent inflammatory foci in the tissues of the lungs, heart (septic endocarditis), kidneys, liver, etc.

The severe course of salmonellosis, especially the septic form, is characterized by a high risk of adverse outcome (development of complications or death).

Salmonellosis symptoms in children

In children, salmonellosis is more severe than in adults, and they also develop severe dehydration and neurotoxicosis extremely quickly.

The disease begins acutely. The baby has vomiting, anxiety, abdominal pain, flatulence. The child is capricious, whiny, refuses to eat. The abdomen is swollen, by the end of the first day diarrhea appears.

The development of intestinal exicosis in a child is accompanied by the appearance of a pulsation of a large fontanelle (babies of the first year of life), shortness of breath, heart rhythm disturbances, a decrease in diuresis, dry skin, cold extremities and marbling of the skin, lethargy, the appearance of pronounced shadows under the eyes, retraction of the eyes, incomplete closure of the eyelids, tremor of the chin or limbs, convulsions.

The severity of exsicosis in children

The duration of diarrhea, depending on the form of the disease and the severity of its course, can range from several days to several weeks.

Diagnosis of salmonellosis

An important point in the diagnosis of salmonellosis is the collection of an anamnesis of the disease. Characteristic are the presence in the patient's history of potentially salmonella-infected products (eggs, cakes, sausages, etc.), contact with a patient or a bacteria carrier, and drinking raw unfiltered water.

Mandatory research includes general analysis blood and urine, analysis of feces for salmonellosis and disgroup, serological studies for salmonellosis.

A specific analysis for salmonellosis is carried out bacteriologically and serologically. For research, feces, blood, pus from a septic focus, vomit, washings from the stomach, urine, bile can be used. The remains of products that the patient has consumed can also be examined.

An analysis for salmonellosis should be ordered before the patient begins to receive etiotropic drug therapy.

To detect Salmonella antigens in the blood, ELISA or RHA is performed. Also, a blood test for salmonellosis can be performed by setting RPHA with paired sera. Antibodies to the pathogen are detected by the end of the first week of illness.

For express diagnostics, molecular genetic diagnostics is carried out on Salmonella DNA using the polymerase chain reaction method.

How to get tested for salmonellosis?

Special preparation before passing the analysis is not required. Blood is given in the morning, on an empty stomach.

Collection of feces is possible at any time. Examination of feces can be carried out to clarify and confirm the diagnosis, monitor the effectiveness of treatment, and also as a standard preventive study during hospitalization in the department.

A rectal swab and fecal analysis for salmonellosis during pregnancy is also carried out as a preventive measure, to prevent an outbreak of salmonellosis in the maternity hospital. It must be understood that in babies this infection is extremely difficult and is accompanied by a high risk of death, so this analysis is included in the list of mandatory planned studies.

A rectal swab is performed with a special disposable swab. The patient lies on his side with legs bent at the knees. After inserting the tampon into the intestine, several rotational movements are performed, then the tampon is placed in a special container and sent to the laboratory.

Treatment of salmonellosis in adults and children

Treatment of salmonellosis at home is possible only with a mild course of the disease in adults. In moderate and severe cases, hospitalization is indicated. Treatment of salmonellosis in young children (especially under three years of age) is always carried out in a hospital setting.

Treatment tactics depend on the severity of the patient's condition. The patient is shown:

• diet and bed rest;
• oral rehydration. If necessary, infusion therapy is carried out to compensate for fluid loss, relieve intoxication and normalize electrolyte balance. The volume of fluid for rehydration is calculated individually, based on the patient's daily physiological need for fluid, the severity of dehydration (fluid deficiency) and pathological fluid loss;
• probiotics;
• prebiotics;
• sorbents;
• enzyme preparations (pancreatin, creon).

To stop the febrile syndrome, antipyretics (non-steroidal anti-inflammatory drugs) are used.

Antibiotics for salmonellosis are prescribed in case of a severe course of the disease or the development of generalized forms. In this case, nalidixic acid preparations, nifuroxazide, kanamycin, gentamicin, amoxicillin + clavulanate, cefexime, trimethoprim + sulfamethaxazole can be used. If necessary, reserve funds, preparations of amikacin, ceftriaxone, cefotaxime, ciprofloxacin, ceftazidime, meropenem, etc. can be used.

The duration of antibiotic therapy leaves from seven to fourteen days.

If necessary, immunoglobulin preparations may also be prescribed. In severe cases, glucocorticosteroids may be indicated.

Nutrition and diet for salmonellosis

Patients are shown diet number 4. Foods that irritate the intestines, fatty and hard to digest foods, dairy products, sweets, etc. are excluded from their diet.

The amount of food is reduced depending on the severity of the disease (by 20% for mild, 30% for moderate and 50% for severe).

Food should be fractional (up to 8-10 times a day in small portions).

In the future, after recovery for two to three months, a sparing diet is shown.

Prevention of salmonellosis

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Specific methods of disease prevention have not been developed. Non-specific prevention consists in observing veterinary and sanitary supervision of farm animals and birds, as well as meat processing technology.

Individual prevention includes personal hygiene, avoiding the use of raw eggs and unboiled unfiltered water.

salmonellosis- an acute infectious disease of humans and animals with a predominant lesion of the gastrointestinal tract (generalized forms are less commonly observed).

Code according to the international classification of diseases ICD-10:

The main lesions caused by salmonella are conventionally divided into 3 groups: typhoid fever and paratyphoid fever, gastroenteritis and septicemia. Most often, the term "salmonellosis" is applied to gastroenteritis caused by these bacteria.

The reasons

Etiology. The causative agents are Gram-negative motile bacteria of the Salmonella genus of the Enterobacteriaceae family.

Epidemiology. Diseases are ubiquitous, the natural reservoir of most pathogens is humans and various animals (including reptiles, amphibians, fish and birds).

Main routes of transmission- food (contaminated food products), water and contact.

Pathogenesis

Salmonella are not able to independently penetrate into the epithelial cells of the gastrointestinal tract, but enter them through endocytosis.

Bacteria are poorly adapted to reproduction in the epithelium and, reaching the basement membrane, penetrate into the lamina propria of the mucous membrane.

From here they penetrate into the bloodstream (can be isolated on blood culture), but most Salmonella do not cause clinical manifestations of bacteremia, because rapidly eliminated by phagocytes. The exception is Salmonella typhimurium.

The risk of developing septicemia is significantly increased in individuals with impaired mononuclear phagocyte activity, such as those with sickle cell anemia and HIV infection.

The causative agent in its own plate of the mucous membrane multiplies and causes the development of a local inflammatory reaction and the influx of fluid into the lesion.

Manifestations of diarrheal syndrome are caused by the production of enterotoxins that increase the level of cyclic adenosine monophosphate, activate PG synthesis, or disrupt protein synthesis (like Shigella toxins).

Symptoms (signs)

Clinical picture and classification

Gastrointestinal form.

The incubation period varies from 12-18 hours to 2-3 days (average - 7-24 hours).

The onset of the disease is acute: body temperature rises, chills, dyspeptic disorders appear (repeated repeated vomiting, copious watery loose stools, abdominal pain).

In the initial period of the disease, the symptoms of intoxication (weakness, headache, chills, etc.) come to the fore. With the gastrointestinal form of salmonellosis, all parts of the gastrointestinal tract are involved in the pathological process.

At the height of the disease, all patients experience nausea, vomiting, loss of appetite; in most patients, these manifestations are accompanied by diarrhea. Vomiting during the first day is repeated. The frequency of stool does not exceed 10-15 r / day. Most often, profuse watery stools with an admixture of mucus are noted.

A constant symptom is abdominal pain (appear in the first hours of the disease) and its soreness on palpation; pains can be spilled or, with severe vomiting, localized in the epigastric and navel areas.

With lesions of the colon, pain can take on a cramping character and move to the lower half of the abdomen. In some patients, the pain is cramping and associated with the act of defecation.

The stool most often remains watery or mushy, but it may contain an admixture of mucus or even blood.

On palpation of the abdomen, pain is determined throughout the abdomen, spasm and hypersensitivity of the sigmoid colon, an enlarged rumbling caecum.

Often, pain is also detected on palpation of the epigastric region.

The reason for the development of acute functional renal failure may be a violation of the blood circulation of the kidneys along with changes in the water and electrolyte balance. The greatest deviations are noted in the development of infectious-toxic shock.

. Generalized form

The typhoid-like variant clinically resembles typhoid fever and paratyphoid fever. Prolonged fever, enlargement of the liver and spleen, pallor of the skin and injection of the sclera are characteristic, the latter are sometimes subicteric. A roseolous rash may appear on the skin of the chest and abdomen

The septic variant is essentially a salmonella sepsis with the formation of typical metastatic foci of inflammation (lungs, pia mater, bone marrow, etc.)

Clinical picture in children and the elderly.

Typhoid and septic variants in children are recorded more often. Severe forms are much more common in young children. The severity of the condition is determined by the severity of dehydration.

In elderly patients, the symptoms of intoxication are usually more pronounced, bacteriocarrier is more often formed and complications develop.

. Bacteriocarrier is considered as a subclinical form of salmonellosis

Acute carrier. The period of isolation of bacteria varies from 15 days to 3 months. Longer isolation (more than 3 months) is regarded as chronic carriage

Transient carrier. Characterized by the absence of clinical symptoms of the disease both at the time of the examination and in the previous 3 months. One - double isolation of the pathogen with three consecutive negative results of bacteriological examination of feces and urine, negative results of serological examination in dynamics.

Diagnostics

Diagnostics

bacteriological research. Materials for research: feces, vomit, gastric lavage, blood, urine. They also examine the remnants of food consumed by the sick, the original products and semi-finished products used for its preparation; daily samples of prepared food, animal feed, swabs from various equipment and other items suspected as a pathogen transmission factor. The optimal time for bacteriological studies in gastrointestinal forms of salmonellosis disease is the first days; with generalized forms - at the end of the second or beginning of the third week. The number of positive results increases significantly with the increase in the frequency of examination. Positive results are most likely to be obtained with a stool test.

RPHA with a cysteine ​​test, which allows differentially determine the titers of antibodies of the IgG class.

Differential diagnosis. Viral gastroenteritis. Other bacterial gastroenteritis (dysentery, cholera, etc.). Sepsis (meningococcal, staphylococcal). Appendicitis. Cholecystitis. Intestinal perforation.

Treatment

TREATMENT

Diet with the use of mechanically and thermally processed foods in the diet

In the gastrointestinal form, gastric lavage is carried out with r - rum of sodium bicarbonate or a weak r - rum of potassium permanganate; metoclopramide is used to relieve dyspepsia

Rehydration therapy

Salt r - ry (for example, Regidron) inside

With infectious - toxic shock, IV degree dehydration, III degree dehydration with unstable hemodynamics, indomitable vomiting, fluid loss with vomiting and diarrhea above 1 l / h; oligoanuria, diabetes and glucose absorption disorders - saline solutions (for example, sodium acetate + sodium chloride, sodium acetate + sodium chloride + potassium chloride) IV

For detoxification (with slight dehydration or after its elimination), colloidal solutions are prescribed together with saline solutions.

Antibiotic therapy is not indicated for uncomplicated forms

For children of the first year of life, elderly patients, with immunosuppressive conditions and generalized infection - orally for 3-7 days (with immunosuppressive conditions, with generalized infection - longer) ampicillin up to 4 g / day (for children of the first year of life - 50-100 mg / kg / day in 3 doses), amoxicillin 0.5-1 g 3 r / day (for children of the first year of life - 20 mg / kg / day in 3 doses), ciprofloxacin 500 mg orally every 12 hours (adults)

In case of bacteriocarrier, in some cases (for example, in people working in food blocks, medical personnel), ciprofloxacin 500 mg orally every 12 hours for a month (until a negative result of bacteriological examination) can be prescribed.

Complications

hypovolemic shock

Infectious - toxic shock

Prevention. It is necessary to comply with hygiene requirements in the production, transportation and storage of food products. Avoid contact with animal feces, keep cages, bedding, etc. clean. Thorough hand washing.

ICD-10. A02 Other Salmonella infections